Medical Records Tech (Coder-Inpatint)

Assignments/duties for each grade level are listed below but may not contain all duties:GS-4: Employees at this level serve as entry level MRTs (Coder) and receive close guidance from more experienced MRTs (Coder). Select and assign codes from current versions of ICD CM and the PCS, and/or, CPT and HCPCS classification systems for inpatient facility and/or professional services. They review record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, and query clinical staff, as appropriate, with close guidance from higher level MRTs (Coder). They also use various computer applications to abstract records, assign codes, and record and transmit data. They ensure audit findings have been corrected and refiled.GS-5: Employees at this grade level serve as developmental level 1 MRTs (Coder) and receive guidance from more experienced MRTs (Coder) for more complex coding procedures. 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. They review record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, and query clinical staff, as appropriate, with guidance from higher level MRTs (Coder). They utilize various computer applications to abstract records, assign codes, and record and transmit data. They also ensure audit findings have been corrected and refiled.GS-6: Employees at this grade level serve in developmental level 2 positions as MRTs (Coder) and receive intermittent monitoring. 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. They review record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, and query clinical staff, as appropriate, with limited guidance from higher level MRTs (Coder). They use various computer applications to abstract records, assign codes, and record and transmit data. They also ensure audit findings have been corrected and refiled.GS-7: Employees at this grade level serve as developmental level 3 MRTs (Coder) and receive minimal monitoring. 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. They review and record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, with minimal guidance from higher level MRTs (Coder). They 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 review provider health record documentation to ensure that it supports the 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 use various computer applications to abstract records, assign codes, and record and transmit data. They ensure audit findings have been corrected and refiled.GS-8: This is the journey level for this assignment. 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. Inpatient 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. Work Schedule: 8:00am-4:30p Monday-Friday Telework: Available Virtual: This is not a virtual position. Functional Statement #: 0000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized