Medical Records Technician (Clinical Documentation Improvement Specialist- Inpatient)
Duties include, but are not limited to:
Reviewing the overall quality and completeness of clinical documentation. Focusing on the concurrent review of patient records with an emphasis on improving documentation while the patient is still in-house. Applies comprehensive knowledge 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 inpatient episodes of care. 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, ensuring documentation supports the codes selected to the highest degree of specificity. Adheres to accepted coding practices, guidelines and conventions to ensure ethical, accurate and complete coding. Reviews Veterans Equitable Resource Allocation input on missed opportunities and provides provider documentation education with VERA coordinator. Monitors regulatory and policy requirements for the full-spectrum of services provided. Develops and conducts seminars, workshops and short courses for clinical and HIM staff. Recommends improvements or changes in documentation when necessary. Compiles and analyzes medical data incidental to a variety of patient care and treatment activities. Participates in clinical rounds. Maintains statistical database in order to identify patterns and variations in coding practices. Work Schedule:
Monday through Friday, 8:
00 AM - 4:
30 PM Telework:
Not Available 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. Experience and Education 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 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 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 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, 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). Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either:
Apprentice/Associate Level Certification through AHIMA or AAPC. Mastery Level Certification through AHIMA or AAPC. 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. English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. 7403(f). GS-9 Grade Determination:
In addition to basic requirements, candidates must meet the grade requirements below. Experience One year of creditable experience equivalent to the journey grade level of an MRT (Coder-Inpatient); 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; for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification. OR Clinical experience such as RN, M.D., or 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. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience and certification above, the candidate must demonstrate all of the following KSAs:
Knowledge of coding and documentation concepts, guidelines, and clinical terminology. Knowledge of anatomy and physiology, pathophysiology, and pharmacology in order to interpret and analyze all information in a patient's health record, including laboratory and other test results, to identify opportunities for more precise and/or complete documentation in the health record. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels. Ability to establish and maintain strong verbal and written communication with providers. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines. Extensive knowledge of coding rules and regulations, to include current clinical classification systems such as ICD CM and PCS. They must also possess a knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), MS-DRG structure, and POA indicators. Knowledge of severity of illness, risk of mortality, and complexity of care. Knowledge of training methods and 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. Definition of Mastery Level Certification. This is considered 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 acceptable for qualifications. Certification titles may change and 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 Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC). Definition of 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, and 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) and Certified Clinical Documentation Specialist. References:
VA Handbook 5005, Part II, Appendix G57 Physical Requirements:
See VA Directive and Handbook 5019, Employee Occupational Health Service.
Estimated Salary: $20 to $28 per hour based on qualifications.
Reviewing the overall quality and completeness of clinical documentation. Focusing on the concurrent review of patient records with an emphasis on improving documentation while the patient is still in-house. Applies comprehensive knowledge 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 inpatient episodes of care. 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, ensuring documentation supports the codes selected to the highest degree of specificity. Adheres to accepted coding practices, guidelines and conventions to ensure ethical, accurate and complete coding. Reviews Veterans Equitable Resource Allocation input on missed opportunities and provides provider documentation education with VERA coordinator. Monitors regulatory and policy requirements for the full-spectrum of services provided. Develops and conducts seminars, workshops and short courses for clinical and HIM staff. Recommends improvements or changes in documentation when necessary. Compiles and analyzes medical data incidental to a variety of patient care and treatment activities. Participates in clinical rounds. Maintains statistical database in order to identify patterns and variations in coding practices. Work Schedule:
Monday through Friday, 8:
00 AM - 4:
30 PM Telework:
Not Available 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. Experience and Education 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 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 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 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, 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). Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either:
Apprentice/Associate Level Certification through AHIMA or AAPC. Mastery Level Certification through AHIMA or AAPC. 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. English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. 7403(f). GS-9 Grade Determination:
In addition to basic requirements, candidates must meet the grade requirements below. Experience One year of creditable experience equivalent to the journey grade level of an MRT (Coder-Inpatient); 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; for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification. OR Clinical experience such as RN, M.D., or 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. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience and certification above, the candidate must demonstrate all of the following KSAs:
Knowledge of coding and documentation concepts, guidelines, and clinical terminology. Knowledge of anatomy and physiology, pathophysiology, and pharmacology in order to interpret and analyze all information in a patient's health record, including laboratory and other test results, to identify opportunities for more precise and/or complete documentation in the health record. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels. Ability to establish and maintain strong verbal and written communication with providers. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines. Extensive knowledge of coding rules and regulations, to include current clinical classification systems such as ICD CM and PCS. They must also possess a knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), MS-DRG structure, and POA indicators. Knowledge of severity of illness, risk of mortality, and complexity of care. Knowledge of training methods and 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. Definition of Mastery Level Certification. This is considered 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 acceptable for qualifications. Certification titles may change and 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 Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC). Definition of 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, and 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) and Certified Clinical Documentation Specialist. References:
VA Handbook 5005, Part II, Appendix G57 Physical Requirements:
See VA Directive and Handbook 5019, Employee Occupational Health Service.
- Department:
0675 Medical Records Technician - Salary Range:
$61,131 to $79,472 per year
Estimated Salary: $20 to $28 per hour based on qualifications.
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