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The incumbent serves as a Medical Record Technician (Coder) in the Health Information Sections (HIMS) of the Business Operations Service (BOS) Service Line. The incumbent is responsible for performing a quality review of patient care documents and assigning codes specific for the type of care provided.
Major duties include, but are not limited to:
- Assigns codes to documented patient care encounters (inpatient and outpatient) covering the full range of health care services provided by the VAMC.
- Selects and assigns codes from the current version of several coding systems to include the International Classification of Diseases-Clinical Modification (ICD-10-CM), Diagnostic and Statistical Manual of Mental Disorders (DSM), 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.
- Performs a comprehensive review of the patient record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.
- Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided.
- Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database.
- Uses a variety of computer based applications in day to day activities and duties.
- Conducts re-reviews of codes abstracted for patient encounters (inpatient and outpatient) identified by the Veteran's Equitable Resource Allocation (VERA) committee to determine if based on the documentation the specific VERA coding requirements were followed; corrects coding as needed to ensure proper patient classification in the VERA program.
- Codes inpatient professional fee services for identified inpatient admissions in support of the Medical Care Cost Recovery (MCCR) program.
Telework: This position may be authorized for telework/ remote work. Determination will be made by the hiring manager for highly qualified applicants.
Functional Statement Title/#: Medical Records Technician (Coder Inpatient and Outpatient), GS-675-4/5/6/7/8
Physical Requirements: Work is primarily sedentary. Employee generally sits to do the work. There may be some walking, standing, or carrying of light items such as patient charts/ records, manuals or files. Employee also extracts information from computer systems which requires ability to utilize keyboards or other similar devices.
Qualification References: VA Handbook 5005/122, PART II, APPENDIX G57 dated December 10, 2019.
This job originated on www.usajobs.gov. For the full announcement and to apply, visit www.usajobs.gov/GetJob/ViewDetails/589668900. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.