Veterans Affairs, Veterans Health Administration Logo
Position Title
Medical Records Technician (Coder-Inpatient)
Agency
Veterans Affairs, Veterans Health Administration
Announcement Number
CBTG-4020-10715343-20-WLH Opens in new window
Open Period
Tuesday, February 18, 2020 to Tuesday, August 18, 2020
For preview purposes only. To apply, please return to the USAJOBS announcement and click the Apply button.
Eligibilities
1. Do you claim Veterans' Preference? (limit characters)
2. Are you a current permanent Federal employee from an agency other than Department of Veterans Affairs?

To verify your eligibility, you must submit a copy of your latest Notification of Personnel Action, Standard Form 50 (SF-50) or equivalent personnel action form.
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3. Please select the appropriate response(s) regarding your referral eligibility: (limit characters)
4. Are you currently employed by the Department of Veterans Affairs?
This includes: Career/Career Conditional or Excepted Service (i.e. Canteen, Hybrid, Title 38, etc. and meets interchange agreement requirements). This does not include temporary, term or temporary intermittent.

To verify your eligibility, you must submit a copy of your most recent Notification of Personnel Action, Standard Form 50 (SF-50).  Your SF-50 must include enough information to be able to determine that time-in-grade requirements have been met (if applicable) and include your position title, pay plan/series/grade, tenure and the type of appointment (i.e. Competitive or Excepted).  Please be aware that award SF-50's do not always include this pertinent information.
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5. Are you an employee of the facility indicated for this position?
This includes: Career/Career Conditional or Excepted Service (i.e. Canteen, Hybrid, Title 38, etc. and meets interchange agreement requirements). This does not include temporary, term or temporary intermittent.

To verify your eligibility, you must submit a copy of your most recent Notification of Personnel Action, Standard Form 50 (SF-50).  Your SF-50 must include enough information to be able to determine that time-in-grade requirements have been met (if applicable) and include your position title, pay plan/series/grade, tenure and the type of appointment (i.e. Competitive or Excepted).  Please be aware that award SF-50's do not always include this pertinent information.
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Preferences
1. Select the lowest grade you are willing to accept for this position. (limit characters)
Assessment 1
Select the appropriate answer to each of the following questions based on your current level of education and/or experience that demonstrates your ability to perform the duties of this position. When answering the questionnaire, remember that your experience and education are subject to verification by investigation. Your resume must provide specific examples or documentation of your experience as proof to support your answers. Your failure to adequately document your experience, education, or certification on your resume may result in you being found not qualified for this position. No assumptions are made regarding your qualifications. (limit characters)
Citizenship. Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with VA Handbook chapter 3, section A, paragraph 3g, Part II.) (limit characters)
1. Are you a citizen of the United States?
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English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). (limit characters)
2. Are you proficient in basic written and spoken English?
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Physical Requirements: In accordance with VA Directive 5019, it is a requirement for the Department of Veterans Affairs to conduct a pre-placement medical evaluation or examination to determine the physical, cognitive and emotional fitness of a candidate before being appointed. An examination is required in any conversion action from a status or position not requiring a physical examination to one requiring such procedures. A pre-placement examination is also required when an employee changes positions or duties that have different physical requirements or medical standards from their prior/current position. (limit characters)
3. I understand the VA's required pre-placement medical evaluation or examination policy, and
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All MRT (Coders) are required to have at least one of the following Experience and/or 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 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 an MRT (Coder).
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4. Do you acquire at least one of the above basic listed required experiences and/or education as listed above?
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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, GS-08; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification.

Loss of Credential. Following initial certification, credentials must be maintained through rigorous continuing education, ensuring the highest level of competency for employers and consumers. An employee in this occupation who fails to maintain the required certification must be removed from the occupation, which may result in termination of employment. At the discretion of the appointing official, an employee may be reassigned to another occupation for which he/she qualifies, if a placement opportunity exists.
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5. Do you have one of the above listed certifications?
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The following questions are used for grade determination as a Medical Records Technician (Coder-Inpatient). Education and experience will be verified. (limit characters)
Medical Records Technician (Coder-Inpatient), GS-04. Assignment. Employees at this level serve as entry level MRTs (Coder) and receive close guidance from more experienced MRTs (Coder). Inpatient MRTs (Coder) select and assign codes from current versions of ICD CM and the PCS, and/or, CPT and HCPCS classification systems for inpatient facility and/or professional services. They review record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, and query clinical staff, as appropriate, with close guidance from higher level MRTs (Coder). They also use various computer applications to abstract records, assign codes, and record and transmit data. They ensure audit findings have been corrected and refiled. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit. (limit characters)
Experience or Education for the GS-04 MRT(Coder-Inpatient): None beyond the basic requirements. (limit characters)
6. For the GS-04 MRT(Coder-Inpatient). Do you have at least the basic requirements listed above?
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Medical Records Technician (Coder-Inpatient), GS-05. Assignment. Employees at this grade level serve as developmental level 1 MRTs (Coder) and receive guidance from more experienced MRTs (Coder) for more complex coding procedures. Inpatient MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services. They review record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, and query clinical staff, as appropriate, with guidance from higher level MRTs (Coder). They utilize various computer applications to abstract records, assign codes, and record and transmit data. They also ensure audit findings have been corrected and refiled. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit.
(a) Experience. One year of creditable experience equivalent to the next lower grade level; OR
(b) 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.
(c) In addition to the experience above, the candidate must demonstrate all of the following knowledge, skills, and abilities (KSA):
i. Ability to use health information technology and various office software products used in MRT (Coder) positions (e.g., the electronic health record, coding and abstracting software, etc.).
ii. Ability to navigate through and abstract pertinent information from health records.
iii. Knowledge of the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting.
iv. Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient records based on health record documentation. v. Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines.
vi. Ability to manage priorities and coordinate work to complete duties within required timeframes and the ability to follow-up on pending issues.
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7. For the GS-05 MRT(Coder-Inpatient). In addition to the basic requirements, do you have the experience and can demonstrate the KSA or the education listed above? (limit characters)
Medical Records Technician (Coder-Inpatient), GS-06. Assignment. Employees at this grade level serve in developmental level 2 positions as MRTs (Coder) and receive intermittent monitoring. Inpatient MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services. They review record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, and query clinical staff, as appropriate, with limited guidance from higher level MRTs (Coder). They use various computer applications to abstract records, assign codes, and record and transmit data. They also ensure audit findings have been corrected and refiled. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit.
(a) Experience. One year of creditable experience equivalent to the next lower grade level, and
(b) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
i. Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation.
ii. Ability to determine whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, and support the assigned codes. This includes the ability to take appropriate actions if health record contents are not complete, accurate, timely, and/or reliable.
iii. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HIPAA).
iv. Ability to accurately apply the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting to various coding scenarios.
v. Comprehensive knowledge of current classification systems, such as ICD Clinical Modification (CM) and PCS, CPT, and HCPCS, and skill in applying said classifications to inpatient records based on health record documentation. vi. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators to obtain correct Medicare Severity Diagnosis Related Group (MS-DRG).vi. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators to obtain correct Medicare Severity Diagnosis Related Group (MS-DRG).
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8. For the GS-06 MRT(Coder-Inpatient). In addition to the basic requirements, do you have the experience and can demonstrate the KSAs listed above? (limit characters)
Medical Records Technician (Coder-Inpatient), GS-7. Assignment. Employees at this grade level serve as developmental level 3 MRTs (Coder) and receive minimal monitoring. Inpatient MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services. They review and record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, with minimal guidance from higher level MRTs (Coder). They review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes. They review provider health record documentation to ensure that it supports the diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature. They query clinical staff with documentation requirements to support the coding process. They use various computer applications to abstract records, assign codes, and record and transmit data. They ensure audit findings have been corrected and refiled. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit.
(a) Experience. One year of creditable experience equivalent to the next lower grade level, and
(b) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
i. Skill in applying current coding classifications to a variety of inpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record.
ii. Ability to communicate with clinical staff for specific coding and documentation issues, such as recording diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health record documentation and code assignment.
iii. Ability to research and solve coding and documentation related issues.
iv. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.
v. Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators, to obtain correct MS-DRG.
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9. For the GS-07 MRT(Coder-Inpatient). In addition to the basic requirements, do you have the experience and can demonstrate the KSAs listed above? (limit characters)
Medical Records Technician (Coder-Inpatient), GS-08. Assignment. This is the journey level for this assignment. Inpatient MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of diagnosis related groups (DRG), and/or assigning CPT/HCPCS codes for inpatient professional services. They independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes. They code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of inpatient settings and specialties. They directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. They must abstract, assign, and sequence codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. They review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature. They query clinical staff with documentation requirements to support the coding process. They also enter and correct information that has been rejected, when necessary. They correct any identified data errors or inconsistencies. They ensure audit findings have been corrected and refiled. They use various computer applications to abstract records, assign codes, and record and transmit data. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit.
(a) Experience. One year of creditable experience equivalent to the next lower grade level, and
(b) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
i. Ability to analyze the health record to identify all pertinent diagnoses and procedures for inpatient coding and to evaluate the adequacy of the documentation. This includes the ability to read and understand the content of the health record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient.
ii. Ability to accurately perform the full scope of inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services.
iii. Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity, and the ability to use judgment in completing assignments using incomplete or inadequate guidelines.
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10. For the GS-08 MRT(Coder-Inpatient). In addition to the basic requirements, do you have the experience and can demonstrate the KSAs listed above (limit characters)
11. I certify that, to the best of my knowledge and belief, all of the information included in this questionnaire is true, correct, and provided in good faith. I understand that if I make an intentional false statement, or commit deception or fraud in this application and its supporting materials, or in any document or interview associated with the examination process, I may be fined or imprisoned (18 U.S.C. 1001); my eligibilities may be canceled; I may be denied an appointment; or I may be removed and debarred from Federal service (5 C.F.R. part 731). I understand that any information I give may be investigated and that responding "No" or providing no response to this item will result in my not being considered for this position.
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ALTHOUGH NOT REQUIRED, ITS HIGHLY RECOMMENDED THAT APPLICANTS COMPLETE THEIR RESUME' USING THE USAJOBS RESUME' BUILDER. All documents requiring a signature must be signed and dated prior to submission to be considered complete. Resume' or CV must include the position title, grade, how to contact you, descriptions of jobs held including the name and address of employer, job title, description of duties, beginning and ending dates, (month and year) of employment, and average hours worked per week, i.e. 40 hours per week, 32 hours per week, 20 hours per week, etc. In describing your experience, please be clear and specific. We may not make any assumptions regarding your experience.

Resume Reminder - Your resume must include the following information for each job listed: (REQUIRED)
Job title
Duties (be as detailed as possible) Even though we do not require a specific resume format, your resume must be clear so that we can fully evaluate your qualifications. To ensure you receive appropriate consideration, please list the duties you performed under each individual job title. If we are unable to match your experiences with the positions held, you may lose consideration for this vacancy. We cannot make assumptions regarding your qualifications.
Month & year start/end dates (e.g. June 2007 to April 2008)
Full-time or part-time status (include hours worked per week...i.e. 40 hours per week, 32 hours per week, 20 hours per week, etc.
Details of your experience and clearly document your ability to demonstrate the KSAs of grade level you are applying to.
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12. I have read and understand the requirements for a complete resume. Failure to follow the instruction for a complete resume will result in NOT being referred.
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13. I have read and understand the requirements for a complete application. Failure to follow the instruction and failure to provide the required documents will result in NOT being referred.
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