Supevisory Medical Records Technician (Coder)
Major Duties Includes:
Applies current Uniform Hospital Discharge Data Set definitions for code assignment. Selects and assigns International Classification of Disease (ICD-10), Current Procedural Terminology (CPT)and Healthcare Common Procedures Coding System (HCPCS) codes. Maintains continuous monitors to ensure completion of all Patient Treatment File (PTF) transactions, Patient Care Encounters (PCE), monthly closeout, quarterly and annual patient census. Applies codes appropriate for the Veterans Equitable Resource Allocation(VERA) for both inpatient and outpatient medical records workload capture. Communicates and treats customers in a courteous, tactful and respectful manner. Provides the customer with consistent information according to established policies and procedures. Handles conflict and problems in dealing with the customer constructively and appropriately. Assists in documentation improvement of the Veterans Equitable Resource Allocation (VERA) Patient Classification Program. Provides guidance on documentation requirements for accurate patient workload capture and code assignments for determination of vesting status. Makes final determinations on the use and submission of ICD-10-CM, ICD-10- PCS and CPI codes used to record new diagnostic terms, treatments, drugs, procedures, and therapies for which no reference of precedent is available. Confers with members of the medical/professional staff to obtain their clinical input to make final determinations, Determines training needs format, and schedule to conduct courses on both quantitative/qualitative analysis of coding assignment. Monitors and reviews coding assignment by coding personnel, the ranking of diagnoses recorded by medical staff. Develops and conducts ongoing training for clinical staff related to documentation improvement, resident supervision, progress note template usage, encounter form completion, code assignment and provides follow-up training. Extracts and presents pertinent data to appropriate clinical staff and management in both narrative and graphical format on a recurring basis, and presents techniques, procedures and processes for correction of areas of inefficiency. Performs recurrent and retrospective DRG, Compliance and Business Integrity audits. Responsible for determining staffing patterns for the section and reassigning personnel to meet changing conditions. Advises medical staff, management, and others regarding the Joint Commission, Veterans Integrated Service Network (VISN), Veterans Affairs (VA) and appropriate requirements for health records as they relate to coding . procedures and requirements. Develops policies and procedures to comply with new and/or changed agency programs such as Correct Coding Initiatives, Compliance and Business Integrity (CBI), Reasonable Charges, Resident Supervision and others. Participates in various committees, sub-committees, huddles and informal meetings related to Compliance, Utilization Review (UR), Quality Management(QM)/Performance Improvement programs, data validation, revenue and medical records. Serves as the Contracting Officer Representative (COR) for coding and related contracts. Ability to interpret, implement, and apply knowledge of privacy and confidentiality requirements affecting individual patient/protect health information. Additional duties assigned. Work Schedule:
Monday - Friday 08:
00 am - 4:
30 pm. Subject to change based on agency needs. Financial Disclosure Report:
Not required Basic Requirements:
a. Citizenship. Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g, this part.) b. Experience and Education (1) Experience. One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a health records. OR, (2) Education. An associate's degree from an accredited college or university recognized by the U.S. Department of Education with a major field of study in health information technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management (e.g., courses in medical terminology, anatomy and physiology, medical coding, and introduction to health records); OR, (3) Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding. The training program must have led to eligibility for coding certification/certification examination, and the sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor, or comparable international accrediting authority at the time the program was completed; OR, (4) Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable
Experience:
(a) Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, and one year above high school, with a minimum of 6 semester hours of health information technology courses. (b) Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service, under close medical and professional supervision, may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder). c. Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:
(1) Apprentice/Associate Level Certification through AHIMA or AAPC. (2) Mastery Level Certification through AHIMA or AAPC. (3) Clinical Documentation Improvement Certification through AHIMA or ACDIS. NOTE:
Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification. May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria). Grade Determinations GS-10:
Experience. One year of creditable experience equivalent to the next lower grade level. Certification. Employees at this level must have a mastery level certification. Assignment. For all assignments above the journey level, the higher-level duties must consist of significant scope, complexity (difficulty), range of variety, and be performed by the incumbent at least 25% of the time. Supervisory MRTs (Coder) are responsible for supervising coding staff at the facility level. Supervisory MRTs (Coder) must be able to perform all duties of a MRT (Coder). The supervisory coder is responsible for the supervision, administrative management, and direction of coding staff. They are responsible for program management of a coding section/unit to ensure performance monitors are established and met. They perform a full range of supervisory responsibilities, to include evaluating the performance of subordinate staff, approving sick and annual leave requests, identifying educational or training needs, resolving employee complaints, and taking disciplinary actions, when necessary. They inform higher level management of anticipated vacancies or increases in workload. They recommend employees for promotions, reassignments, recognitions, retention or release of probationary employees, or other changes of assigned personnel. They make decisions on the selection of employees for vacant or new positions. They serve as an expert coding resource to ensure accuracy and integrity of all coding. They collaborate with revenue, compliance, and other departments to support coding accuracy that is consistent with the official guidelines for coding and reporting. They resolve claim edits referred to coding management and monitor reports for outstanding services, rejects, or un-coded episodes of care for inpatients and/or outpatients. The supervisory coder ensures claim denials related to coding errors are resolved, and/or daily coding rejects are corrected for accurate billing and data collection. They provide education to clinical and coding staff. They assess current audit findings and evaluate impact to coding and documentation practices. They oversee the reporting of coding and documentation audit results to leadership. They collect and prepare data for studies involving inpatient stays and outpatient encounters for clinical evaluation purposes, prepare and maintain a variety of complex records and daily, monthly, or on demand reports, as requested. The supervisory coder creates and monitors outpatient reports, inpatient case mix reports, top DRGs, and key performance indicators to identify patterns, trends, and variations. They investigate and evaluate potential causes for changes or problems and collaborate with the appropriate staff to effect resolution or explain variances. They participate in the formulation of objectives and strategies utilizing coded data to support goals for patient care, teaching, research, and optimizing management of resources. Supervisory MRTs whose assignments involve two or more MRT specialty areas will be assigned the parenthetical title for the predominant specialty area. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
1. Ability to perform a full range of supervisory duties, to include recommending awards, approving leave, evaluating work, resolving staff issues, and assigning, planning, and coordinating work to ensure duties are completed in an accurate and timely fashion. 2. Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined). 3. Ability to provide or coordinate staff development and training. 4. Leadership and managerial skills, including skill in interpersonal relations and conflict resolution to deal with employees, team leaders, and managers. 5. Ability to collect and analyze data, identify trends, and present results in various formats. References:
VA Handbook 5005/122PART II APPENDIX G57 dated December 12, 2019 The full performance level of this vacancy is GS-10. Physical Requirements:
Light lifting, under 15 pounds; Light carrying, under 15 pounds; Reaching above shoulder; use of fingers; Both hands required; Walking (up 0.50 hours); Standing (up 0.50 hours); Sitting for up to 7 hours per day.
Estimated Salary: $20 to $28 per hour based on qualifications.
Applies current Uniform Hospital Discharge Data Set definitions for code assignment. Selects and assigns International Classification of Disease (ICD-10), Current Procedural Terminology (CPT)and Healthcare Common Procedures Coding System (HCPCS) codes. Maintains continuous monitors to ensure completion of all Patient Treatment File (PTF) transactions, Patient Care Encounters (PCE), monthly closeout, quarterly and annual patient census. Applies codes appropriate for the Veterans Equitable Resource Allocation(VERA) for both inpatient and outpatient medical records workload capture. Communicates and treats customers in a courteous, tactful and respectful manner. Provides the customer with consistent information according to established policies and procedures. Handles conflict and problems in dealing with the customer constructively and appropriately. Assists in documentation improvement of the Veterans Equitable Resource Allocation (VERA) Patient Classification Program. Provides guidance on documentation requirements for accurate patient workload capture and code assignments for determination of vesting status. Makes final determinations on the use and submission of ICD-10-CM, ICD-10- PCS and CPI codes used to record new diagnostic terms, treatments, drugs, procedures, and therapies for which no reference of precedent is available. Confers with members of the medical/professional staff to obtain their clinical input to make final determinations, Determines training needs format, and schedule to conduct courses on both quantitative/qualitative analysis of coding assignment. Monitors and reviews coding assignment by coding personnel, the ranking of diagnoses recorded by medical staff. Develops and conducts ongoing training for clinical staff related to documentation improvement, resident supervision, progress note template usage, encounter form completion, code assignment and provides follow-up training. Extracts and presents pertinent data to appropriate clinical staff and management in both narrative and graphical format on a recurring basis, and presents techniques, procedures and processes for correction of areas of inefficiency. Performs recurrent and retrospective DRG, Compliance and Business Integrity audits. Responsible for determining staffing patterns for the section and reassigning personnel to meet changing conditions. Advises medical staff, management, and others regarding the Joint Commission, Veterans Integrated Service Network (VISN), Veterans Affairs (VA) and appropriate requirements for health records as they relate to coding . procedures and requirements. Develops policies and procedures to comply with new and/or changed agency programs such as Correct Coding Initiatives, Compliance and Business Integrity (CBI), Reasonable Charges, Resident Supervision and others. Participates in various committees, sub-committees, huddles and informal meetings related to Compliance, Utilization Review (UR), Quality Management(QM)/Performance Improvement programs, data validation, revenue and medical records. Serves as the Contracting Officer Representative (COR) for coding and related contracts. Ability to interpret, implement, and apply knowledge of privacy and confidentiality requirements affecting individual patient/protect health information. Additional duties assigned. Work Schedule:
Monday - Friday 08:
00 am - 4:
30 pm. Subject to change based on agency needs. Financial Disclosure Report:
Not required Basic Requirements:
a. Citizenship. Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g, this part.) b. Experience and Education (1) Experience. One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a health records. OR, (2) Education. An associate's degree from an accredited college or university recognized by the U.S. Department of Education with a major field of study in health information technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management (e.g., courses in medical terminology, anatomy and physiology, medical coding, and introduction to health records); OR, (3) Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding. The training program must have led to eligibility for coding certification/certification examination, and the sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor, or comparable international accrediting authority at the time the program was completed; OR, (4) Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable
Experience:
(a) Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, and one year above high school, with a minimum of 6 semester hours of health information technology courses. (b) Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service, under close medical and professional supervision, may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder). c. Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:
(1) Apprentice/Associate Level Certification through AHIMA or AAPC. (2) Mastery Level Certification through AHIMA or AAPC. (3) Clinical Documentation Improvement Certification through AHIMA or ACDIS. NOTE:
Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification. May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria). Grade Determinations GS-10:
Experience. One year of creditable experience equivalent to the next lower grade level. Certification. Employees at this level must have a mastery level certification. Assignment. For all assignments above the journey level, the higher-level duties must consist of significant scope, complexity (difficulty), range of variety, and be performed by the incumbent at least 25% of the time. Supervisory MRTs (Coder) are responsible for supervising coding staff at the facility level. Supervisory MRTs (Coder) must be able to perform all duties of a MRT (Coder). The supervisory coder is responsible for the supervision, administrative management, and direction of coding staff. They are responsible for program management of a coding section/unit to ensure performance monitors are established and met. They perform a full range of supervisory responsibilities, to include evaluating the performance of subordinate staff, approving sick and annual leave requests, identifying educational or training needs, resolving employee complaints, and taking disciplinary actions, when necessary. They inform higher level management of anticipated vacancies or increases in workload. They recommend employees for promotions, reassignments, recognitions, retention or release of probationary employees, or other changes of assigned personnel. They make decisions on the selection of employees for vacant or new positions. They serve as an expert coding resource to ensure accuracy and integrity of all coding. They collaborate with revenue, compliance, and other departments to support coding accuracy that is consistent with the official guidelines for coding and reporting. They resolve claim edits referred to coding management and monitor reports for outstanding services, rejects, or un-coded episodes of care for inpatients and/or outpatients. The supervisory coder ensures claim denials related to coding errors are resolved, and/or daily coding rejects are corrected for accurate billing and data collection. They provide education to clinical and coding staff. They assess current audit findings and evaluate impact to coding and documentation practices. They oversee the reporting of coding and documentation audit results to leadership. They collect and prepare data for studies involving inpatient stays and outpatient encounters for clinical evaluation purposes, prepare and maintain a variety of complex records and daily, monthly, or on demand reports, as requested. The supervisory coder creates and monitors outpatient reports, inpatient case mix reports, top DRGs, and key performance indicators to identify patterns, trends, and variations. They investigate and evaluate potential causes for changes or problems and collaborate with the appropriate staff to effect resolution or explain variances. They participate in the formulation of objectives and strategies utilizing coded data to support goals for patient care, teaching, research, and optimizing management of resources. Supervisory MRTs whose assignments involve two or more MRT specialty areas will be assigned the parenthetical title for the predominant specialty area. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
1. Ability to perform a full range of supervisory duties, to include recommending awards, approving leave, evaluating work, resolving staff issues, and assigning, planning, and coordinating work to ensure duties are completed in an accurate and timely fashion. 2. Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined). 3. Ability to provide or coordinate staff development and training. 4. Leadership and managerial skills, including skill in interpersonal relations and conflict resolution to deal with employees, team leaders, and managers. 5. Ability to collect and analyze data, identify trends, and present results in various formats. References:
VA Handbook 5005/122PART II APPENDIX G57 dated December 12, 2019 The full performance level of this vacancy is GS-10. Physical Requirements:
Light lifting, under 15 pounds; Light carrying, under 15 pounds; Reaching above shoulder; use of fingers; Both hands required; Walking (up 0.50 hours); Standing (up 0.50 hours); Sitting for up to 7 hours per day.
- Department:
0675 Medical Records Technician - Salary Range:
$58,260 to $75,740 per year
Estimated Salary: $20 to $28 per hour based on qualifications.
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