Medical Records Technician (Medical Coder)
Department of Veterans Affairs - New Orleans, LA

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Vacancy Identification Number: 839293

Functional Statement is available for review in Human Resources Management. This position is assigned to Business Operations Office of the SLVHCS, New Orleans, LA.

TOUR OF DUTY: Monday thru Friday, 7:30 AM to 4:00 PM
    KEY REQUIREMENTS
  • Subject to background/suitability investigation

DUTIES: Assigns codes to documented patient care encounters (inpatient and outpatient) for the specialty and subspecialty health care services provided by the Southeast Louisiana Healthcare System (SLVHCS). Assigns codes to documented patient care provided on a Fee Basis for services provided to the veterans of SLVHCS. Has significant knowledge of medical terminology, anatomy & physiology, disease processes, treatments, diagnostic tests, medications, procedures and accepted health care services to ensure proper code selection. Selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties. The coding systems include the International Classification of Diseases-Clinical Modification (ICD-9-CM), Diagnostic and Statistical Manual of Mental Disorders (DSM), Current Procedural Terminology (CPT), and 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, also adheres to the coding guidelines specific to the Veterans Equitable Resources Allocation (VERA) program that categories 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 SLVHCS and institutes timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs. Perform a comprehensive review of the patient 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. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data and reports incorrect documentation or codes in the electronic 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 and independently researches references to resolve any questionable code errors; contacts supervisor as appropriate. Uses 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 medical record applications (VISTA and CPRS) as well as the code selection software (e.g., QuadraMed nCoder+ Suite) and 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 medical 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.

QUALIFICATIONS REQUIRED: QUALIFICATION REQUIREMENTS: VA Handbook 5005/15, Part II, Appendix G35

BASIC REQUIRMENTS

a. Citizenship . Citizen of the United States.

b. Educationor Experience

(1) Experience . Two years of experience that demonstrates the applicant's ability to perform the work, or provides familiarity with the work. Six months of the required 2 years of experience must have provided the knowledge, skills, abilities, and other characteristics (KSAs) needed to perform MRT work.

OR,

(2) Education. Successful completion of an associate's degree with a major field of study in medical record technology/health information technology which was accredited by the American Health Information Management Association (AHIMA) at the time the program was completed.

OR,

(3) Experience/Education Combination. Equivalent combinations of experience and education are qualifying. The following educational/training substitutions are appropriate in this provision for combining education and experience:

(a) Successful completion of an associate's degree in a field of study other than medical records/health information will substitute for 18 months of the required experience.

(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 1 year of experience

(c) Successful completion of a post-high school course of study in medical record technology, which includes courses in anatomy, physiology, and medical record techniques and procedures, may substitute on a month-for-month basis for up to 1 year of experience.

(d) Successful completion of post-high school courses for medical administrative personnel, obtained in a closely supervised training program given by the Armed Forces, may be substituted for experience on a month-for-month basis for up to 6 months provided the training program included courses in anatomy, physiology, and medical record techniques and procedures.

GRADE REQUIREMENTS

GS-7

(a) Experience. One year of experience comparable to the next lower grade level and must fully meet the KSAs at that level including those for tumor registry or coder assignments if applicable. In addition, the candidate must demonstrate the following KSAs:

1. Medical Record Technician Coding Positions. Medical coding assignments at this grade level represent the advanced developmental level leading to the full performance level. It is expected that the medical coder will do more than validate code assignments made by clinical staff, but will have the skill to make independent judgment in selection of codes based on medical documentation and personal coding knowledge and skill. Reviewing codes selected by physicians/ health care providers or reviewing entries on an encounter form or superbill is not considered comprehensive coding and, without the demonstration of additional skills, is not acceptable to achieve this level. Since coding rules are specific to individual classification systems, knowledge of coding systems other than the one utilized in the position for which the individual is being boarded does not automatically meet the requirements of the position. Generally, to receive credit for experience, the coder should have performed the type of coding specified as a significant portion of duties on a regular and recurring basis, and provide evidence of the core competencies identified.

a. Demonstrated Knowledge, Skills, and Abilities

1. Knowledge of classification systems, such as current versions of ICD, CPT, SNOMED or HCPCS, and skill in applying coding knowledge to a wide range of specialty areas;

2. Knowledge of Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as well as Medicare/Centers for Medicare & Medicaid Services (CMS) and/or VHA medical record documentation requirements;

3. Ability to communicate with clinical staff on coding and documentation issues such as recording inpatient and outpatient diagnoses and procedures, the use of encounter forms, the correct sequencing of diagnoses/ procedures, and/or the relationship between health care documentation and code assignment;

4. Ability to research and solve complex questions related to coding and documentation, such as adequate health information documentation, coding, billing, resident supervision, etc.; and

5. Skill in reviewing and correcting system or processing errors, reviewing transmission reports, and ensuring all assigned episodes are complete and accurate as appropriate to the duties assigned.

GS-8

(a) Experience. One year of experience comparable to the next lower grade level for the appropriate assignment area and must fully meet the KSAs at that level.

1. Medical Record Technician (Medical Coder) Positions. This is considered to be the full performance level for this assignment. Certification at this grade level is highly desired. In addition, the candidate must demonstrate the following KSAs:

a. Demonstrated Knowledge, Skills, and Abilities

1. Ability to analyze the medical 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 medical record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient;

2. Skill in reviewing medical record documentation and assigning current versions of the classification systems required in the current position, such as ICD and CPT; and

3. Advanced knowledge of the full scope of coding and abstracting including inpatient discharges, surgical cases, diagnostic studies and procedures, outpatient encounters, and inpatient professional fees for a highly diversified range of specialties and subspecialties, such as orthopedics, neurosurgery, cardiology, gastroenterology, plastic surgery, spinal cord injury, blind rehabilitation, anesthesia, acute and long term psychiatry including addiction treatment, hospice, ambulatory surgery, and other types of care.

Physical Requirements. See VA Directive and Handbook 5019

ENGLISH LANGUAGE PROFICIENCY: Proficiency in the English language is required for direct patient care positions. (P.L. 95-201).

PHYSICAL REQUIREMENTS : Pre-employment Physical Required

PROBATIONARY PERIOD : This position requires completion of a 1-years probationary period, if not already served.

DRUG-FREE WORKPLACE: The VA has established a Drug-Free Federal Workplace Policy. All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with the VA for a period of six months. This policy extends to random testing for the use of illegal drugs by employees who occupy testing designated positions defined as sensitive in Section 7(d) of Executive Order 12564.

HOW YOU WILL BE EVALUATED: You will be evaluated on the detailed information submitted in your resume that reflects your knowledge, skills, and ability neccessary to meet the qualification of this position.

BENEFITS: Working for the Department of Veterans Affairs offers a comprehensive benefits package that includes, in part, paid vacation, sick leave, holidays, life insurance, health benefits, and participation in the Federal Employees Retirement System. In addition to the traditional "dollars and cents" benefits, we offer a range of benefits to help balance work and life. For more information please visit us at the http://www.va.gov/jobs/job_benefits/benefits.asp

OTHER INFORMATION: PBI Interviews: Any interviews that may be conducted will utilize the Performance Based Interviewing process (PBIs). For more information on the performance based interview process, see www.va.gov/pbi

Eligibles: Agency Career Transition Assistance Plan (CTAP) and Interagency Career Transition Assistance Program (ICTAP). Federal Employees seeking CTAP/ICTAP eligibility must submit proof that they meet the requirements of 5 CFR 330.605(a) CTAP and 5 CFR 330.704 for ICTAP. This includes a copy of the agency notice, a copy of their most recent Performance Rating and copy of their most recent SF50 noting current position, grade level, and duty location. Please annotate your application to reflect that you are applying as a CTAP or ICTAP eligible.

Equal Employment Opportunity: The United States Government does not discriminate in employment on the basis of race, color, religion, sex, national origin, political affiliation, sexual orientation, marital status, disability, age, membership in an employee organization or other non-merit factors.

Reasonable Accommodation: Federal agencies provide reasonable accommodations to applicants with disabilities. If you need accommodation for any part of the application process, contact the hiring agency. The decision on granting reasonable accommodation will be on a case-by-case basis.

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The United States Department of Veterans Affairs (VA) is a government-run military veteran benefit system with Cabinet-level status. It is...