OUR MISSION: To fulfill President Lincoln's promise - "To care for him who shall have borne the battle and for his widow, and his orphan" - by serving and honoring the men and women who are America's Veterans. How would you like to become a part of a team providing compassionate care to Veterans?
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This position is located in the Health Information Management Section (HIMS) of the Health Administration Service Line at the W.G. (Bill) Hefner VA Medical Center. The Medical Records Technician (Coder) is responsible for performing a quality review of patient care documents and assigning codes specific for the type of care provided.
This is considered to be the full performance level for this assignment. Coding certification/credentials at this grade level is highly desired.
- Assigns codes to documented patient care encounters (inpatient and outpatient) covering the full range of health care services provided by the VAMC.
- Selects and assigns codes from the current version of several coding systems to include the International Classification of Diseases-Clinical Modification (ICD-10-CM), Diagnostic and Statistical Manual of Mental Disorders (DSM), Current Procedural Terminology (CPT), and HCPCS.
- Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding.
- Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
- Performs a comprehensive review of the patient record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. Patient records may be paper or electronic.
- Uses a variety of window based applications in day to day activities and duties, such as Outlook, Excel, Word, and Access;
- 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, workioad, accepted nomenclature, and proper sequencing.
- Establishes the primary and secondary diagnosis and procedure codes for billable outpatient encounters following applicable regulations, instructions, and requirements for allowable reimbursement;
Work Schedule: Monday-Friday 8:00am - 4:30pm