Medical Records Technician (Coder-Outpatient and Inpatient) - Ann Arbor - job 854187

Department of Veterans Affairs

Date: 06/11/2021

City: Ann Arbor, Michigan

Employment type: Full-time


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Summary


This position is located in the Health Information Management (HIM) section at the VA Ann Arbor Healthcare System (VAAAHS). MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers. These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure.


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Responsibilities



  • Assigns codes to documented patient care encounters (inpatient or outpatient) covering the full range of health care services provided by the VAMC.

  • Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection.

  • 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).

  • Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding.

  • Applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (in inpatient and outpatient settings) used to classify patients.

  • Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.

  • Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.

  • 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.

  • Insures provider documentation is complete and supports the diagnoses and procedures coded.

  • Consults with the professional staff for clarification of conflicting or ambiguous clinical data.

  • Reports incorrect documentation or codes in the electronic patient health record.

  • 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.

  • Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database in Austin.

  • Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines.

  • Researches references to resolve any questionable code errors; contacts supervisor as appropriate.

  • Utilizes a variety of window based 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.

  • Ensures current versions of all software applications are loaded and functional after any updates or changes.

  • Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs, at the direction of the supervisor, on unit operations, coding, abstracting, and use of an electronic health record.

  • Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines.


Work Schedule: Monday-Friday 8:00am to 4:30pm


Financial Disclosure Report: Not required


Travel Required


Not required


Supervisory status


No


Promotion Potential


8



  • Job family (Series)


0675 Medical Records Technician


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Requirements


Conditions of Employment



  • You must be a U.S. Citizen to apply for this job

  • Designated and/or random drug testing may be required

  • Selective Service Registration is required for males born after 12/31/1959

  • You may be required to serve a probationary period

  • Subject to a background/security investigation

  • Must be proficient in written and spoken English

  • Selected applicants will be required to complete an online onboarding process


Qualifications


BASIC REQUIREMENTS:


a. Citizenship. Citizen of the United States.


b. 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).


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.


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.


GRADE DETERMINATIONS:


(1) GS-4 MRT (Coder-Outpatient and Inpatient) - Entry Level:


(a) Experience or Education. None beyond basic requirements.


(b) Assignment. Employees at this level serve as entry level MRTs (Coder) and receive close supervision from more experienced MRTs (Coder).


(2) GS-5 MRT (Coder-Outpatient and Inpatient) Developmental Level 1:


(a) Experience. One year of creditable experience equivalent to the next lower grade level;


OR


(b) Education. Successful completion of a bachelor'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 management, or a related degree with a minimum of 24 semester hours in health information management or technology.


(b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:




  1. Ability to use health information technology and various office software products used in MRT (Coder) positions (e.g., the electronic health record, coding and abstracting software, etc.).




  2. Ability to navigate through and abstract pertinent information from health records.




  3. Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines.




  4. 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




  5. Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines.



  6. Ability to manage priorities and coordinate work to complete duties within required timeframes, and the ability to follow-up on pending issues.


(d) Assignment. Employees at this grade level serve as developmental level 1MRTs (Coder) and receive guidance from more experienced MRTs (Coder) for more complex coding procedures.


(3) GS-6 MRT (Coder-Outpatient and Inpatient) Developmental Level 2:


(a) Experience. One year of experience equivalent to the next lower level.


(b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:




  1. Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation.




  2. 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.




  3. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HIPAA).




  4. Ability to accurately apply the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT Guidelines to various coding scenarios.




  5. Comprehensive knowledge of current classification systems, such as ICDCM, PCS, CPT, HCPCS, and skill in applying classifications to both inpatient and outpatient records based on health record documentation.



  6. Knowledge of complication or comorbidity/major complication or comorbidity(CC/MCC) and POA indicators to obtain correct MS-DRG.


(c) Assignment. Employees at this grade level serve in developmental positions as MRT coders and receive intermittent monitoring.


(4) GS-7 MRT (Coder-Outpatient and Inpatient) Developmental Level 3:


(a) Experience. One year of experience equivalent to the next lower grade level.


(b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the


following KSAs:




  1. Skill in applying current coding classifications to a variety of inpatient and outpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record.




  2. Ability to communicate with clinical staff for specific coding and documentation issues, such as recording inpatient and outpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health record documentation and code assignment.




  3. Ability to research and solve coding and documentation related issues.




  4. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.



  5. 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.


(c) Assignment. Employees at this grade level serve as developmental level 3 MRTs (Coder) and receive minimal monitoring.



  • (PLEASE CONTINE TO THE EDUCATION SECTION FOR THE GS-8 MRT GRADE DETERMINATIONS)*


Education



  • Additional Information from the qualification section:


(5) GS-8 MRT (Coder-Outpatient and Inpatient)Full Performance Level:


(a) Experience. One year of experience equivalent to the next lower grade level.


(b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:




  1. 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.




  2. 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.



  3. 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.


(c) Assignment. This is the journey level for this assignment. MRTs (Coder) at this level perform the full scope of inpatient and outpatient coding duties.MRTs(Coder) select and assign codes from current versions of ICD CM, 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 CM and 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 CM codes for diagnosis and complications, and CPT/HCPCS codes for surgeries, procedures, evaluation and management services, and inpatient professional services. They 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. They 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. They directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. They 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. They review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned, and is consistent with required medical coding nomenclature. They query clinical staff with documentation requirements to support the coding process. They enter and correct information that has been rejected, when necessary. They correct any identified data errors or inconsistencies. They also ensure audit findings have been corrected and refiled. They use various computer applications to abstract records, assign codes, and record and transmit data. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit.


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).


IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.


Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.





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