Medical Records Technician (Coder)

The Medical Records Technician (Coder-Inpatient/Outpatient) is located in the Health Information Management (HIM) section at the Clement J. Zablocki VA Medical Center. Medical Records Technicians (Coder-Inpatient/Outpatient) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure. To perform this task, they must possess expertise in International Classification of Disease(ICD), Current Procedural Terminology(CPT) and the Healthcare Common Procedure Coding System (HCPCS). Duties Include but are not limited to: Select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient/outpatient facility and/or professional services. Code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of Inpatient/Outpatient settings and specialties. 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. 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/outpatient professional services. 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. Ensure audit findings have been corrected and refiled. Use various computer applications to abstract records, assign codes, and record and transmit data. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit. Directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. Work Schedule: Monday - Friday 8:00am - 4:30pm Compressed/Flexible: Not authorized. Telework: Available Functional Statement #: 10482F, 10483F, 10484F, 10485F, 10486F Relocation/Recruitment Incentives: Not authorized. Permanent Change of Station (PCS): Not authorized. PCS Appraised Value Offer (AVO): Not authorized.