Medical Records Techninian (CDIS) Outpatient and Inpatient Coder
a. Citizenship. Citizen of the United States.
b. 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.
(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;
(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).
To meet the grade requirements of a Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient)), GS-9 the below is required in addition to the basic requirements.
(a) Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient);
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);
Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement;
Clinical experience, such as Registered Nurse (RN), Medical Doctor (M.D.), or Doctor of Osteopathy (DO), and one year of experience in clinical documentation improvement.
(b) Certification. Mastery Level Certification through AHIMA or AAPC. or 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.Employees at this level must have either a mastery level certification or a Clinical Documentation Improvement Certification
Experience is defined as experience performing as an Outpatient CDISs performing all duties of a MRT (Coder-Outpatient). Duties are as CDISs serve as the liaison between health information management and clinical staff; responsible for facilitating improved overall quality, education, completeness, and accuracy of health record documentation through extensive interaction with clinical, coding, and other associated staff to ensure clinical documentation supports services rendered to patients, appropriate workload, and resource allocations; reviewing documentation and facilitate modifications to the health record to ensure accurate complexity of care and utilization of resources; identifying opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity, accurately address all acute and chronic conditions, and reflect the true health status of patients; recommending changes and/or updates to medical center policy pertaining to clinical documentation improvement; serving as a technical expert in health record content and documentation requirements; query clinical staff to clarify ambiguous, conflicting, or incomplete documentation; reviewing appropriateness of and responses to queries through review of query reports; responsible for performing reviews of the health record documentation, developing criteria, collecting data, graphing and analyzing results, creating reports, and communicating orally and/or in writing to appropriate leadership and groups; obtaining appropriate corrective action plans from responsible clinical service directors and recommend improvements or changes in documentation practices when applicable; adhering to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policies, and medical-legal requirements.
In addition to the experience above, the candidate must demonstrate all of the following KSAs:
Demonstrated Knowledge, Skills, and Abilities:
i. Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
ii. 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.
iii. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.
iv. Ability to establish and maintain strong verbal and written communication with providers.
v. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines.
vi. Extensive knowledge of coding rules and regulations to include current clinical classification systems (such as ICD, CPT, and HCPCS).
vii. Knowledge of CPT Evaluation and Management (E/M) criteria to ensure the correct selection of E/M codes that match patient type, setting of service, and level of E/M service provided.
viii. 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.
References: VA Handbook 5005/122 December 10, 2019 PART II APPENDIX G57
Physical Requirements: Work is sedentary but also demands standing, walking, bending, twisting, and carrying light
IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.
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.