Medical Records Technician (Coder-Outpatient and Inpatient)

Selects and assigns codes from the current version of several coding systems to include ICD, CPT, and/or HCPCS. Assigns codes to documented patient care encounters (inpatient and outpatient) covering the full range of health care services provided by the VAMC. Patient encounters are often complicated and complex requiring extensive coding expertise. Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection. 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. Applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (in inpatient and outpatient settings) 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. Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided. Provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. Ensures provider documentation is complete and supports the diagnoses and procedures coded. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation or codes in the electronic patient health record. Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA databases. Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines. Independently researches references to resolve any questionable code errors, contacts supervisor as appropriate. 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. May be assigned one or more of the following regular or recurring duties: Identifies the principal diagnosis and principal procedure (when applicable) for every inpatient discharge, also identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG). Upon patient admission to the Community Living Center/Nursing Home Care Unit, codes the admission diagnosis for use by unit staff. All diagnoses and procedure codes are selected from the current version of the ICD coding system. Conducts re-reviews of codes abstracted for patient encounters (inpatient and outpatient) identified by the 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. Establishes the primary and secondary diagnosis and procedure codes for outpatient professional and technical fee encounters 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. Understands the nuances of the CPT coding system for Third Party Insurance cost recovery and accurately interprets instructional notations; bundles encounters when appropriate; uses established processes to communicate potential billing issues to Consolidated Patient Account Center (CPAC) staff. Codes all identified surgical procedures; applies ICD and CPT coding guidelines and selects proper codes using the current code set and the encoder product suite; adds Anesthesia and Pathology codes for all billable surgical cases, which may involve creating the encounters. Updates codes for current inpatient and Contract Nursing Home admissions for quarterly census and as directed for billable long stay (30+ days) admissions to reflect all patient conditions and care up to the census date or to the requested billing date. May be required to review and enter coded data from paid Community Care claims using documentation (e.g., hard-copy claims) obtained from non-VA facilities. Work Schedule: 8:00 am-4:30 pm Monday-Friday Telework: Not applicable, this is a remote position Virtual: This is not a virtual position. Functional Statement #: 00000 Relocation/Recruitment Incentives: Not authorized Permanent Change of Station (PCS): Not authorized