Summary
This position is located in the Health Information Management (HIM) section at the Hershel Woody Williams VA Medical Center. MRTs (Coder) 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.
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Duties
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The
Medical Records Technician (Coder - Inpatient/Outpatient) assigns 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.
Major Duties include, but are not limited to:
- Selects and assigns codes from current versions of ICD-10-CM, ICD-10-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-10-CM and ICD-10-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-10-CM codes for diagnosis and complications, and CPT/HCPCS codes for surgeries, procedures, evaluation and management services, and inpatient professional services.
- Independently reviews and abstracts clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes.
- Codes all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of ambulatory/inpatient settings and specialties.
- Directly consults with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record.
- Abstracts, assigns, and sequences codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered.
- Reviews provider health record documentation to ensure that it supports diagnostic and procedural codes assigned, and is consistent with required medical coding nomenclature.
- Queries clinical staff with documentation requirements to support the coding process.
- Enters and corrects information that has been rejected, when necessary.
- Corrects any identified data errors or inconsistencies. They also ensure audit findings have been corrected and refiled. They use various computer applications to abstract records, assign codes, and record and transmit data.
Work Schedule: FT, Monday-Friday, 8am - 4:30pm
Recruitment/Relocation Incentives (Sign-on Bonus): Not authorized.
Permanent Change of Station (Relocation Assistance): Not authorized.
Pay: Competitive salary and regular salary increases. When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade).
Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year)
Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience.
Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child.
Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66
Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA
Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)
Telework: Available, Regularly Teleworks 6+ Days a pay period.
Virtual: This is not a virtual position.
Permanent Change of Station (PCS): Not authorized
Requirements
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Conditions of employment
- Selective Service Registration is required for males born after 12/31/1959.
- 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.
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. 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.
BASIC REQUIREMENTS:
United States Citizenship: You must be a U.S. Citizen to apply for this job. Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
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).
*****Certification/Credentials***** 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. CCA, CPC-A, or COC-A
- Mastery Level Certification through AHIMA or AAPC. CCS, CCS-P, RHIT, RHIA, CPC, COC, CIC
- Clinical Documentation Improvement Certification through AHIMA or ACDIS. CDIP or CCDS
Loss of Credential. 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.
Qualifications
BASIC REQUIREMENTS (continued)
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. DOE with a major field of study in HIT/HIM, or a related degree with a minimum of 12 semester hours in HIT/HIM (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. DOE 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. *See Education Section for more information.
GRADE REQUIREMENTS:
Medical Records Technician (Coder-Outpatient and Inpatient), GS-4
- Experience or Education. None beyond basic requirements.
- Assignment. Employees at this level serve as entry level MRTs (Coder) and receive close supervision from more experienced MRTs (Coder).
Medical Records Technician (Coder-Outpatient and Inpatient), 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.
- Assignment. Employees at this grade level serve as developmental level 1 MRTs (Coder) and receive guidance from more experienced MRTs (Coder) for more complex coding procedures.
- 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, 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.
Medical Records Technician (Coder-Outpatient and Inpatient), GS-6
- Experience. One year of creditable experience equivalent to the next lower grade level.
- Assignment. Employees at this grade level serve in developmental level 2 positions as MRTs (Coder) and receive intermittent monitoring.
- 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, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT Guidelines to various coding scenarios.
- Comprehensive knowledge of current classification systems, such as ICD CM, PCS, CPT, HCPCS, 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 (CC/MCC) and POA indicators to obtain correct MS-DRG.
Medical Records Technician (Coder-Outpatient and Inpatient), GS-7
- Experience. One year of creditable experience equivalent to the next lower grade level.
- Assignment. Employees at this grade level serve as developmental level 3 MRTs (Coder) and receive minimal monitoring.
- 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 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.
- 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.
Medical Records Technician (Coder-Outpatient and Inpatient), GS-8
- Experience. One year of cr