Medical Records Technician; Coder Auditor

Summary

Auditors must be able to perform all duties of a MRT (Coder). Auditors serve as experts of current coding conventions and guidelines related to professional and facility coding. Auditors perform audits of encounters to identify areas of non-compliance in coding. They facilitate improved overall quality - completeness - and accuracy of coded data.

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
• 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)

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

Grade Determinations:
Medical Records Technician (Coder) Auditor - GS-9

Experience:

One year of creditable experience equivalent to the journey grade level of a MRT (Coder)

Certification:
Employees at this level must have a mastery level certification. Mastery Level Certification is a higher‑level health information management or coding certification and is limited to certification 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 and are not…