Medical Record Technician ( Inpatient Coder)

These coding practitioners analyze and abstract patients health records and assign alpha-numeric codes for each diagnosis and procedure. To perform this task they 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.

The duties may include but are not limited to the following:

• Assigns codes to documented patient care encounters (inpatient Coder) covering the full range of health care services provided by the VAMC.
• Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD) Current Procedural Terminology (CPT) 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 or Evaluation and Management code to ensure ethical accurate and complete coding.
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
• Performs a comprehensive review of the patient health 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.
• Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the 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.
• Uses a variety of computer 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.
• 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 health record.

Work Schedule: 7:30am-4:00pm Monday - Friday
Virtual: Remote 100% Outside of Area
Functional Statement #: 10599
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized

• 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. Acceptable form(s) of identification will be required to complete pre-employment requirements ( Effective May 7 2025 drivers licenses or state-issued dentification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).

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.
• Experience and Education: 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 (2) Education. An associates 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 (3) 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 (4) 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 4 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: (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:GS-4 None beyond basic requirements.GS-5 One year of creditable experience equivalent to the next lower grade level; OR Education. Successful completion of a bachelors 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 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;
• Ability to navigate through and abstract pertinent information from health records;
• Knowledge of the ICD CM PCS Official Conventions and Guidelines for Coding and Reporting and CPT guidelines;
• 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;
• 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 One year of creditable experience equivalent to the next lower grade 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; 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;
• Ability to apply laws and regulations on the confidentiality of health information;
• Ability to accurately apply the ICD CM PCS Official Conventions and Guidelines for Coding and Reporting and CPT Guidelines to various coding scenarios;
• Comprehensive knowledge of current classification systems and skill in applying classifications to both inpatient and outpatient records based on health record documentation.
• Knowledge of complication or comorbidity/major complication or comorbidity and POA indicators to obtain correct MS-DRG.

GS-7 One year of creditable experience equivalent to the next lower grade 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 and outpatient 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 inpatient and outpatient diagnoses and procedures the correct sequencing of diagnoses and/or procedures and the relationship between health record documentation and code assignment; 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 One year of creditable experience equivalent to the next lower grade 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 accurately perform the full scope of outpatient coding including ambulatory surgical cases diagnostic studies and procedures and outpatient encounters and inpatient facility 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.

Reference: VA Handbook 5005/122 PART II APPENDIX G57. For more information on this qualification standard please visit full performance level of this vacancy is actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-8.

Physical Requirements: Sedentary involving little physical effort.