Vacancy Identification Number (VIN): 10715343.Learn more about this agency
This is an open continuous vacancy announcement. Applicants will first be referred 15 calendar days after the opening date and periodically throughout the announcement period. Final application disposition will be completed once all positions have been filled or the announcement reaches the end of the open period stated in the announcement.
Please read this announcement in its entirety before beginning the application process to ensure you submit all the required documents. All documents requiring signature must be signed and dated prior to submission in order to be considered complete.
These are the required documents for this position. See Required Document section for additional information before applying.
- Certification MRT(Coder)
- Application for Associated Health Occupations, VA Form 10/2850c
This job opportunity announcement (JOA) will be used to fill two (2) full-time and permanent Medical Records Technician (Coder-Inpatient) vacancies at the Lexington, KY Veteran Affairs Medical Center (VAMC).
This position is located in the Health Information Management (HIM) section at the Lexington, KY VA Health Care System. 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. These coding practitioners analyze and abstract patients' health records and assign 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). MRTs (Coder) may also provide education related to coding and documentation.
This is the journey level for this assignment. Inpatient MRTs (Coder) select and assign codes from current versions of ICD-10-CM, ICD-10-PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services. In-patient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of diagnosis related groups (DRG), and/or assigning CPT/HCPCS codes for inpatient professional services. They independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes. They code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of inpatient settings and specialties. They directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. They must abstract, assign, and sequence codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. They review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature. They query clinical staff with documentation requirements to support the coding process. They also enter and correct information that has been rejected, when necessary. They correct any identified data errors or inconsistencies. They 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: Monday - Friday, Tour of duty flexible between the hours of 6:00 am and 6:00 pm. (Tour of duty will be fixed 8 hours.)
Financial Disclosure Report: Not required
- United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
- Physical Requirements. See VA Directive and Handbook 5019, Employee Occupational Health Service.
- English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).
- Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:
- (1) Apprentice/Associate Level Certification through AHIMA or AAPC.
- (2) Mastery Level Certification through AHIMA or AAPC.
- (3) Clinical Documentation Improvement Certification through AHIMA or ACDIS.
Job family (Series)
This job originated on www.usajobs.gov. For the full announcement and to apply, visit www.usajobs.gov/GetJob/ViewDetails/560065600. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.