This position is located in the Health Administration Services (HAS) section of the VA Texas Valley Coastal Bend Health Care System. The Medical Records Technician (Coder) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided.Learn more about this agency
Duties include but are not limited to:
- Assigns codes to documented patient care encounters (inpatient or outpatient) covering the full range of health care services provided by the VA Medical Center.
- Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection.
- Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
- Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding.
- Applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (in inpatient and outpatient settings)used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.
- Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VA Medical Center.
- Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. Patient health records may be paper or electronic.
- Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.
- Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data.
- Reports incorrect documentation or codes in the electronic patient health record.
- Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines.
Work Schedule: 8:00 am to 4:30 pm, Monday thru Friday
Financial Disclosure Report: Not required
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This job originated on www.usajobs.gov. For the full announcement and to apply, visit www.usajobs.gov/GetJob/ViewDetails/523232100. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.