Summary The Medical Record Technician/Coder is a staff position located under the Health Information Management Section of the Medical Administration Service. This position is responsible for maintaining the quality of patient records, assigning of appropriate International Classification of Diseases Clinical Modification (ICD), Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes, and various other duties as assigned. Responsibilities Duties May Include But Are Not Limited To: Timely, accurate and complete capture of required abstracted data from each inpatient and ambulatory care episode of treatment; Code all inpatient stays (facility and professional fees), all write-in diagnoses and procedures for outpatient encounters and laboratory, radiology, surgical and outpatient encounters that are billed to insurance companies; Manually code from the medical record documentation and enter into the appropriate software packages; Timely and accurate coding purpose of visit (diagnoses) including identifying the primary and secondary diagnoses to the most specific code available, services provided (procedures and/or Evaluation and Management level of care), practitioner, and other case mix data for all ambulatory and inpatient encounters; Maintains a control system to ensure comprehensive submission of all codes for the care provided into the Patient Care Encounter (PCE), Automated Information Capture System (AICS), Patient Treatment File (PTF), Appointment Management, Surgery Package and other applicable programs in VISTA; Use of judgment to adapt and interpret data to meet the data collection requirements accurately and within established time constraints; Abstracting the diagnoses, procedures performed level of patient evaluation, drugs injected etc, for all inpatient stays; Work closely with members of the health care team to perform the coding activities with highest possible degree of accuracy; Reviews the patient record to ensure all conditions for which care was given have been documented by the physician in the proper sequence of importance, and all operations and procedures have been described appropriately and are related to clinical diagnosis recorded; Provides technical advice to the professional staff relative to the best method of recording diagnoses and operations to assure maximum reimbursement potential; Assists professional staff in diagnostic/procedural sequencing; Completes Patient Treatment File (PTF) in Quadramed and Vista by abstracting information, including clinical and demographic information, from the record; Responsible for retrospective coding as well as concurrent coding as necessary; Codes diagnoses, operations and procedures (inpatient and outpatient), which requires knowledge in a variety of coding systems, using the International Classification of Diseases (ICD), Current Procedural Terminology (CPT) and HCPCS Level II Code Book (HCPCS) ensuring completeness and conformance to accepted VA directives, JC requirements, ICD coding conventions and guidelines for optimal Diagnostic Related Group (DRG) assignment; Codes information from the medial records of patients to generate a clinical care patient care database for the Medical Center; Reviews and screens the entire medical record to abstract medical, surgical, laboratory, pharmaceutical, demographic, social and administrative data from the medical record in a timely manner; Participates in regular meetings with the objective of solving problems, brainstorming, educating physicians and others as to the coding policies and procedures of the facility, as well as promoting consistency of data collected; Takes the initiative in one-on-one provider training to improve medical record documentation for the episodes of care provided; Assists physician, ancillary, administrative personnel and other clinical staff and ward clerks with concurrent documentation requirements in compliance with coding guidelines; retrieving patient health care data from various sources such as consolidated health records, Computerized Patient Record System (CPRS), diagnostic, therapeutic indices or clinical logs for research, planning, budgeting and marketing projects; Stays alert to repeat written-in diagnoses/procedures on the same clinic form and notifies the supervisor for corrective action; Gathers information for time studies or quality assessment reports; Performs quantitative/qualitative analysis of outpatient/inpatient medical records to identify areas of the medical record, which contain incomplete, inaccurate or inconsistent documentation; Maintains confidentiality of all records and documents regarding patients; Performs other related record reviews and coding as requested and assigned by the lead or supervisor. Work Schedule: Monday - Friday, 7:30am-4:00pm or 8:00am-4:30pm Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Requirements Conditions of Employment 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. 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. Qualifications 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: United States Citizenship: 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) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). Experience or Education: 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, 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 (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; OR, 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: 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 (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. 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: Medical Records Technician (Coder-Outpatient), GS-08: Experience: One year of creditable experience equivalent to the next lower grade level including: reviewing record documentation to abstract all required medical and administrative data with minimal guidance from higher level MRTs (Coder); reviewing and abstracting clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes; reviewing provider health record documentation to ensure that it supports the diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature; and use of various computer applications to abstract records, assign codes, and record and transmit data. Demonstrated Knowledge, Skills, and Abilities (KSAs): 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. Preferred Experience: Certified through AHIMA or AAPC (CCS, CCS-P, RHIT, RHIA, CPC, COC, CIC) Inpatient and Outpatient Coding Experience Ability to abstract information from health records Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS-08. Physical Requirements: The work is sedentary. Some work may require movement between offices, hospitals, warehouses, and similar areas for meetings and to conduct work. Work may also require walking/standing, in conjunctions with travel to and attendance at meetings and/or conferences away from the work site. Incumbent may carry and lift light items weighing less than 15 pounds. Education IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education. NOTE: If your school has changed names, or is no longer in existence, you must provide this information in your application. Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/. Additional Information Receiving Service Credit or Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience. This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed. During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions. This job opportunity announcement may be used to fill additional vacancies. This position is in the Excepted Service and does not confer competitive status. VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority. Pursuant to VHA Directive 1193.01, VHA health care personnel (HCP) are required to be fully vaccinated against COVID-19 subject to such accommodations as required by law (i.e., medical, religious or pregnancy). VHA HCPs do not include remote workers who only infrequently enter VHA locations. If selected, you will be required to be fully vaccinated against COVID-19 and submit documentation of proof of vaccination before your start date. The agency will provide additional information regarding what information or documentation will be needed and how you can request a legally required accommodation from this requirement using the reasonable accommodation process. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement. Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.