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Role Description

This position is located in the Health Information Management (HIM) section at the Roseburg VA Medical Center. 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 alpha­numeric codes for each diagnosis and procedure.

Responsibilities

• The Medical Records Technician (MRT) 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.
• Selects and assigns codes from current versions of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records.
• Inpatient duties consist of:
  • Performance of a comprehensive review of documentation within the health record to assign ICD-10-CM and ICD-10-PCS codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of DRGs.
• Outpatient duties consist of:
  • Performance of a comprehensive review of documentation within the health record to accurately assign ICD-10-CM codes for diagnosis and complications, and CPT/HCPCS codes for surgeries, procedures, evaluation and management services, and inpatient professional services.

Functions

• Assigns codes to documented patient care encounters (inpatient and 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, and the principles and practices of health services.
• Selects and assigns codes from the current version of several coding systems including ICD, CPT, and/or HCPCS.
• Adheres to accepted coding practices, guidelines, and conventions to ensure ethical, accurate, and complete coding.
• Monitors ever-changing regulatory and policy requirements affecting coded information.
• Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data.
• Assists facility staff with documentation requirements to accurately reflect the patient care provided.
• Directly consults with professional staff for clarification of conflicting or ambiguous clinical data.

Although these positions currently allow for 100% remote work, they may fall under the Presidential Memorandum titled "Return to In-Person Work."

Work Schedule

• Monday - Friday, 8:00am-4:30pm

Telework

• Remote, 100% telework

Virtual

• This is not a virtual position.

Functional Statement #

• 000000

Relocation/Recruitment Incentives

• Not Authorized

Permanent Change of Station (PCS)

• Not Authorized

Financial Disclosure Report

• Not required

Qualifications

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• Experience: One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health records.
• 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.
• 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.
• Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.

Requirements

• Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either:
  • Apprentice/Associate Level Certification through AHIMA or AAPC.
  • Mastery Level Certification through AHIMA or AAPC.
  • Clinical Documentation Improvement Certification through AHIMA or ACDIS.
• English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).

Benefits

• Preferred at least one year of outpatient coding experience.
• A coding certification is required of one- CPC, CCS, RHIT, or RHIA through AAPC or AHIMA.

Physical Requirements

• Physical aspects associated with work required of this assignment are typical for the occupation.
• Exceptions: A pre-placement examination is required for any occupation or assignment that requires the operation of a government-owned or -leased motor vehicle.