Medical Records Technician (CODER AUDITOR) INPATIENTOUTPATIENT

Duties included but are not limited to:

Applies comprehensive 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.

Reviews assigned 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 (E/M) code to ensure ethical accurate and complete coding.

Applies guidelines specific to certain diagnoses procedures and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.

Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.

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. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data.

Expertly searches the patient record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient health record.

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

Reviews analyzes and reports performance monitors for PTF PCE VERA and Non-VA Medical Care (purchased care) coding.

Audit accurate and complete assignment of ICD-10-CM and ICD-10-PCS codes MS-DRG POA status and discharge disposition values for inpatient health records. Audit accurate and complete assignment of ICD-10-CM CPT and HCPCS codes including appropriate E/M assignment and modifier usage for outpatient health records. Audit function includes evaluation of clinical documentation to support optimal code assignment.

Reviews coding and assist coders in improving coding accuracy; provides coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulations; initiates various reports and analyze data.

Facilitates improved overall quality completeness and accuracy of coded data. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education to all members of the patient care team on an ongoing basis.

Responsible for performing audits of coded data developing criteria collecting data graphing and analyzing results creating reports and communicating in writing and/or in person to appropriate leadership and groups.

Collaboratively works with coding staff and clinical staff to provide support and education on coding issues. Provides training and education to coding and clinical staff. Researches complex coding issues and participates in process improvements related to coding.

Assists in the development of guidelines for data quality consistency and monitoring for compliance to improve the quality for clinical financial and administrative data to ensure that all coded data is fully documented and supported. Such efforts are conducted to ensure the accuracy of billing denials and prevention against fraud and abuse and to optimize the medical centers authorized reimbursement for utilization of resources provided.

As a technical expert in health information coding matters provides advice and guidance on documentation and coding requirements. Maintains current knowledge to ensure that coding and documentation meets regulatory guidelines and audit standards and results in appropriate data capture and reimbursement.

Work Schedule: Monday - Friday 8:00am - 4:30pm
Telework: May be authorized.
Virtual: This is not a virtual position
Functional Statement #: PD000000
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
Financial Disclosure Report: Not required

• You must be a U.S. Citizen to apply for this job.
• Selective Service Registration is required for males born after 12/31/1959.
• Must be proficient in written and spoken English.
• You may be required to serve a probationary period.
• Subject to background/security investigation.
• Selected applicants will be required to complete an online onboarding process.
• Training-Service Agreement and Mobility Agreement required.
• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
• Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) - See Additional Information below for details.

Basic Requirements:

a. Citizenship.

Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3 section A paragraph 3g this part.)

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 associates 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-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.

English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. 7403(f)

Grade Determinations:

Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient)) GS-9

(a) Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient);

OR

An associates degree or higher and three years of experience in clinical documentation improvement (candidates must also have successfully completed coursework in medical terminology anatomy and physiology medical coding and introduction to health records);

OR

Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement;

OR

Clinical experience such as Registered Nurse (RN) Medical Doctor (M.D.) or Doctor of Osteopathy (DO) and one year of experience in clinical documentation improvement.

(b) Certification. Employees at this level must have either a mastery level certification or a Clinical Documentation Improvement Certification.

(c) In addition to the experience above Must demonstrated Knowledge Skills and Abilities listed below:


i. Knowledge of coding and documentation concepts guidelines and clinical terminology.
ii. Knowledge of anatomy and physiology pathophysiology and pharmacology to interpret and analyze all information in a patients health record including laboratory and other test results to identify opportunities for more precise and/or complete documentation in the health record.
iii. Ability to collect and analyze data and present results in various formats which may include presenting reports to various organizational levels.
iv. Ability to establish and maintain strong verbal and written communication with providers.
v. Knowledge of regulations that define healthcare documentation requirements including The Joint Commission CMS and VA guidelines.
vi. Extensive knowledge of coding rules and regulations to include current clinical classification systems such as ICDCM and PCS CPT and HCPCS. They must also possess knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) MS-DRG structure and POA indicators.
vii. Knowledge of severity of illness risk of mortality complexity of care for inpatients and CPT Evaluation and Management (E/M) criteria to ensure the correct selection of E/M codes that match patient type setting of service and level of E/M service provided for outpatients.
viii. Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development. The training sessions may be technical in nature or may focus on teaching techniques for the improvement of clinical documentation issues.

References: VA Handbook 5005/122 December 10 2019 PART II APPENDIX G57

Physical Requirements: This position is primarily sedentary.