Medical Records Technician (Coder)
Assigns codes to documented patient care encounters (inpatient or outpatient) for the specialty and subspecialty health care services provided by the FHCC Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided Provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing Codes diagnosis, operations, and procedures based on knowledge of coding systems, including ICD, CPT and HCPCS, ensuring that codes are complete and conform to accepted VA regulations, Joint Commission, ICD coding conventions, and guidelines for optimal reimbursement Adheres to the coding guidelines specific to the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resources needs Identifies health record deficiencies, tracks deficiencies and ensures that appropriate individual completes their deficiencies Reviews and screens the entire medical record to abstract medical, surgical, laboratory, pharmaceutical, demographic, social and administrative data from the medical record in a timely manner Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services Codes inpatient professional fee services for identified inpatient admissions in support of the Medical Care Cost Recovery (MCCR) program Codes all Operating Room procedures reported in the Surgical Package of the VistA hospital system; applies ICD and CPT coding systems and guidelines and selects proper codes Maintains confidentiality of all records and documents regarding patients Work Schedule:
Full time, Monday through Friday, 7:
30am to 4pm Financial Disclosure Report:
Not required 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. English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. 7403(f). Experience and Education 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, 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, 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, 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:
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 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 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. NOTE:
Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification. Preferred
Experience:
Candidates possessing the required certification by the American Health Information Management Association(AHIMA), Certified Coding Specialist(CCS),Certified Coding Specialist-Physician Based (CCS-P), or Certified Professional Coder-Apprentice(CPC-A) and/or the American Academy of Professional Coders(AAPC) as a Certified Professional Coder (CPC) or Certified Outpatient Coder(COC), Certified Inpatient Coder(CIC). Candidates possessing 3 years of inpatient and/or outpatient coding experience. Grade Determination:
Medical Records Technician, GS-8 Full Performance Level (Journey Level)Experience. One year of creditable experience equivalent to the next lower grade level. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
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 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:
VA Handbook 5005/122, Part II, Appendix G57 - MEDICAL RECORD TECHNICIAN QUALIFICATION STANDARDS. Physical Requirements:
Light Lifting, under 15 pounds; Light carrying, under 15pounds; Reaching above shoulder; Use of fingers; Both hands required; Walking (up .5 hours); Standing (up .5 hours); Sitting for up to 7 hours per day. Veterans preference does not apply to this job announcement per HRML 05-19-12 Annual Determination of Staffing Shortages (Bulletin dated 10/08/2020).
Estimated Salary: $20 to $28 per hour based on qualifications.
Full time, Monday through Friday, 7:
30am to 4pm Financial Disclosure Report:
Not required 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. English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. 7403(f). Experience and Education 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, 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, 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, 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:
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 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 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. NOTE:
Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification. Preferred
Experience:
Candidates possessing the required certification by the American Health Information Management Association(AHIMA), Certified Coding Specialist(CCS),Certified Coding Specialist-Physician Based (CCS-P), or Certified Professional Coder-Apprentice(CPC-A) and/or the American Academy of Professional Coders(AAPC) as a Certified Professional Coder (CPC) or Certified Outpatient Coder(COC), Certified Inpatient Coder(CIC). Candidates possessing 3 years of inpatient and/or outpatient coding experience. Grade Determination:
Medical Records Technician, GS-8 Full Performance Level (Journey Level)Experience. One year of creditable experience equivalent to the next lower grade level. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
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 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:
VA Handbook 5005/122, Part II, Appendix G57 - MEDICAL RECORD TECHNICIAN QUALIFICATION STANDARDS. Physical Requirements:
Light Lifting, under 15 pounds; Light carrying, under 15pounds; Reaching above shoulder; Use of fingers; Both hands required; Walking (up .5 hours); Standing (up .5 hours); Sitting for up to 7 hours per day. Veterans preference does not apply to this job announcement per HRML 05-19-12 Annual Determination of Staffing Shortages (Bulletin dated 10/08/2020).
- Department:
0675 Medical Records Technician - Salary Range:
$53,121 to $69,057 per year
Estimated Salary: $20 to $28 per hour based on qualifications.
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