Medical Record Technician (Coder - Inpatient)

Duties include, but are not limited to: Select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services. Comprehensive review of inpatient documentation within the health record to assign ICD codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures using ICD-PCS for accurate assignment of diagnosis-related groups (DRG), and/or assigning CPT/HCPCS codes for inpatient professional services. Independently review and abstract clinical data from the inpatient record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes. Code all complicated and complex medical/specialty disease processes, patient injuries, and all medical procedures in a wide range of inpatient settings and specialties. Consult directly with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. Abstract, assign, and sequence codes into the encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. Query clinical staff with documentation requirements to support the coding process. Enter and correct information that has been rejected; correct any identified data errors or inconsistencies. Maintain a 95% coding accuracy on quality audits. Ensure audit findings have been corrected and refiled. Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs, at the direction of the supervisor, on unit operations, coding, abstracting, and use of an electronic health record. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs. Adheres to accepted coding practices, guidelines, and conventions when choosing the most appropriate diagnosis, operation, procedure, or ancillary code to ensure ethical, accurate, and complete coding. Also applies codes based on guidelines specific to certain diagnoses, methods, and other criteria 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. Use various required computer applications to abstract records, assign codes, and record and transmit data. Work Schedule: Monday - Friday, 8:00am - 4:30pm PST Telework: Not Available Virtual: This position is Remote 100% Functional Statement #: 07110F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized