Medical Records Technician (Coder-Outpatient)

SummaryThis position is located in the Veterans Health Administration (VHA) - Southeast Network (VISN 7) - VA Augusta Health Care System in Augusta - Georgia located in the Health Information Management Section (HIMs) of Health Administration Service (HAS). 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.QualificationsApplicants 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 RequirementsUnited States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA PolicyExperience and Education: ExperienceOne year of creditable experience that indicates knowledge of medical terminology - anatomy - physiology - pathophysiology - medical coding - and the structure and format of a health recordsOR - EducationAn 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 codingThe 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 completedOR - Experience/Education CombinationEquivalent combinations of creditable experience and education are qualifying for meeting the basic requirementsCertificationMust have either (1) - (2) - or (3) below: Apprentice/Associate Level Certification through AHIMA or AAPCMastery Level Certification through AHIMA or AAPCClinical Documentation Improvement Certification through AHIMA or ACDISMay 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 the basic requirements for employment - the following criteria must be met when determining the grade of candidatesMedical Records Technician (Coder-Outpatient) - GS-4 Experience or EducationNone beyond basic requirementsMedical Records Technician (Coder-Outpatient) - GS-5 ExperienceOne year of creditable experience equivalent to the next lower grade level-OR- EducationSuccessful completion of four years of education above high school leading to a bachelor's degree from an accredited college or universityDemonstrated Knowledge - Skills - and AbilitiesIn 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 recordsKnowledge of the ICD CM - PCS Official Conventions and Guidelines for Coding and Reporting - and CPT guidelinesAbility to apply knowledge of medical terminology - human anatomy/physiology - and disease processes to accurately assign codes to outpatient/ambulatory surgery records - based on health record documentationvKnowledge of The Joint Commission requirements - Centers for Medicare and Medicaid Services (CMS) - and/or health record documentation guidelinesAbility to manage priorities and coordinate work - in order to complete duties within required timeframes - and the ability to follow-up on pending issuesMedical Records Technician (Coder-Outpatient) - GS-6 ExperienceOne year of creditable experience equivalent to the next lower grade levelDemonstrated Knowledge - Skills - and AbilitiesIn 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 outpatient coding and evaluate the adequacy of the documentationAbility 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 codesThis includes the ability to take appropriate actions if health record contents are not complete - accurate - timely - and/or reliableAbility to apply laws and regulations on the confidentiality of health information (e.g. - Privacy Act - Freedom of Information Act - and Health Insurance Portability and Accountability Act (HIPAA))Ability to accurately apply the ICD CM - procedure coding system (PCS) Official Conventions and Guidelines for Coding and Reporting - and CPT guidelines to coding scenariosvComprehensive knowledge of current classification systems - such as ICD CM - CPT - and HCPCS - and skill in applying said classifications to outpatient episodes of care - and/or inpatient professional services based on health record documentationMedical Records Technician (Coder-Outpatient) - GS-7 ExperienceOne year of creditable experience equivalent to the next lower grade levelDemonstrated Knowledge - Skills - and AbilitiesIn addition to the experience above - the candidate must demonstrate all of the following KSAs: Skill in applying current coding classifications to a variety of specialty care areas for outpatient episodes of care and/or inpatient professional services to accurately reflect service and care provided based on documentation in the health recordAbility to communicate with clinical staff for specific coding and documentation issues - such as recording diagnoses and procedures - ensuring the correct sequencing of diagnoses and/or procedures - and verifying the relationship between health record documentation and coder assignmentAbility to research and solve coding and documentation related issuesSkill in reviewing and correcting system or processing errors and ensuring all assigned work is completeMedical Records Technician (Coder-Outpatient) - GS-8 ExperienceOne year of creditable experience equivalent to the next lower grade levelDemonstrated Knowledge - Skills - and AbilitiesIn 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 documentationThis includes the ability to read and understand the content of the health record - the terminology - the significance of the findings - and the disease process/pathophysiology of the patientAbility to accurately perform the full scope of outpatient coding - including ambulatory surgical cases - diagnostic studies and procedures - and outpatient encounters - and/or inpatient professional fee services codingSkill 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 guidelinesPreferred Experience: For Internal Applicants: 1 year VHA outpatient codingReference: 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 in the range of GS-4 to GS-8. Physical Requirements: In accordance with VA Handbook 5019 - Employee Occupational Health Service.DutiesTotal Rewards of a Allied Health Professional Applies knowledge of medical record content - terminology - anatomy - physiology - disease processes - and official coding guidelines to assign basic and routine outpatient or inpatient professional service codesSelects and assigns codes from current versions of ICD - CPT - and/or HCPCSLearns to select diagnosis - operation - or procedure codes based on accepted coding practices - guidelines - conventions - and policies with instruction from a senior coder or supervisorReviews record documentation to abstract required medical - surgical - ancillary - demographic - social - and administrative data - developing an understanding of the organization and structure of an electronic patient record under guidanceRefers coding and documentation questions from providers to a senior coder or supervisor for resolution or guidanceUtilizes the facility's computer system and software applications to code - abstract - record - and transmit data to the national VA database in Austinreviews identified data errors with a senior coder or supervisor and makes corrections as directedUses a variety of computer applications - including Outlook - Excel - Word - and Access - and develops proficiency with health record applications (VistA and CPRS) and the encoder product suitePerforms other duties as assigned depending on grade levelWork Schedule: Monday - Friday - 7:00am - 3:30pmRecruitment Incentive (Sign-on Bonus): Not AuthorizedPermanent Change of Station (Relocation Assistance): Not AuthorizedPay: Competitive salary and regular salary increasesPaid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave - 13 days of sick leave - 11 paid Federal holidays per year) Parental Leave: After 12 months of employment - up to 12 weeks of paid parental leave in connection with the birth - adoption - or foster care placement of a childChild Care Subsidy: After 60 days of employment - full time employees with a total family income below $144 -000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: Remote 100% Outside of Area(Temporary - Pending Approval) Virtual: This is not a virtual positionFunctional Statement #: 56560F - 56561F - 56562F - 56563F - 55932FPermanent Change of Station (PCS): Not Authorized.