Medical Record Technician (Medical Coder)

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: a. Citizenship: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. b. Experience and Education: Please see education and experience requirements below in the “Education” section. c. Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675series 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. d. 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). Details on grandfathering are listed in the assessment questionnaire. Grade Determinations: In addition to meeting the Basic Requirements, the grade specific requirements and Knowledge, Skills and Abilities (KSAs) must be met as listed below as specified at each grade level. Medical Records Technician (Coder), GS-4 Required Experience: None beyond basic requirements. OR Medical Records Technician (Coder), GS-5 Required Experience. One year of creditable experience equivalent to the next lower grade level. Examples of experience include: Selects and assigns codes from the current versions of the International Classification of Diseases (ICD) Clinical Modification (CM) and Procedure Coding System (PCS) for inpatient facility MS-DRG coding, and Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS) for inpatient professional coding and outpatient coding. Reviews record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data with guidance and instruction from supervisor or senior coder to develop knowledge of the organization and structure of an electronic patient record. AND Demonstrated the following GS-05 Knowledge, Skills, and Abilities: In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to use health information technology and software products used in MRT (Coder) positions (e.g., the electronic health record, coding and abstracting software, etc.); Ability to navigate through and abstract pertinent information from health records; Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines; Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient and outpatient episodes of care based on health record documentation; Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines; and Ability to manage priorities and coordinate work, in order to complete duties within required timeframes, and the ability to follow-up on pending issues. Medical Records Technician (Coder), GS-6 Required Experience. One year of creditable experience equivalent to the next lower grade level. Assigns codes to documented patient care encounters (inpatient and outpatient) for one or more specialty and subspecialty health care services provided by the VAMC. Selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties. Demonstrated the following GS-06 Knowledge, Skills, and Abilities Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation. Ability to determine whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, and support the assigned codes. This includes the ability to take appropriate actions if health record contents are not complete, accurate, timely, and/or reliable. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HIPAA). Ability to accurately apply the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT Guidelines to various coding scenarios. Medical Records Technician (Coder), GS-7 Required Experience. One year of creditable experience equivalent to the next lower grade level. Identifies the principal diagnosis and principal procedure for every inpatient discharge; also identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG). Codes inpatient professional fee services for identified inpatient admissions. AND Demonstrated the following Knowledge, Skills, and Abilities: In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to research and solve coding and documentation related issues. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete. Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators to obtain correct MS-DRG. Medical Records Technician (Coder), GS-8 Required Experience. One year experience equivalent to the next lower grade level. Examples of experience include: 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. Review provider health record documentation to ensure that it supports the diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature. And 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. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS-8. The actual grade at which an applicant may be selected for this vacancy is GS 8. Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service
This position is in the Coding Section at the VA Maryland Health Care System (VAMHCS). The Medical Records Technician (Coder) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided. This is considered the full performance level for this assignment. Coders at this level perform either inpatient or outpatient coding duties, or a combination of inpatient and outpatient coding duties.