Medical Records Technician (Coder InOut)

The Medical Record Technician (Coder-Outpatient and Inpatient) analyzes and abstracts patients health records and assigns alpha-numeric codes for each diagnosis and procedure. To perform this task they must possess expertise in International Classification of Diseases (ICD) Current Procedural Terminology (CPT) and the Healthcare Common Procedure Coding System (HCPCS). MRT (Coder) may also provide education related to coding and documentation. Major duties include but not limited to:

• Assigns codes to documented patient care encounters (inpatient and outpatient) covering the full range of health care services provided by the VAMC.
• 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.
• 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. Patient health records may be paper or electronic.
• 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.
• Expertly 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.
• All other duties assigned

Work Schedule: Monday-Friday; 7:00am-3:30pm
Recruitment Incentive (Sign-on Bonus): Not Authorized
Permanent Change of Station (Relocation Assistance): Not Authorized
Paid 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)
Selected applicants may qualify for credit toward annual leave accrual based on prior work experience or military service experience.
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 child.
Child Care Subsidy: After 60 days of employment full time employees with a total family income below $144000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66.
Retirement: 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: Not Available
Virtual: This is not a virtual position.
Functional Statement #: 60594-F 60592-F60593-F605589-F 60590-F
Permanent Change of Station (PCS): Not Authorized

• 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.
• Subject to background/security investigation.
• Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements ( Effective May 7 2025 drivers licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
• Complete all application requirements detailed in the Required Documents section of this announcement.

As a condition of employment for accepting this position you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public determining if your employment advances the public interest we may consider:

• your performance and conduct;
• the needs and interests of the agency;
• whether your continued employment would advance organizational goals of the agency or the Government; and
• whether your continued employment would advance the efficiency of the Federal service.

Upon completion of your trial period your employment will be terminated unless you receive certification in writing that your continued employment advances the public interest.

• Basic Requirements:
  • United States Citizenship: Be a citizen of the United States. 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- Outpatient and Inpatient ) must be proficient in spoken and written English.
  • 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.

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 Continued:

• 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
• 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.
• 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 below:

• Apprentice/Associate Level Certification through AHIMA or AAPC.
• Mastery Level Certification through AHIMA or AAPC.
• 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. Proof of your certification must be included in your application package.

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).

Grade Determinations:
GS-04 Entry Level Experience or Education: none beyond the basic education or experience.
GS-05 Developmental Level Experience: One year of creditable experience equivalent to the next lower grade level OR
Education: I have a bachelors 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. Must provide transcripts with your application AND
Demonstrated 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 various office 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.
• Ability to manage priorities and coordinate work to complete duties within required timeframes and the ability to follow-up on pending issues.

GS-06 Experience: One year of creditable experience equivalent to the next lower grade level 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.
• 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.
• Comprehensive knowledge of current classification systems such as ICD CM PCS CPT HCPCS and skill in applying classifications to both inpatient and outpatient records based on health record documentation.
• Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG.

GS-07 Experience. One year of creditable experience equivalent to the next lower grade level AND
Demonstrated Knowledge Skills and Abilities. In 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 record.
• Ability 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 assignment.
• 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.

GS-08 Experience. One year of creditable experience equivalent to the next lower grade level 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 findings 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/or inpatient professional fee services coding.
• 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.