Medical Records Technician (Coder-Outpatient)

Temporarily eligible for Remote work within 50 miles of a VA Medical Center. May fall under the Presidential Memorandum tiled "Return to In-Person Work" which will require you to go into the office if the exemption is not approved at the next review. Duties may include but are not limited to: MRT GS-04 Assignment. Entry level MRTs (Coder) receive close guidance from more experienced MRTs. Outpatient MRTs select and assign codes from current versions of ICD Clinical Modification (CM), CPT, and HCPCS classification systems. MRTs 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. They use various computer applications to abstract records, assign codes, and record and transmit data. They ensure audit findings have been corrected and refiled. MRT GS-05 Assignment. Developmental level 1 MRTs (Coder) receive guidance from more experienced MRTs for more complex coding procedures. Outpatient MRTs select and assign codes to outpatient episodes of care, and/or inpatient professional services from current versions of ICD CM, CPT, and HCPCS classification systems. 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. MRT GS-06 Assignment. Developmental level 2 positions as MRTs (Coder) receive intermittent monitoring. Outpatient MRTs may perform coding on outpatient episodes of care and/or inpatient professional services. They select and assign codes from current versions of ICD CM, CPT, and HCPCS classification systems. 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. MRT GS-07 Assignment. Developmental level 3 MRTs (Coder) receive minimal monitoring. Outpatient MRTs perform coding on outpatient episodes of care and/or inpatient professional services. They select and assign codes from current versions of ICD CM, CPT, and HCPCS classification systems. They review record documentation to abstract all required 9 medical, surgical, ancillary, demographic, social and administrative data, with minimal guidance from higher level MRTs. 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 also review provider health record documentation to ensure that it supports the diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature. MRTs in this assignment also query clinical staff with documentation requirements to support the coding process. MRT GS-08 Assignment. Outpatient MRTs (Coder) at this level perform the full scope of outpatient coding including ambulatory surgical cases, diagnostic studies and procedures, outpatient encounters, and/or inpatient professional services. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD CM codes for diagnoses, CPT/HCPCS codes for surgeries, procedures and evaluation, and management 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 disease processes, 10 patient injuries, and all procedures in a wide range of ambulatory settings and specialties. They also directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. MRTs must abstract, assign, and sequence codes into encoder software to support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. They also 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 also query clinical staff with documentation requirements to support the coding process. They enter and correct information that has been rejected, when necessary. Work Schedule: Monday to Friday, 8:00am to 4:30pm EST Remote: The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required. The selectees must live within 50 miles of a VA Medical Center (NOTE: This does not include CBOCs). Telework: Not applicable, this is a remote position. Virtual: This is not a virtual position. Functional Statement #: PD13980F, PD13981F, PD13982F, PD13983F, and PD13984F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized