Medical Records Technician Coder (Auditor)
Auditor Duties:
Performs weekly or monthly audits of outpatient encounters. Reviews results of external audits and prepares education and/or audit responses. Perform monthly audits related to VHA Directives to include in-house and contract coding audits. EPRP reviews, revenue related/CPAC audits and other coding risk areas identified by Compliance, CPAC, VISN, extremal auditors medical center leadership and HIMs. Researches current guidelines related to inpatient and outpatient services and provides guidance to coding department and clinical staff accordingly. Participates in committees /work groups to provide to provide input as a coding expert related to coding services and identify risk areas to improve clinical documentation and coding accuracy. Produces audit reports, graphs, presentations, to track and trend coding errors and accuracy rates using quantitative and qualitative methods. Works with Lead Coder to identify' training deficiencies and areas or Improvement. Provides feedback to coders to improve accuracy as requested. Provides feedback to providers, including education and training on coding guidelines and corrective measures. Ensures coding assignment and documentation follows VHA Coding guidelines, Joint Commission on Accreditation of healthcare organization (JCAHOO), ICD-IO, CPT/AMA coding conventions, and payer guidelines for optima! reimbursement. Thoroughly reviews the patient's record to ensure that all conditions of care, operations, and procedures are properly documented by the clinician and sequenced in order of importance. Audits new providers as they are newly employed. Performs other related duties as assigned. Demonstrated experience coding auditing. Ability to interpret and apply knowledge of clinical classification systems such as International Classification of Disease (CD), Current Procedural Technology (CPT), (Systematized Nomenclature of Medicine (SNOMED), Healthcare Common Procedure Coding System (HCPCS) and health information systems. Ability to determine and evaluate compliance with the standards of regulatory and accrediting bodies such as Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), the Centers of Medicare and Medicaid Services etc. Ability to provide technical advice and or provide oversight on health information issues, privacy and coding compliance. This includes skill in interpreting and adapting health information management guidelines that are not completely applicable to the work or have gaps in specificity; Ability to extract information generate reports from various databases (e.g. clinical, financial), and analyze data including a consideration of such issues as applicability, validity, reliability and the quality and characteristics of the data source etc. Ability to produce various reports, graphs and PowerPoint presentations. Ability to meet deadlines and reporting times for provider and coding audits. Advance knowledge of full scope of coding and abstracting including inpatient discharges, minor procedures, 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, spinal cord injury, blind rehabilitation, acute and long-term psychiatry including addiction treatment, hospice, ambulatory surgery, and other types of care. Ability to communicate tactfully and effectively, both orally and in writing, to meet program objectives. This may include preparing reports in various formats, presenting data to various organizational levels and providing technical education to medical staff. Reviews, audits, monitor and complete other assignments in specified time frames Work Schedule:
8:
00 am - 4:
30 pm Financial Disclosure Report:
Not required 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:
(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). Experience and 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) TRANSCRIPTS REQUIRED; 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 TRANSCRIPTS REQUIRED; 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. TRANSCRIPTS REQUIRED (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).TRANSCRIPTS REQUIRED Grade Determinations:
To qualify as a Medical Records Technician - Coding Auditor GS-09, you must have one (1) year of creditable experience equivalent to the journey grade level of a MRT (Coder). This experience can include but is not limited to the following:
perform the full scope of inpatient and outpatient coding duties. MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD CM and PCS codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of DRGs. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD CM codes for diagnosis and complications, and CPT/HCPCS codes for surgeries, procedures, evaluation and management services, and inpatient professional services. They independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes. They code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of ambulatory/inpatient settings and specialties. They directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. They abstract, assign, and sequence codes into encoder software to obtain correct diagnosis-related DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. They review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned, and is consistent with required medical coding nomenclature. They query clinical staff with documentation requirements to support the coding process. They enter and correct information that has been rejected, when necessary. They correct any identified data errors or inconsistencies. They also ensure audit findings have been corrected and refiled. Employees at this level must have a mastery level certification. This is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC. To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation. Stand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualifications. Certification titles may change and certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies. However, current mastery level certifications include:
Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC). Documentation of this certification must be provided with your application package. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
1. Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined). 2. Ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner. 3. Ability to review coded data and supporting documentation to identify adherence to applicable standards, coding conventions and guidelines, and documentation requirements. 4. Ability to format and present audit results, identify trends, and provide guidance to improve accuracy. 5. Skill in interpersonal relations and conflict resolution to deal with individuals at all organizational levels. References:
VA Handbook 5005/112 Part II Appendix G57 The full performance level of this vacancy is GS-9. Physical Requirements:
While work is mostly sedentary, there are also demands for some walking and long periods of sitting. The incumbent may be required to answer numerous telephone calls and must have adequate eyesight and hand dexterity to allow for reading and operating a computer terminal. See VA Directive and Handbook 5019.
Estimated Salary: $20 to $28 per hour based on qualifications.
Performs weekly or monthly audits of outpatient encounters. Reviews results of external audits and prepares education and/or audit responses. Perform monthly audits related to VHA Directives to include in-house and contract coding audits. EPRP reviews, revenue related/CPAC audits and other coding risk areas identified by Compliance, CPAC, VISN, extremal auditors medical center leadership and HIMs. Researches current guidelines related to inpatient and outpatient services and provides guidance to coding department and clinical staff accordingly. Participates in committees /work groups to provide to provide input as a coding expert related to coding services and identify risk areas to improve clinical documentation and coding accuracy. Produces audit reports, graphs, presentations, to track and trend coding errors and accuracy rates using quantitative and qualitative methods. Works with Lead Coder to identify' training deficiencies and areas or Improvement. Provides feedback to coders to improve accuracy as requested. Provides feedback to providers, including education and training on coding guidelines and corrective measures. Ensures coding assignment and documentation follows VHA Coding guidelines, Joint Commission on Accreditation of healthcare organization (JCAHOO), ICD-IO, CPT/AMA coding conventions, and payer guidelines for optima! reimbursement. Thoroughly reviews the patient's record to ensure that all conditions of care, operations, and procedures are properly documented by the clinician and sequenced in order of importance. Audits new providers as they are newly employed. Performs other related duties as assigned. Demonstrated experience coding auditing. Ability to interpret and apply knowledge of clinical classification systems such as International Classification of Disease (CD), Current Procedural Technology (CPT), (Systematized Nomenclature of Medicine (SNOMED), Healthcare Common Procedure Coding System (HCPCS) and health information systems. Ability to determine and evaluate compliance with the standards of regulatory and accrediting bodies such as Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), the Centers of Medicare and Medicaid Services etc. Ability to provide technical advice and or provide oversight on health information issues, privacy and coding compliance. This includes skill in interpreting and adapting health information management guidelines that are not completely applicable to the work or have gaps in specificity; Ability to extract information generate reports from various databases (e.g. clinical, financial), and analyze data including a consideration of such issues as applicability, validity, reliability and the quality and characteristics of the data source etc. Ability to produce various reports, graphs and PowerPoint presentations. Ability to meet deadlines and reporting times for provider and coding audits. Advance knowledge of full scope of coding and abstracting including inpatient discharges, minor procedures, 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, spinal cord injury, blind rehabilitation, acute and long-term psychiatry including addiction treatment, hospice, ambulatory surgery, and other types of care. Ability to communicate tactfully and effectively, both orally and in writing, to meet program objectives. This may include preparing reports in various formats, presenting data to various organizational levels and providing technical education to medical staff. Reviews, audits, monitor and complete other assignments in specified time frames Work Schedule:
8:
00 am - 4:
30 pm Financial Disclosure Report:
Not required 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:
(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). Experience and 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) TRANSCRIPTS REQUIRED; 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 TRANSCRIPTS REQUIRED; 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. TRANSCRIPTS REQUIRED (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).TRANSCRIPTS REQUIRED Grade Determinations:
To qualify as a Medical Records Technician - Coding Auditor GS-09, you must have one (1) year of creditable experience equivalent to the journey grade level of a MRT (Coder). This experience can include but is not limited to the following:
perform the full scope of inpatient and outpatient coding duties. MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD CM and PCS codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of DRGs. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD CM codes for diagnosis and complications, and CPT/HCPCS codes for surgeries, procedures, evaluation and management services, and inpatient professional services. They independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes. They code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of ambulatory/inpatient settings and specialties. They directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. They abstract, assign, and sequence codes into encoder software to obtain correct diagnosis-related DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. They review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned, and is consistent with required medical coding nomenclature. They query clinical staff with documentation requirements to support the coding process. They enter and correct information that has been rejected, when necessary. They correct any identified data errors or inconsistencies. They also ensure audit findings have been corrected and refiled. Employees at this level must have a mastery level certification. This is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC. To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation. Stand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualifications. Certification titles may change and certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies. However, current mastery level certifications include:
Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC). Documentation of this certification must be provided with your application package. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
1. Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined). 2. Ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner. 3. Ability to review coded data and supporting documentation to identify adherence to applicable standards, coding conventions and guidelines, and documentation requirements. 4. Ability to format and present audit results, identify trends, and provide guidance to improve accuracy. 5. Skill in interpersonal relations and conflict resolution to deal with individuals at all organizational levels. References:
VA Handbook 5005/112 Part II Appendix G57 The full performance level of this vacancy is GS-9. Physical Requirements:
While work is mostly sedentary, there are also demands for some walking and long periods of sitting. The incumbent may be required to answer numerous telephone calls and must have adequate eyesight and hand dexterity to allow for reading and operating a computer terminal. See VA Directive and Handbook 5019.
- Department:
0675 Medical Records Technician - Salary Range:
$58,092 to $75,521 per year
Estimated Salary: $20 to $28 per hour based on qualifications.
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