Medical Records Technician (Coder-Outpatient and Inpatient)

The technician is assigned to the Health Information Management Section, coding/analysis unit, VAMC Memphis, TN. Inpatient/Outpatient MRT Coders 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, 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. They review provider health record documentation to ensure that it supports 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 also enter and correct information that has been rejected, when necessary. They correct any identified data errors or inconsistencies. They ensure audit findings have been corrected and refiled. They use various computer applications to abstract records, assign codes, and record and transmit data. MRT Coders may be assigned to a single facility or region, such as a consolidated coding unit. Work Schedule: Monday - Friday 7:30 a.m. - 4:00 p.m. Compressed/Flexible: Negotiable after hire. Position is remote work eligible and is exempted from return to office requirements. Remote exempted positions are reviewed annually and do not imply permanent remote work status. Telework: ADHOC Functional Statement #: 71148-F