Medical Records Technician-Coder
Duties to Include but not limited to:
Select and assign codes from current versions of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD-10-CM and ICD-10-PCS codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of DRGs. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD-10-CM codes for diagnosis and complications, and CPT/HCPCS codes for surgeries, procedures, evaluation and management services, and inpatient professional services. Independently 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. Code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of ambulatory/inpatient settings and specialties. Directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record Abstract, assign, and sequence codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. Review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature. Query clinical staff with documentation requirements to support the coding process. Enter and correct information that has been rejected, when necessary. Correct any identified data errors or inconsistencies. Ensure audit findings have been corrected and refiled. Use various computer applications to abstract records, assign codes, and record and transmit data. Work Schedule:
Monday-Friday 8:
00am-4:
30pm; or 7:
30am-4:
00pm 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. Certification. Persons hired or reassigned to 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. 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:
To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 08/13/2020. Specialized
Experience:
You must have one year of specialized experience equivalent to at least the next lower grade GS-7. in the normal line of progression for the occupation in the organization. Examples of specialized experience would typically include, but are not limited to:
Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS) to both inpatient and outpatient records, Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture, Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record, and Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite. References:
VA Handbook 5005, Appendix G-57 Physical Requirements:
The work is primarily sedentary, although some slight physical effort may be required.
Estimated Salary: $20 to $28 per hour based on qualifications.
Select and assign codes from current versions of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD-10-CM and ICD-10-PCS codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of DRGs. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD-10-CM codes for diagnosis and complications, and CPT/HCPCS codes for surgeries, procedures, evaluation and management services, and inpatient professional services. Independently 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. Code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of ambulatory/inpatient settings and specialties. Directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record Abstract, assign, and sequence codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. Review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature. Query clinical staff with documentation requirements to support the coding process. Enter and correct information that has been rejected, when necessary. Correct any identified data errors or inconsistencies. Ensure audit findings have been corrected and refiled. Use various computer applications to abstract records, assign codes, and record and transmit data. Work Schedule:
Monday-Friday 8:
00am-4:
30pm; or 7:
30am-4:
00pm 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. Certification. Persons hired or reassigned to 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. 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:
To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 08/13/2020. Specialized
Experience:
You must have one year of specialized experience equivalent to at least the next lower grade GS-7. in the normal line of progression for the occupation in the organization. Examples of specialized experience would typically include, but are not limited to:
Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS) to both inpatient and outpatient records, Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture, Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record, and Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite. References:
VA Handbook 5005, Appendix G-57 Physical Requirements:
The work is primarily sedentary, although some slight physical effort may be required.
- Department:
0675 Medical Records Technician - Salary Range:
$47,899 to $62,629 per year
Estimated Salary: $20 to $28 per hour based on qualifications.
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