Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient))
- United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
- English Language Proficiency: Proficient in spoken and written English as required by 38 U.S.C. 7402(d), and 7407(d).
- Experience & Education:
- 1. Experience. 1 year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, & 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 & physiology, medical coding, & 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 & physiology, medical terminology, basic ICD diagnostic/procedural, & basic CPT coding. The training program must have led to eligibility for coding certification/certification examination, & 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 & education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education & creditable experience:(a) 6 months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, & 1 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 & 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, & health record techniques & procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder).
Certification. Employees at this level must have either a mastery level certification or a Clinical Documentation Improvement Certification.
Master Level Certification: Certification is limited to those 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 & are not acceptable for qualifications. Certification titles may change & 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 Informatic Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Cordera (COC), Certified Inpatient Coder (CIC).
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, & 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) & Certified Clinical Documentation Specialist (CCDS).You must also demonstrate the following KSAs:
1. Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
2. Knowledge of anatomy & physiology, pathophysiology, and pharmacology to interpret & analyze all information in a patient's health record, including laboratory & other test results to identify opportunities for more precise and/or complete documentation in the health record.
3. Ability to collect & analyze data & present results in various formats, which may include presenting reports to various organizational levels
4. Ability to establish & maintain strong verbal & written communications with providers.
5. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, & VA guidelines.
6. Extensive knowledge of coding rules & regulations, to include current clinical classification systems such as ICDCM & PCS, CPT, & HCPCS. They must also possess knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), MS-DRG structure, & POA indicators.
7. Knowledge of severity of illness risk of mortality, complexity of care for inpatients, & CPT Evaluation & Management (E/M) criteria to ensure the correct selection of E/M codes that match patient type, setting of service, & level of E/M service provided for outpatients.
8. Knowledge of training methods & 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.
- Certified Professional Coder and/or Clinical Documentation Improvement Specialist
- 2 years minimum of experience in Inpatient/Outpatient setting
- Extensive knowledge and skills in the use of different types of software applications which include but are not limited to; word processing, spreadsheet and data base software for data validation programs
IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.
Note: If your school has changed names, or is no longer in existence, you must provide this information in your application.
Note: If your school was approved by the Database of Accredited Postsecondary Institutions and Programs at the time the program was completed, but is no longer listed on the website, you must provide documentation of accreditation with your application packet.
Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.