Medical Records Technician (CDIS) Outpatient
Responsible for reviewing the overall quality and completeness of clinical documentation. Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection. Reviews clinical documentation and provides education to clinical staff on both inpatient and outpatient episodes of care including admissions and discharges, observation, emergency department/urgent care, and clinic visits. Prepare and conduct provider education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding. Provides education to providers on the need for accurate and complete documentation in the health record, appropriate code selection of Evaluation and Management (E/M), Current Procedural Terminology (CPT) and ICD-10 diagnosis codes, and ensuring documentation supports the codes selected to the highest degree of specificity. 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. Reviews VERA input on missed opportunities in provider documentation identified by the VERA coordinator and coordinate provider documentation education with the VERA coordinator. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. 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. Develops and conducts seminars, workshops, short courses, informational briefings, and conferences concerned with health record documentation, educational and functional training requirements to ensure program objectives are met for clinical and Health Information Management (HIM) staff. Facilitates improved overall quality, completeness and accuracy of health record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers and HIM coding staff to ensure clinical documentation and services rendered to patients is complete and accurate. Compiles, reviews, abstracts, analyzes and interprets medical data incidental to a variety of patient care and treatment activities. Work Schedule:
Monday - Friday, 8:
00 AM - 4:
30 PM Financial Disclosure Report:
Not required Basic Requirements:
United States Citizenship:
Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. English Language Proficiency:
Proficient in spoken and written English as required by 38 U.S.C. 7402(d), and 7407(d).
Experience:
Oneyear of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, & 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 & physiology, medical coding, & 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 & physiology, medical terminology, basic ICD diagnostic/procedural, & basic CPT coding. The training program must have led to eligibility for coding certification/certification examination, & 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 & creditable
Experience:
(a) 6 months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, & 1 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 & 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, & health record techniques & procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder). Grade Determination GS-09 Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient); OR, An associate's degree or higher and three years of experience in clinical documentation improvement (candidates must also have successfully completed coursework in medical terminology, anatomy and physiology, medical coding, and introduction to health records); OR, Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement; OR, Clinical experience, such as Registered Nurse (RN), Medical Doctor (M.D.), or Doctor of Osteopathy (DO), and one year of experience in clinical documentation improvement. Certification. Employees at this level must have either a mastery level certification or a clinical documentation improvement certification as per the below:
Master Level Certification:
Certification is limited to those obtained through AHIMA or AAPC. To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation. Stand-alone specialty certifications do not meet the definition of mastery level certification & are not acceptable for qualifications. Certification titles may change & certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies. However, current mastery level certifications include:
Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P), Registered Health Information Technician (RHIT), Registered Health Informatic Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Cordera (COC), Certified Inpatient Coder (CIC). Clinical Documentation Improvement Certification:
This is limited to certification obtained through AHIMA or the Association of Clinical Documentation Improvement Specialists (ACDIS). To be acceptable for qualifications, the specific certification must certify mastery in clinical documentation. Certification titles may change, & certifications that meet the definition of clinical documentation improvement certification may be added/removed by the above certifying bodies. However, current Clinical Documentation Improvement Certifications include:
Clinical Documentation Improvement Practitioner (CDIP) & Certified Clinical Documentation Specialist (CCDS). You must also demonstrate the following KSAs:
1. Knowledge of coding and documentation concepts, guidelines, and clinical terminology. 2. Knowledge of anatomy & physiology, pathophysiology, and pharmacology to interpret & analyze all information in a patient's health record, including laboratory & other test results to identify opportunities for more precise and/or complete documentation in the health record. 3. Ability to collect & analyze data & present results in various formats, which may include presenting reports to various organizational levels. 4. Ability to establish & maintain strong verbal & written communications with providers. 5. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, & VA guidelines. 6. Extensive knowledge of coding rules & regulations, to include current clinical classification systems such as ICDCM & PCS, CPT, & HCPCS. They must also possess knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), MS-DRG structure, & POA indicators. 7. Knowledge of severity of illness risk of mortality, complexity of care for inpatients, & CPT Evaluation & Management (E/M) criteria to ensure the correct selection of E/M codes that match patient type, setting of service, & level of E/M service provided for outpatients. 8. Knowledge of training methods & teaching skills sufficient to conduct continuing education for staff development. The training sessions may be technical in nature or may focus on teaching techniques for the improvement of clinical documentation issues. References:
VA Handbook 5005/122 G35 Medical Record Technician Qualification Standards 12/10/2019. The full performance level of this vacancy is GS-09. The actual grade at which an applicant may be selected for this vacancy is GS-09. Physical Requirements:
Light lifting (under 15 pounds); light carrying (under 15 pounds); use of fingers; both hands required; hearing (aid permitted); sitting for up to 8 hours; repetitive motions for computer data entry.
Estimated Salary: $20 to $28 per hour based on qualifications.
Monday - Friday, 8:
00 AM - 4:
30 PM Financial Disclosure Report:
Not required Basic Requirements:
United States Citizenship:
Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. English Language Proficiency:
Proficient in spoken and written English as required by 38 U.S.C. 7402(d), and 7407(d).
Experience:
Oneyear of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, & 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 & physiology, medical coding, & 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 & physiology, medical terminology, basic ICD diagnostic/procedural, & basic CPT coding. The training program must have led to eligibility for coding certification/certification examination, & 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 & creditable
Experience:
(a) 6 months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, & 1 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 & 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, & health record techniques & procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder). Grade Determination GS-09 Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient); OR, An associate's degree or higher and three years of experience in clinical documentation improvement (candidates must also have successfully completed coursework in medical terminology, anatomy and physiology, medical coding, and introduction to health records); OR, Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement; OR, Clinical experience, such as Registered Nurse (RN), Medical Doctor (M.D.), or Doctor of Osteopathy (DO), and one year of experience in clinical documentation improvement. Certification. Employees at this level must have either a mastery level certification or a clinical documentation improvement certification as per the below:
Master Level Certification:
Certification is limited to those obtained through AHIMA or AAPC. To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation. Stand-alone specialty certifications do not meet the definition of mastery level certification & are not acceptable for qualifications. Certification titles may change & certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies. However, current mastery level certifications include:
Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P), Registered Health Information Technician (RHIT), Registered Health Informatic Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Cordera (COC), Certified Inpatient Coder (CIC). Clinical Documentation Improvement Certification:
This is limited to certification obtained through AHIMA or the Association of Clinical Documentation Improvement Specialists (ACDIS). To be acceptable for qualifications, the specific certification must certify mastery in clinical documentation. Certification titles may change, & certifications that meet the definition of clinical documentation improvement certification may be added/removed by the above certifying bodies. However, current Clinical Documentation Improvement Certifications include:
Clinical Documentation Improvement Practitioner (CDIP) & Certified Clinical Documentation Specialist (CCDS). You must also demonstrate the following KSAs:
1. Knowledge of coding and documentation concepts, guidelines, and clinical terminology. 2. Knowledge of anatomy & physiology, pathophysiology, and pharmacology to interpret & analyze all information in a patient's health record, including laboratory & other test results to identify opportunities for more precise and/or complete documentation in the health record. 3. Ability to collect & analyze data & present results in various formats, which may include presenting reports to various organizational levels. 4. Ability to establish & maintain strong verbal & written communications with providers. 5. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, & VA guidelines. 6. Extensive knowledge of coding rules & regulations, to include current clinical classification systems such as ICDCM & PCS, CPT, & HCPCS. They must also possess knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), MS-DRG structure, & POA indicators. 7. Knowledge of severity of illness risk of mortality, complexity of care for inpatients, & CPT Evaluation & Management (E/M) criteria to ensure the correct selection of E/M codes that match patient type, setting of service, & level of E/M service provided for outpatients. 8. Knowledge of training methods & teaching skills sufficient to conduct continuing education for staff development. The training sessions may be technical in nature or may focus on teaching techniques for the improvement of clinical documentation issues. References:
VA Handbook 5005/122 G35 Medical Record Technician Qualification Standards 12/10/2019. The full performance level of this vacancy is GS-09. The actual grade at which an applicant may be selected for this vacancy is GS-09. Physical Requirements:
Light lifting (under 15 pounds); light carrying (under 15 pounds); use of fingers; both hands required; hearing (aid permitted); sitting for up to 8 hours; repetitive motions for computer data entry.
- Department:
0675 Medical Records Technician - Salary Range:
$54,976 to $71,470 per year
Estimated Salary: $20 to $28 per hour based on qualifications.
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