Medical Records Technician (Medical Coding)

Quick Facts

• Role: Medical Records Technician (Medical Coding)

• Work setting: Inpatient and outpatient coding using electronic health record and coding/abstracting software

Description

Assign diagnosis and procedure codes for inpatient and outpatient patient encounters by analyzing and abstracting information from health records. Select appropriate codes using current coding systems and guidelines (ICD, CPT, HCPCS), ensure complete and compliant documentation, and support accurate coding for reimbursement. Perform inpatient discharge coding including principal diagnosis/procedure and DRG-related elements, and conduct coding re-reviews when required.

Responsibilities

• Assign codes to inpatient and outpatient encounters across the full range of services

• Use current ICD, CPT, and/or HCPCS code sets and follow coding conventions, guidelines, and policies

• Monitor and apply changing regulatory and coding policy requirements

• Review patient records to abstract medical, surgical, ancillary, demographic, social, and administrative data

• Assist with documentation requirements so provider documentation supports assigned diagnoses/procedures

• Search records to find documentation justifying code assignments

• Use facility systems and applications to code, abstract, record, and transmit data to the national VA database

• Perform inpatient discharge coding: principal diagnosis and principal procedure (when applicable), plus significant complications/comorbidities for DRG/MS-DRG

• Conduct VERA committee re-reviews and correct codes as needed

• Code inpatient professional fee services

• Code outpatient encounter diagnoses/procedures, link diagnoses to procedures, and determine appropriate Evaluation & Management level

• Code Operating Room procedures and add anesthesia and pathology codes to the patient care encounter for billable surgical cases

• Update codes for inpatient and contract nursing home admissions and other designated encounters on required schedules

• Code Care in the Community fee-for-service encounters using paper or electronic non-VA documentation

• Code diagnoses from paper forms for VA registries

• Orient and instruct new personnel/students on unit operations, coding, abstracting, and electronic health record use

Requirements

• U.S. citizenship

• Proficiency in written and spoken English

• Subject to background/security investigation

• Complete required application steps, including an online assessment

• Selective Service registration (for eligible males)

• Participation in seasonal influenza vaccination program

• Complete online onboarding and pre-employment requirements

• Meet basic education/experience requirements in medical terminology, anatomy/physiology, pathophysiology, and medical coding (as specified)

• MRT (Coder) certification via AHIMA or AAPC (Apprentice/Associate or Mastery), or CDI certification via AHIMA or ACDIS (or approved grandfathering)

Benefits

A comprehensive federal employee benefits package (eligibility depends on position type).