Medical Records Technician

3 weeks ago

Columbus, Ohio, United States Veterans Health Administration Full time
Coding practitioners analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure.

Outpatient Medical Record Technicians (Coder) select and assign codes to outpatient episodes of care, and/or inpatient professional services from current versions of ICD-10-CM, CPT, and HCPCS classification systems.


Duties include but are not limited to:


Reviews record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data with guidance and instruction from supervisor or senior coder to develop knowledge of the organization and structure of an electronic or paper patient record.

Utilizes the facility computer system and software applications to code, abstract, record, and transmit data.

Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines.

Research references to resolve any questionable code errors; contacts a senior coder or supervisor when needed.

Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines.

Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding.

Also adheres to the coding guidelines specific to the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.

Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VMCC.

Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.

Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.

Assigns codes to documented patient care encounters (outpatient and/or inpatient professional services) covering the full range of health care services provided by the VAACC.

Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.

Ensures provider documentation is complete and supports the diagnoses and procedures coded. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation or codes in the electronic patient health record.

Work Schedule:
Monday-Friday 8:00 am -4:30 pm

Telework:
Available. Expected to come in for trainings, IT issues or when needed

Virtual:
This is not a virtual position.

Work will be performed via Telework. (Telework agreement based on coding satisfactory performance)

Functional Statement #
917230

Relocation/Recruitment Incentives
:
Not Authorized

Permanent Change of Station (PCS):
Not Authorized

Fi

nancial Disclosure Report:
Not required

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