Medical Records Technician; Coder

Overview

The Medical Records Technician (Coder) position is located in the Health Informatics Management Section (HIMS) of the Business Office at the Providence VA Medical Center.

• The Medical Records Technician (Coder) is responsible for performing a quality review of patient care documents and assigning codes specific for the type of care provided.
• Identifies the principal diagnosis and principal procedure (when applicable) for every inpatient discharge.
• Identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnostic Related Group (DRG).
• Upon patient admission to the Nursing Home Care Unit, codes the admission diagnosis for use by unit staff.
• Conducts re-reviews of codes abstracted for patient encounters (inpatient and outpatient) identified by the VISN VERA committee to determine if based on the documentation the specific VERA coding requirements were followed.
• Cc orths coding as needed to ensure proper patient classification in the VERA program.
• Codes inpatient professional fee services for identified inpatient admissions in support of the Medical Care Cost Recovery (MCCR) program.
• Code selection is based upon strict compliance with regulatory fraud and abuse guidelines and VA-specific guidance for optimum allowable reimbursement.
• Establishes the primary and secondary diagnosis and procedure codes for billable outpatient encounters following applicable regulations, instructions, and requirements for allowable reimbursement.
• Links the appropriate diagnosis to the procedure and/or determines level of Evaluation & Management service provided.
• Understands the nuances of the CPT coding system for Third Party Insurance cost recovery and accurately interprets instructional notations; bundles encounters when appropriate; identifies non-billable encounters.
• Codes all Operating Room procedures reported in the Surgical Package of the Vista hospital system and applies ICD-9-CM and CPT coding guidelines using the Quadra Medn Coder + software.
• Ensures all procedures file to the appropriate Patient Care Encounter (PCE) and adds Anesthesia and Pathology codes to the PCE encounter for all billable surgical cases.
• Updates codes for current inpatient and Contract Nursing Home admissions for quarterly census and as directed for billable long stay admissions to reflect all patient conditions and care up to the census date or requested billing date.
• Reviews and codes assigned Fee Service patient encounters (inpatient and outpatient) using documentation obtained from non-VA facilities such as Community Hospitals, Emergency Rooms, and military facilities.
• Codes diagnoses from paper forms for VA registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc.

• Basic Requirements:
  United States Citizenship;
  English Language Proficiency; and other qualifications as required.
• 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 Options (either may apply):
• An associate’s degree from an accredited college or university with a major in health information technology/health information management or related degree with 12 semester hours in health information technology/health information management.
• Completion of an AHIMA approved coding program or other intensive coding training program of approximately one year or more, including 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 institution must be accredited by a national accreditor at the time of completion.
• Experience/Education Combination:
  Equivalent combinations of creditable experience and education are qualifying.
• Educational/training substitutions for combining education and creditable experience (details provided in the original listing) may apply.
• Certification:
  Hiring or reassignment to MRT (Coder) positions requires one of:
  Appren…