ICD CM, PCS

classification systems for inpatient facility and/or professional services. Inpatient duties consist of the performance and review of documentation within the health record to assign ICD codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for assignment of diagnosis related groups (DRG),and/or assigning

CPT/HCPCS

codes.

Qualifications:

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, and/or reliable. 3. Ability to accurately apply the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting to various coding scenarios. 4. 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). 5. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG. Medical records Technician Coder Outpatient/Inpatient GS-7 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. 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. 2. 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. 3. Ability to research and solve coding and documentation related issues. 4. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.. Medical Records Technician Coder Outpatient and Inpatient GS-8 Experience. One year of creditable experience equivalent to the next lower grade level, AND Demonstrated Knowledge, Skills & Abilities. In addition to the experience above, 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. 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. 2. 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. 3. 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 completing assignments using incomplete or inadequate guidelines. 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