Medical Records Technician (Coder - Outpatient and Inpatient) analyzes and abstracts patients' health records and assign alpha-numeric codes for each diagnosis and procedure. To perform this task, he/she must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS).
This position is in the Health Information Management Service (HIMS) at the VA Western New York Health Care System (VAWNYHCS). MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings.
GS-4 Applies knowledge of medical record content, medical terminology, anatomy & physiology, diseases processes, and official coding guidelines to assign codes to the most basic and routine outpatient and inpatient services.
Selects and assigns codes from the current versions of the International Classification of Diseases (ICD) Clinical Modification (CM) and Procedure Coding System (PCS) for inpatient facility MS-DRG coding, and Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS) for inpatient professional coding and outpatient coding.
Incumbent with instruction from a senior coder or supervisor learns to select diagnosis, operation, or procedure codes based on the accepted coding practices, guidelines, conventions and policy. GS-5 Establishes the primary and secondary diagnosis and procedure codes for billable outpatient encounters for one specialty or subspecialty following applicable regulations, instructions, and requirements for allowable reimbursement.
Links the appropriate diagnosis to the procedure and/or determines level of E/M service provided.
Uses basic knowledge of the CPT and HCPCS coding systems for Third Party Insurance cost recovery Codes less complex Operating Room procedures reported in the Surgical Package of the VistA hospital system Updates ICD diagnosis and procedure codes for the quarterly inpatient and Contract Nursing Home census for assigned inpatient admissions; Applies ICD and CPT coding systems and guidelines and selects proper codes using the current code set and the encoder product suite Incumbent updates any assigned billable long stay (30+ days) inpatient admissions to reflect all patient conditions and care up for monthly billing.
GS-6 Assigns codes to documented patient care encounters (inpatient and outpatient) for one or more specialty and subspecialty health care services provided by the VAMC Incumbent has knowledge of medical terminology, anatomy & physiology, diseases, treatments, diagnostic tests, and medications to ensure proper code selection. Incumbent selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties.
Incumbent monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Uses skill and knowledge of the organization and structure of the patient health record to capture and justify code assignment. Incumbent at the direction of the supervisor assists in orienting and instructing new personnel and/or students from affiliated health information or medical record technology programs.
GS-7 Receives minimal monitoring. MRTs (Coder) perform a combination of inpatient and outpatient coding duties Selects and assigns codes from current versions of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records.
Incumbent adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding. Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.
Incumbent expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record. GS-8 Incumbent is at the journey level for this assignment. MRTs (Coder) at this level perform the full scope of inpatient and outpatient coding duties.
MRTs (Coder) select and assign codes from current versions of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. Directly consults with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. Independently plans and executes tasks related to medical record coding and documentation.
Incumbent expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record. Work Schedule: Monday - Friday 7:00am - 3:30pm ** This is a remote position** Functional Statement #: 21Q25-A
Basic Requirements: Experience And Education. 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, 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, 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, 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: Six months of creditable experience that indicates knowledge of medical 4 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.
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). 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). 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: Only education or degrees recognized by the U.S.
Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education.
For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $41519 – $82840/yr.
Yes, this position is fully remote.
This position requires a Other security clearance.
Applications close on 2026-09-18.
This position is open under the 'Public' hiring path.
Source: USAJOBS.gov — U.S. Federal Government
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