Medical Records Technician (Coder Outpatient and Inpatient)

Summary

MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting - and/or physician-based settings - such as physician offices - group practices - multi-specialty clinics - and specialty centers. These coding practitioners analyze and abstract patients' health records - and assign alpha-numeric codes for each diagnosis and procedure.

Qualifications
Basic Requirements
• U.S.

Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy
• Experience &

Education: Must meet ONE of the following 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
• 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)
• Education 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. Dept
• of Education accreditor - or comparable international accrediting authority at the time the program was completed
• 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 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
• Certification: Must have either 1 - 2 - or 3 below: Apprentice/Associate Level Certification through AHIMA or AAPC
• Mastery Level Certification through AHIMA or AAPC
• Clinical Documentation Improvement Certification through AHIMA or ACDIS
• 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: IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education
• GS-4 Experience or Education
• None beyond basic requirements
• GS-5 Experience
• One year of creditable experience equivalent to the next lower grade level
• Education
• Successful completion of a bachelor'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 management - or a related degree with a minimum of 24 semester hours in health information management or technology
• Demonstrated Knowledge - Skills - and Abilities
• In addition to the experience above - the candidate must demonstrate all of the following KSAs: Ability to use health information technology and software products used in MRT (Coder) positions (e.g.
• the electronic health record - coding and abstracting software - etc.)
• Ability to navigate through and abstract pertinent information from health records
• Knowledge of the ICD CM - PCS Official Conventions and Guidelines for Coding and Reporting - and CPT guidelines
• Ability to apply knowledge of medical terminology - human anatomy/physiology - and disease processes to accurately assign codes to inpatient and outpatient episodes of care based on health record documentation
• Knowledge of The Joint Commission requirements - Centers f

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