Summary
The Medical Records Technician (MRT) Coder is responsible for performing a quality review of patient care documents and assigning codes specific to the type of care provided. For this assignment, Inpatient MRTs (Coders) select and assign codes from current versions of ICD-CM, PCS, and/or CPT and HCPCS classification systems for the full scope of inpatient facility and/or professional services.
Responsibilities
The duties below are for the GS-0675-08, Journey Level. FUNCTIONS OR SCOPES OF PRACTICE INCLUDE BUT ARE NOT LIMITED TO: Utilize various computer applications to abstract records and assign codes to documented patient care records. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD codes for: Diagnosis Complications/major complications Comorbid/major comorbid conditions Surgery And procedures for accurate assignment of diagnosis-related groups (DRG), and/or assigning PCS/HCPCS codes for inpatient facility and/or professional services. They code all complicated and complex disease processes, patient injuries, and all procedures in a wide range of inpatient settings and specialties. Has in-depth knowledge of: Medical terminology Anatomy & physiology Diseases Treatments Diagnostic tests And medications to ensure proper code selection. Selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties. Coding systems include: Current versions of the International Classification of Diseases (ICD) Procedure Coding System (PCS) 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 Evaluation and Management code to ensure ethical, accurate, and complete coding. Adheres to the coding guidelines specific to the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs. Maintains current knowledge of regulatory and policy requirements affecting coded information. Independently reviews health record documentation to abstract all required: Medical Surgical Ancillary Demographic, social, and administrative data and queries clinical staff, as appropriate. Patient health records may be paper or electronic. Independently assesses: Basic documentation requirements Coding requirements Accepted nomenclature and proper sequencing to obtain correct DRG Supports medical necessity Resolves encoder edits and ensures codes accurately reflect services rendered Ensures provider documentation supports the diagnoses and procedures coded. Directly consults with clinical staff to resolve issues related to conflicting or questionable clinical documentation. Utilizes the facility computer system and software applications to: Code Abstract Record and transmit data to the national VA database in Austin Corrects any identified data errors Inconsistencies or audit findings in a timely manner to ensure acceptance in the national VA database within established timelines. Research references to resolve any questionable code errors; contacts a senior coder or supervisor when needed. 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 health record applications (VistA and CPRS) as well as the encoder product suite Ensures current versions of all software applications are loaded and functional after any updates or changes. 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. Other Duties as assigned. Work Schedule: M-F 8:00 am - 4:30 pm or as determined by the supervisor. Compressed/Flexible: This may be authorized at the supervisor's discretion. Telework: This is a Remote position. Virtual: This is not a virtual position. Functional Statement #: 11975F, 11976F, 11977F, 11978F, 11979F
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. 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. 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. Loss of Credential: Following initial certification, credentials must be maintained through rigorous continuing education, ensuring the highest level of competency for employers and consumers. An employee in this occupation who fails to maintain the required certification must be removed from the occupation, which may result in termination of employment. Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service. English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). 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-Inpatient): GS-4: Experience or Education: None beyond basic requirements. Assignment: Employees at this level serve as entry-level MRTs (Coder) and receive close guidance from more experienced MRTs (Coder). Inpatient MRTs (Coder) select and assign codes from current versions of ICD-CM and the PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services. They review record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data, and query clinical staff, as appropriate, with close guidance from higher-level MRTs (Coder). They also use various computer applications to abstract records, assign 11 codes, and record and transmit data. They ensure audit findings have been corrected and refiled. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit. GS-5: Experience: One year of creditable experience equivalent to the next lower grade level; OR Education: Successful completion of a bachelor'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 management or a related degree with a minimum of 24 semester hours in health information management or technology. 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 and PCS Official Conventions and Guidelines for Coding and Reporting Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient records 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-6: Experience: One year of creditable experience equivalent to the next lower grade level. 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 and PCS Official Conventions and Guidelines for Coding and Reporting to various coding scenarios Comprehensive knowledge of current classification systems, such as ICD Clinical Modification (CM) and PCS, CPT, and HCPCS, and skill in applying said classifications to inpatient records based on health record documentation Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators to obtain correct Medicare Severity Diagnosis Related Group (MS-DRG). GS-7: Experience: One year of creditable experience equivalent to the next lower grade level 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 inpatient specialty care areas 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, the correct sequencing of diagnoses and/or procedures, and the relationship between health record documentation and code 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 Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators, to obtain correct MS-DRG. GS-8: Experience: One year of creditable experience equivalent to the next lower grade level 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 inpatient 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 comments, and the disease process/pathophysiology of the patient Ability to accurately perform the full scope of inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services 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. 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. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-04 to GS-08.
Requirements
You must be a U.S. Citizen to apply for this job. To be considered for this position, you must complete all required steps in the process. In addition to the application and questionnaire, this position requires an online assessment. The online assessment measures critical general competencies required to perform the 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 (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Must pass a pre-employment physical examination. 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 may 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 interest. In 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.
Education
Experience and Education: Experience: One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, structure and format of 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., Medical terminology, anatomy and physiology, medical coding, and introduction to health records); OR, Completion of an AHIMA-approved coding program, or other intensive coding training program of approximately one year or more that included courses in anatomy, 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 qualify 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 unpaid employment equivalent to an MRT (Coder). 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/.