(1) Creditable Experience
(a) Knowledge of Current Medical Record Technology. To be creditable, the experience must have required the use of knowledge, skills, abilities, and other characteristics (also referred to as core competencies) associated with current health information or medical record technology and/or cancer registry practice.
(b) Quality of Experience. Experience is only creditable if it is either directly related to the position to be filled or in a related field. Qualifying experience must also be at a level comparable to medical record technology experience at the next lower grade level.
(c) Part-Time Experience. Part-time experience as a professional medical record technician is credited according to its relationship to a full-time workweek. For example, a medical record technician would receive 1 week of full-time credit for each 2 weeks of half-time work.
(d) Specialized Areas for Medical Record Technicians
Medical Coders analyze and abstract medical record data and assign codes using clinical classification systems. Medical coding requires independent judgment based on medical record documentation and personal coding knowledge and skill. Certification is offered by AHIMA as a Certified Coding Associate (CCA), Certified Coding Specialist (CCS), Certified Coding Specialist-Physician-based (CCS-P), or Registered Health Information Technician (RHIT). Certification is offered by the American Academy of Professional Coders (AAPC) as a Certified Professional Coder Apprentice (CPC-A), Certified Professional Coder-Hospital Apprentice (CPC-H-A), Certified Professional Coder (CPC) or Certified Professional Coder-Hospital (CPC-H) and is highly desired at the higher grade levels.
Grade Determinations. In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates.
Grade and salary to be determined by the Medical Records Technician Board.
(a) Experience or Education. None beyond basic requirements.
(b) Demonstrated Knowledge, Skills, and Abilities
1. Basic knowledge of medical terminology;
2. Basic knowledge of disease processes and human anatomy;
3. Basic knowledge of medical record/health information guidelines, techniques, and procedures;
4. Knowledge of the medical and legal significance of medical records.
(c) Assignment. Employees at this level serve in entry level MRT career development positions in any area of medical records. It is expected that they receive guidance from more experienced staff members for more complex issues, and require daily direct supervision.
(a) Experience. In addition to the basic requirements, at least 1 year of experience at the next lower grade level and must fully meet the KSAs at that level. In addition, the candidate must demonstrate the following KSAs:
(b) Education. Successful completion of a baccalaureate degree from an accredited college or university with a major field of study in medical record technology/health information technology or a related degree with courses related to medical record technology sufficient to evidence the core competencies identified.
(c) Demonstrated Knowledge, Skills, and Abilities
1. Ability to apply knowledge of medical terminology, human anatomy/pathophysiology, and disease processes sufficient to appropriately file, locate, and disclose health information;
2. Ability to correctly apply a practical knowledge of laws and regulations related to the confidentiality of health information and the release of information from medical records;
3. Knowledge of the internal organization of medical records and medical record references and procedures as appropriate to the position.
4. Ability to use health information software appropriate to the position, such as the electronic patient record, record tracking systems, chart deficiency systems, coding and abstracting systems, release of information systems, document scanning technology, electronic spreadsheets, transcription systems, encoder products, electronic encounter forms, database software, etc.
(d) Assignments. Employees at this grade level serve in developmental positions as MRTs in any of the identified specialized areas and receive guidance from more experienced staff members for more complex medical records and/or coding procedures.
(a) Experience. One year of experience comparable to the next lower level and must fully meet the KSAs at that level. In addition, the candidate must demonstrate the following KSAs:
(b) Demonstrated Knowledge, Skills and Abilities
1. Ability to apply knowledge of medical terminology, human anatomy/pathophysiology, and disease processes to fully understand the content of a patient record;
2. Ability to navigate efficiently through the paper and electronic medical record to find needed information;
3. Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity and ability to use judgment in completing assignments with incomplete or inadequate guidelines;
4. If assigned to medical record analysis, ability to judge whether medical records contain sufficient information for regulatory requirements; are acceptable as legal documents; are adequate for continuity of patient care; and support education and research needs. This includes the ability to take appropriate actions if medical record contents are not adequate; accurate, timely, and/or reliable;
5. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, Health Insurance Portability and Accountability Act (HIPAA);
6. If assigned to a tumor registry position, ability to apply guidelines and standards for the maintenance of an approved tumor registry; and
7. If assigned to a medical coding position, comprehensive knowledge of classification systems, such as current versions of International Classification of Diseases (ICD), Current Procedural Technology (CPT), the Systematized Nomenclature of Medicine (SNOMED) or Healthcare Common Procedure Coding System (HCPCS), and skill in applying coding knowledge.
(c) Assignments. Employees at this level typically work in any specialty area of medical record/health information. In some instances, they may be assigned lead or supervisory positions when the highest level of non-supervisory MRT work is at a lower level. They receive little guidance from more experienced staff members.
(a) Experience. One year of experience comparable to the next lower grade level and must fully meet the KSAs at that level including those for tumor registry or coder assignments if applicable. In addition, the candidate must demonstrate the following KSAs:
(b) Assignments. Employees at this level will be assigned to a specific area of medical record/health information (tumor registry, medical coding, or medical records). They may be in lead or supervisory positions, as appropriate to the assignment.
Medical Record Technician Coding Positions. Medical coding assignments at this grade level represent the advanced developmental level leading to the full performance level. It is expected that the medical coder will do more than validate code assignments made by clinical staff, but will have the skill to make independent judgment in selection of codes based on medical documentation and personal coding knowledge and skill. Reviewing codes selected by physicians/ health care providers or reviewing entries on an encounter form or superbill is not considered comprehensive coding and, without the demonstration of additional skills, is not acceptable to achieve this level. Since coding rules are specific to individual classification systems, knowledge of coding systems other than the one utilized in the position for which the individual is being boarded does not automatically meet the requirements of the position. Generally, to receive credit for experience, the coder should have performed the type of coding specified as a significant portion of duties on a regular and recurring basis, and provide evidence of the core competencies identified.
(c) Demonstrated Knowledge, Skills and Abilities
(1) Knowledge of classification systems, such as current versions of ICD, CPT, SNOMED or HCPCS, and skill in applying coding knowledge to a wide range of specialty areas;
(2) Knowledge of Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as well as Medicare/Centers for Medicare & Medicaid Services (CMS) and/or VHA medical record documentation requirements;
(3) Ability to communicate with clinical staff on coding and documentation issues such as recording inpatient and outpatient diagnoses and procedures, the use of encounter forms, the correct sequencing of diagnoses/ procedures, and/or the relationship between health care documentation and code assignment;
(4) Ability to research and solve complex questions related to coding and documentation, such as adequate health information documentation, coding, billing, resident supervision, etc.; and
(5) Skill in reviewing and correcting system or processing errors, reviewing transmission reports, and ensuring all assigned episodes are complete and accurate as appropriate to the duties assigned,
(a) Experience. One year of experience that equipped you with the particular knowledge, skills, and abilities to perform the duties of this position successfully that is equivalent to at least the GS-7 level.
(b) Assignments. Employees at this grade level will be assigned to a specific area of medical record/health information, e.g., tumor registry, medical coding, or medical records. They may be in lead or supervisory positions, as appropriate to the assignment. Core competencies for the different assignments are listed with the assignment.
Medical Record Technician (Medical Coder) Positions. This is considered to be the full performance level for this assignment. Certification at this grade level is highly desired. In addition, the candidate must demonstrate the following KSAs:
a. Demonstrated Knowledge, Skills, and Abilities
(1) Ability to analyze the medical 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 medical record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient;
(2) Skill in reviewing medical record documentation and assigning current versions of the classification systems required in the current position, such as ICD and CPT; and
(3) Advanced knowledge of the full scope of coding and abstracting including inpatient discharges, surgical cases, 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, plastic surgery, spinal cord injury, blind rehabilitation, anesthesia, acute and long term psychiatry including addiction treatment, hospice, ambulatory surgery, and other types of care.
IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE.
VA Handbook 5005/15, Part II, Appendix G35 Medical Record Technician Qualification Standard GS-675 at: http://www.va.gov/ohrm/joblistings/VAQualStds.doc (also available in the local Human Resources Office)
APPLICANTS PLEASE NOTE: Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications. Applicants must, therefore, only report attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education. Applicants can verify accreditation at the following website: http://www.ed.gov/admins/finaid/accred/index.html. All education claimed by applicants will be verified by the appointing agency accordingly. *** If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. ***
When applying for Federal Jobs, eligible Veterans should claim preference on their application or résumé. Applicants claiming preference based on service-connected disability, or based on being the spouse or mother of a disabled or deceased Veteran, must complete an SF 15, Application for 10-Point Veteran Preference. Veterans who are still in the service may be granted tentative preference on the basis of information contained in their applications, but they must produce a DD Form 214 or other proof prior to appointment to document entitlement to preference. For more information on Veterans' Preference, please visit http://www.fedshirevets.gov/job/veterans.aspx.
HOW YOU WILL BE EVALUATED:
Your application, résumé and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment. You may also be evaluated based upon the question responses you provide during a structured interview. In responding to structured interview questions you should be sure to cite specific examples of experience, explain exactly what you did, and the outcome.