Med Rec Tech (Med Coder Inpatient and Outpatient)

This position is in the Health Information Management Service (HIMS) at the VA Western New York Health Care System (VAWNYHCS). MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings. GS-4 Applies knowledge of medical record content, medical terminology, anatomy & physiology, diseases processes, and official coding guidelines to assign codes to the most basic and routine outpatient and inpatient services. Selects and assigns codes from the current versions of the International Classification of Diseases (ICD) Clinical Modification (CM) and Procedure Coding System (PCS) for inpatient facility MS-DRG coding, and Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS) for inpatient professional coding and outpatient coding. Incumbent with instruction from a senior coder or supervisor learns to select diagnosis, operation, or procedure codes based on the accepted coding practices, guidelines, conventions and policy. GS-5 Establishes the primary and secondary diagnosis and procedure codes for billable outpatient encounters for one specialty or subspecialty following applicable regulations, instructions, and requirements for allowable reimbursement. Links the appropriate diagnosis to the procedure and/or determines level of E/M service provided. Uses basic knowledge of the CPT and HCPCS coding systems for Third Party Insurance cost recovery Codes less complex Operating Room procedures reported in the Surgical Package of the VistA hospital system Updates ICD diagnosis and procedure codes for the quarterly inpatient and Contract Nursing Home census for assigned inpatient admissions; Applies ICD and CPT coding systems and guidelines and selects proper codes using the current code set and the encoder product suite Incumbent updates any assigned billable long stay (30+ days) inpatient admissions to reflect all patient conditions and care up for monthly billing. GS-6 Assigns codes to documented patient care encounters (inpatient and outpatient) for one or more specialty and subspecialty health care services provided by the VAMC Incumbent has knowledge of medical terminology, anatomy & physiology, diseases, treatments, diagnostic tests, and medications to ensure proper code selection. Incumbent selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties. Incumbent monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Uses skill and knowledge of the organization and structure of the patient health record to capture and justify code assignment. Incumbent at the direction of the supervisor assists in orienting and instructing new personnel and/or students from affiliated health information or medical record technology programs. GS-7 Receives minimal monitoring. MRTs (Coder) perform a combination of inpatient and outpatient coding duties Selects and assigns codes from current versions of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. Incumbent adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding. Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. Incumbent expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record. GS-8 Incumbent is at the journey level for this assignment. MRTs (Coder) at this level perform the full scope of inpatient and outpatient coding duties. MRTs (Coder) select and assign codes from current versions of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. Directly consults with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. Independently plans and executes tasks related to medical record coding and documentation. Incumbent expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record. Work Schedule: Monday - Friday 7:00am - 3:30pm Functional Statement #: PD11347F Financial Disclosure Report: Not required