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. Major duties include: Reviews and analyzes clinical medical record documentation for all specialties from CPRS and/or VistA Imaging to determine the reason for the episode, conditions addressed and all procedures performed. Specialties include but are not limited to Neurosurgery, Vascular, Orthopedics, Gastroenterology, Cardiology, Pulmonary, Psychiatry, and Primary Care/Medicine. Selects and assigns codes from the current version of one or more coding systems appropriate for the type of care provided. Current clinical classification systems include ICD-10-CM, CPT, and HCPCS. Sequences the codes appropriately. Assigns modifiers to CPT/HCPCS codes as appropriate. Reviews and analyzes clinical medical record and determines the primary and secondary diagnoses and procedure codes for billable outpatient encounters. Codes all billable outpatient encounters identified. Links the appropriate diagnoses to the procedures. May assist with the following duties if needed: Surgical coding: Reviews and analyzes clinical medical record documentation to accurately capture the reason for the surgery, the surgery performed, and any additional diagnoses or procedures related to the surgery for all procedures in the Surgical Package of VistA. A Assigns appropriate codes for all surgeries and cardiac catheterizations. Assigns codes for Anesthesia and Pathology encounters for all billable surgical cases. Links the appropriate diagnoses to the procedures. Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding. Guidelines include the Official ICD-10 Guidelines for Coding and Reporting, the VHA Handbook for Coding Guidelines, VHA Resident Supervision Guidelines, and the Veterans Equitable Resource Allocation (VERA) program. Maintains current knowledge of regulatory and policy requirements affecting coded information. Ensures resident supervision guidelines are met when applicable. Reviews record documentation to abstract other required data, i.e. injury dates, referring providers, etc. Enters information into appropriate software package. Reviews all coding edits returned in encoder product and revises coding as appropriate. Reviews coverage determination issues regarding medical necessity of specific procedures and diagnostic tests if applicable. Ensures all documentation is present, accurate, complete and in an appropriate format. Ensures that documentation meets Joint Commission and VA requirements. Identifies problems in documentation and forwards to supervisor as necessary. Reviews documentation regarding conditions that have been adjudicated as a service connection (SC) condition or for special treatment authorities related to exposures or experiences and forwards to Utilization Review as appropriate. Communicates and interacts appropriately with a variety of staff from other areas/services (i.e. billing, utilization review, other coders, medical record specialists, scanning technicians, providers, etc.), for multiple reasons. Follows appropriate channels and communication methods outlined, (i.e., e-mail, spreadsheets, etc.). Work Schedule: 7:00 AM - 1530 PM, Monday- Friday 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 #: 000000 Relocation/Recruitment Incentives: Not Authorized