Medical Records Technician (Coder-Outpatient and Inpatient)

Veterans Health Administration • Montgomery, AL

4d • Onsite

About The Position

This position is located in the Health Information Management (HIM) section at the Central Alabama Veterans Health Care System (CAVHCS). Medical Records Technicians (Coders) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers. Major duties may include, but are not limited to: applying knowledge of medical record content, medical terminology, anatomy & physiology, disease processes, and official coding guidelines to assign codes to the most basic and routine outpatient and/or inpatient professional services. This role involves selecting and assigning codes from the current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS). The position requires adherence to accepted coding practices, guidelines, and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding, including coding guidelines specific to the Veterans Equitable Resource Allocation. The role also involves monitoring ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC, as timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs. The Medical Records Technician will establish the primary and secondary diagnosis and procedure codes for outpatient encounters following applicable regulations, instructions, and requirements for allowable reimbursement; link the appropriate diagnosis to the procedure and/or determine the level of E/M service provided. Understanding the nuances of the CPT coding system for Third Party Insurance cost recovery and accurately interpreting instructional notations, bundling encounters when appropriate, and identifying non-billable encounters are key responsibilities. HCPCS codes are used per guidelines. The position requires coding all Operating Room procedures reported in the Surgical Package of the VistA hospital system; applying ICD and CPT coding systems and guidelines and selecting proper codes using the current code set and the encoder product suite; ensuring all procedures file to the appropriate Patient Care Encounter (PCE); and adding Anesthesia and Pathology codes to the PCE encounter for all billable surgical cases. Additionally, the role involves coding diagnoses from paper forms for VA registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc.

Requirements

• 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.
• 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.
• 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 will 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.
• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• English Language Proficiency: Must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).
• 1 year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a health records.
• An associate's degree from an accredited college or university recognized by 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.
• Completion of an AHIMA approved coding program, or other intense coding training program of approximately 1year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, & basic CPT coding. Training program must have led to eligibility for coding certification/certification examination, and sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor, or comparable international accrediting authority at time the program was completed.
• Equivalent combinations of creditable experience & education are qualifying for meeting basic requirements.
• 6 months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and health record, and 1year 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 Armed Forces or U.S. Maritime Service, under close medical & professional supervision, may be substituted on a month-for-month basis for up to 6months of experience provided training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires 6 additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder).
• Apprentice/Associate Level Certification through AHIMA or AAPC.
• Mastery Level Certification through AHIMA or AAPC.
• Clinical Documentation Improvement Certification through AHIMA or ACDIS.
• Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding & Reporting, & CPT guidelines.
• Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines.
• Comprehensive knowledge of current classification systems, such as ICD CM, PCS, CPT, HCPCS, and skill in applying classifications to both inpatient & outpatient records based on health record documentation.
• Skill in interpreting & adapting health information guidelines that are not completely applicable to work, or have gaps in specificity, and ability to use judgment in completing assignments using incomplete or inadequate guidelines.

Nice To Haves

• Ability to communicate with clinical staff for specific coding & documentation issues, such as recording inpatient & outpatient diagnoses & procedures, correct sequencing of diagnoses and/or procedures, and relationship between health record documentation & code assignment.
• Ability to research & solve coding & documentation related issues.
• Ability to review & correct system or processing errors & ensuring all assigned work is complete.
• Ability to abstract, assign, & sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), & POA indicators to obtain correct MS-DRG.

Responsibilities

• Applies knowledge of medical record content, medical terminology, anatomy & physiology, diseases processes, and official coding guidelines to assign codes to the most basic and routine outpatient and/or inpatient professional services.
• Selects and assigns codes from the current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
• With instruction from a senior coder or supervisor learns to select diagnosis, operation, or procedure codes based on the accepted coding practices, guidelines, conventions and policy.
• Assigns codes to documented patient care encounters (outpatient professional services); encounters are routine and less complex or for only one specialty or subspecialty.
• Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding.
• Adheres to the coding guidelines specific to the Veterans Equitable Resource Allocation.
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
• Establishes the primary and secondary diagnosis and procedure codes for outpatient encounters following applicable regulations, instructions, and requirements for allowable reimbursement; links the appropriate diagnosis to the procedure and/or determines level of E/M service provided.
• Identifies non-billable encounters.
• Codes all Operating Room procedures reported in the Surgical Package of the VistA hospital system; applies ICD and CPT coding systems and guidelines and selects proper codes using the current code set and the encoder product suite; ensures all procedures file to the appropriate Patient Care Encounter (PCE); adds Anesthesia and Pathology codes to the PCE encounter for all billable surgical cases.
• Codes diagnoses from paper forms for VA registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc.
• 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.
• Ability to apply knowledge of medical terminology, human anatomy/physiology, & disease processes to accurately assign codes to inpatient & outpatient episodes of care based on health record documentation.
• Ability to manage priorities & coordinate work to complete duties within required timeframes, & ability to follow-up on pending issues.
• Ability to analyze health record to identify all pertinent diagnoses & procedures for coding and to evaluate adequacy of 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, & support assigned codes.
• Ability to take appropriate actions if health record contents are not complete, accurate, timely, and/or reliable.
• Ability to apply laws and regulations on confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HIPAA).
• Ability to accurately apply ICD CM, PCS Official Conventions and Guidelines for Coding & Reporting, & CPT Guidelines to various coding scenarios.
• Ability to communicate with clinical staff for specific coding & documentation issues, such as recording inpatient & outpatient diagnoses & procedures, correct sequencing of diagnoses and/or procedures, and relationship between health record documentation & code assignment.
• Ability to research & solve coding & documentation related issues.
• Ability to abstract, assign, & sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), & POA indicators to obtain correct MS-DRG.
• Ability to analyze health record to identify all pertinent diagnoses & procedures for coding & to evaluate adequacy of documentation. This includes ability to read & understand content of health record, terminology, significance of comments, & disease process/pathophysiology of patient.
• Ability to accurately perform full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, & outpatient encounters, & inpatient facility coding, including inpatient discharges, surgical cases, diagnostic studies & procedures, & inpatient professional services.

Benefits

• A career with the U.S. government provides employees with a comprehensive benefits package.
• As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding.
• Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree