Medical Records Coder (Outpatient)

Quick Facts

Remote position; Monday–Friday, 8:00am–4:30pm (work hours may change based on agency needs).

Description

Remote outpatient medical coder reviews patient records to assign accurate diagnosis and procedure codes. The role ensures documentation supports ICD-10-CM/ICD-10-PCS, CPT, and/or HCPCS code selection, resolves unclear or conflicting clinical documentation with clinical staff, and corrects audit issues. You will also monitor compliance with evolving coding and policy requirements and support quality reporting.

Responsibilities

• Assign and validate diagnostic and procedural coded data to support research, reimbursement, quality measurement, and evaluation of care.
• Apply ICD-10-CM/ICD-10-PCS Official Guidelines, CPT guidelines, and established coding guidance (e.g., AMA CPT Assistant, AHA Coding Clinic).
• Use medical terminology, anatomy & physiology, disease processes, treatments, diagnostic tests, medications, and procedures to select appropriate codes.
• Review assigned codes from current coding systems (ICD, CPT, HCPCS) and code according to accepted guidelines, including E/M rules and modifier usage.
• Follow coding classification rules specific to the VERA program for VA patients.
• Audit accuracy and completeness of coded data (including MS-DRG, POA status, and discharge disposition for inpatient; and E/M assignment/modifiers for outpatient) and evaluate documentation support.
• Consult professional staff to clarify conflicting or ambiguous clinical data and ensure documentation supports optimal code assignment.
• Monitor regulatory and policy updates that affect coded information for the full spectrum of services.
• Assist staff with documentation requirements and provide coding/regulatory/sequence technical support.
• Analyze coding performance monitors for inpatient, outpatient, VERA, and purchased care; produce reports and communicate findings to leadership.
• Provide coding guidance and education to improve coding accuracy and consistency.
• Perform audits of coded data, develop audit criteria, collect and analyze results, graph/trend data, and communicate outcomes in writing or in person.

Requirements

• U.S. Citizenship.
• Proficiency in written and spoken English.
• Subject to background/security investigation and pre-employment physical examination.
• Completion of VA online onboarding and pre-employment requirements.
• Selective Service registration required for males born after 12/31/1959.
• Participation in VA seasonal influenza vaccination program.
• Required to serve a 1–2-year trial period and obtain written certification that continued employment advances the public interest.
• Meet basic requirements via qualifying experience and/or education in medical terminology, anatomy/physiology/pathophysiology, medical coding, and health record structure.
• MRT (Coder) GS-0675 certification requirement: AHIMA/AAPC Apprentice/Associate or Mastery level; Clinical Documentation Improvement certification may apply for CDIS assignments.

Benefits

A federal government career offers a comprehensive benefits package; eligibility depends on position type and schedule.