Medical Records Technician (Coder-Outpatient and Inpatient)

Description:

The position is aligned under the Health Information Management Section (HIMS) of Medical Administration Service (MAS) with North Florida/South Georgia Veterans Health System (NF/SG VHS); Lake City VA Medical Center. The Medical Record Technician (MRT/Coder) is responsible for performing a quality review of patient care documents and assigning codes specific to care provided.

Requirements:

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met.

Basic Requirements :

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.

Experience and Education:

• (1) Experience . One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a health records.

OR

• (2) Education. An associate's degree from an accredited college or university recognized by the U.S. Department of Education with a major field of study in health information technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management (e.g., courses in medical terminology, anatomy and physiology, medical coding, and introduction to health records);

OR

• (3) Completion of an AHIMA approved coding program , or other intense coding training program of approximately one year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding. The training program must have led to eligibility for coding certification/certification examination, and the sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor, or comparable international accrediting authority at the time the program was completed;

OR,

• (4) Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable experience: (a)Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, and one year above high school, with a minimum of 6 semester hours of health information technology courses. (b)Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service, under close medical and professional supervision, may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder).

Certification. Persons hired or reassigned t o MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:

• (1) Apprentice/Associate Level Certification through AHIMA or AAPC.
• (2) Mastery Level Certification through AHIMA or AAPC.
• (3) Clinical Documentation Improvement Certification through AHIMA or ACDIS.

English Language Proficiency . MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).

May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria).

Grade Determinations : In addition to meeting the basic requirements stated above, the following qualifications criteria must be met in determining the appropriate grade assignment of candidates.

Medical Records Technician (Coder-Outpatient and Inpatient), GS-8

(a) Experience. One year of creditable experience equivalent to the next lower grade level (duties include: MRTs (Coder) perform a combination of inpatient and outpatient coding duties. Selects and assigns codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. They review record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data with minimal guidance from higher level MRTs (Coder). They review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes. They review provider health record documentation to ensure that it supports the diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature).

While we no longer require essay-style responses to our Knowledge's Skills, Abilities, and Other Characteristics (KSAOs), you must be able to demonstrate that you possess the (below) competencies which are necessary to perform the work of the position. Please ensure your resume/CV/application contains sufficient information to support the level of experience/education/training; otherwise, we will not be able to award you credit for the experience/education/training you claim. These are the KSA's for this subject position:

• Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation. This includes the ability to read and understand the content of the health record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient.
• Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and inpatient facility coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services.
• Skill in interpreting and adapting health information guidelines that are not 19 completely applicable to the work, or have gaps in specificity, and the ability to use judgment in completing assignments using incomplete or inadequate guidelines.

References: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/ .

Physical Requirements: The work is mainly sedentary in nature. Typically, the Employee may sit to do the work. There may be some walking, standing, bending, and climbing step(s) to conduct meetings or perform quality assurance activities.