Basic Requirements
Citizenship: Citizen of the United States.
English Language Proficiency: MRT Coders must be proficient in spoken and written English required by 38 USC 7403(f).
Experience and Education:
- One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding and the structure and format of health records.
OR
- An associates degree from an accredited college/university recognized by the U.S. Department of Education (major field of study in health information technology/health information management or related degree with at least 12 semester hours in HIT/HIM).
OR
- 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. This must have led to eligibility for coding certification/certification examination and accredited by a national US Department of Education accreditor or comparable international accrediting authority at the time the program was completed.
OR
- Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.
- 6 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 HIT courses.
- 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 US Maritime Service, under close medical and professional supervision, may be substituted on a month-for-month basis for up to 6 months of experience provided the training program included courses in anatomy, physiology and health record techniques and procedures. Also requires 6 additional months of creditable experience that is paid or non-paid employment equivalent to a MRT Coder.
Certification: Persons hired or reassigned to MRT Coder positions in the GS-0675 series in VHA must have one of the below. No other certifications are accepted.
- Apprentice/Associate Level Certification from AHIMA or AAPC
- Mastery Level Certification from AHIMA or AAPC
- Clinical Documentation Improvement Certification from AHIMA or ACDIS
Grandfathering Provision: All persons employed in VHA as a MRT Coder on December 10, 2019 are considered to have met all qualification requirements for the title, series and grade held, including positive education and certification that are part of the basic requirements of the occupation. For employees who do not meet all the basic requirements in this standard, but met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply: Such employees may be reassigned, promoted up to and including the journey level, or changed to lower grade within the occupation, but will not be promoted beyond the GS8 level or placed in supervisory or managerial positions. Such employees in an occupation that requires a certification only at higher grade levels must meet the certification requirement before they can be promoted to the higher-grade levels.
Grade Determinations
GS-5: 1 year of creditable experience equivalent to the next lower grade level;
OR successful completion of a bachelor'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 management, or a related degree with a minimum of 24 semester hours in health information management or technology.
Demonstrated Knowledge, Skills, and Abilities (KSAs):
-Ability to use health information technology and software products used in MRT (Coder) positions (e.g., the electronic health record, coding and abstracting software, etc.).
-Ability to navigate through and abstract pertinent information from health records.
-Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines.
-Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to outpatient/ambulatory surgery records, based on health record documentation.
-Knowledge of The Joint Commission requirements, Centers for Medicare and Medicaid Services (CMS), and/or health record documentation guidelines.
-Ability to manage priorities and coordinate work, in order to complete duties within required timeframes, and the ability to follow-up on pending issues.
GS-6: 1 year of creditable experience equivalent to the next lower grade level.
Demonstrated KSAs:
-Ability to analyze the health record to identify all pertinent diagnoses and procedures for outpatient coding and evaluate the adequacy of the documentation.
-Ability to determine whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, and support the assigned codes. This includes the ability to take appropriate actions if health record contents are not complete, accurate, timely, and/or reliable.
-Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and Health Insurance Portability and Accountability Act (HIPAA)).
-Ability to accurately apply the ICD CM, procedure coding system (PCS) Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines to coding scenarios.
-Comprehensive knowledge of current classification systems, such as ICD CM, CPT, and HCPCS, and skill in applying said classifications to outpatient episodes of care, and/or inpatient professional services based on health record documentation.
GS-7: 1 year of creditable experience equivalent to the next lower grade level.
Demonstrated KSAs:
-Skill in applying current coding classifications to a variety of specialty care areas for outpatient episodes of care and/or inpatient professional services to accurately reflect service and care provided based on documentation in the health record.
-Ability to communicate with clinical staff for specific coding and documentation issues, such as recording diagnoses and procedures, ensuring the correct sequencing of diagnoses and/or procedures, and verifying the relationship between health record documentation and coder assignment.
-Ability to research and solve coding and documentation related issues.
-Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.
GS-8: 1 year of creditable experience equivalent to the next lower grade level.
Demonstrated KSAs:
-Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation. This includes the ability to read and understand the content of the health record, the terminology, the significance of the findings, and the disease process/pathophysiology of the patient.
-Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and/or inpatient professional fee services coding.
-Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity, and the ability to use judgment in completing assignments using incomplete or inadequate guidelines.
Reference: For more information on this qualification standard, please visit
https://www.va.gov/ohrm/QualificationStandards/.
Physical Requirements: VA Directive and Handbook 5019, Employee Occupational Health Service.
The full performance level of this vacancy is GS-8. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-8.