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.
- English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).
Experience and Education:
- Experience. One year of creditable experience equivalent to the journey grade level GS-8 of a MRT (Coder-Outpatient and Inpatient);OR,
- Education. 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; 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.
- Mastery Level Certification is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC.
- Clinical Documentation Improvement Certification is limited to certification obtained through AHIMA or ACDIS.
Mastery Level Certification: To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation. 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).
Clinical Documentation Improvement Certification: To be acceptable for qualifications, the specific certification must certify mastery in clinical documentation. Current Clinical Documentation Improvement Certifications include: Clinical Documentation Improvement Practitioner (CDIP) and Certified Clinical Documentation Specialist.
Assignment: For all assignments above the journey level, the higher-level duties must consist of significant scope, complexity (difficulty), range of variety, and be performed by the incumbent at least 25% of the time. CDISs must be able to perform all duties of a MRT (Coder-Outpatient and Inpatient). CDISs serve as the liaison between health information management and clinical staff. They are 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 is captured, and resources are properly allocated. They review documentation and facilitate modifications to the health record to ensure accurate severity of illness, risk of mortality, complexity of care, and utilization of resources. They identify 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. They recommend changes and/or update medical center policy pertaining to clinical documentation improvement. They serve as a technical expert in health record content and documentation requirements.
Grade Determinations:
GS-9, MRT CDIS (Outpatient and Inpatient)
Demonstrated Knowledge, Skills, and Abilities: In addition to the experience above, the candidate must demonstrate all of the following KSAs:
i. Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
ii. Knowledge of anatomy and physiology, pathophysiology, and pharmacology 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 ICDCM and PCS, CPT, and HCPCS. They must also possess knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), MS-DRG structure, and POA indicators.
vii. Knowledge of severity of illness, risk of mortality, complexity of care for inpatients, and 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 for outpatients.
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.
Reference: For more information on this qualification standard, please visit
https://www.va.gov/ohrm/QualificationStandards/.
The full performance level of this vacancy is GS 9
Physical Requirements: . See VA Directive and Handbook 5019, Employee Occupational Health Service.