Job Description

BASIC REQUIREMENTS. 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 AAS 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: (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. Certification. Persons hired or reassigned to MRT Coder positions in the GS-0675 series in VHA must have either 1,2 or 3 below: Apprentice/Associate Level Certification through AHIMA or AAPC. Mastery Level Certification through AHIMA or AAPC. Clinical Documentation Improvement Certification through AHIMA or ACDIS. GRADE DETERMINATIONS AND ASSIGNMENTS. Medical records Technician Coder Outpatient/Inpatient GS-4 Experience or Education- None beyond basic requirements above. Medical records Technician Coder Outpatient/Inpatient GS-5 Experience. One year creditable experience equivalent to the next lower grade level OR Education. Successful completion of a BAS 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. Demonstrated Knowledge Skills & Abilities In addition to the experience, the candidate must demonstrate all of the following KSAs: 1. 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. 2. Ability to navigate through and abstract pertinent information from health records. 3. Knowledge of the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting. 4. . 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. 5. Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines. 6. Ability to manage priorities and coordinate work to complete duties within required timeframes, and the ability to follow-up on pending issues. Medical records Technician Coder-Outpatient/Inpatient GS-6 Experience. One year creditable experience equivalent to the next lower grade level AND Demonstrated Knowledge, Skills & Abilities. In addition to the experience, the candidate must demonstrate all of the following KSAs: 1. Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation. 2. 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,