Medical Records Technician (Coder-Outpatient)

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met.

Basic Requirements:
Citizenship: Be a citizen of the United States. Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.

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. Department of Education with a major field of study in health information
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. Department of Education 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. The following educational/training substitutions are appropriate for combining education and creditable experience:

• Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, and one year above high school, with a minimum of 6 semester hours of health information technology courses.
• Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service, under close medical and professional supervision, may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder).

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.

Grandfathering Provision. May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation.

Grade Determination
Medical Records Technician (Coder-Outpatient), GS-8
Experience. One year of creditable experience equivalent to the next lower grade level which includes:

• Skill in applying current coding classifications to a variety of specialty care areas for outpatient episodes of care and/or inpatient professional services 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 diagnoses and procedures, ensuring the correct sequencing of diagnoses and/or procedures, and verifying the relationship between health record documentation and coder 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.

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. This includes the ability to read and understand the content of the health record, the terminology, the significance of the findings, and the disease process/pathophysiology of the patient.
• Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and/or inpatient professional fee services coding.
• Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity, and the ability to use judgment in completing assignments using incomplete or inadequate guidelines.

Preferred Experience: May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation.

References: VA Handbook 5005-122 PART II APPENDIX G57 - Medical Records Technician (Coder) Qualification Standard

The full performance level of this vacancy is GS-8. The actual grade at which an applicant may be selected for this vacancy is GS-8.

Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service.