Medical Records Technician

**Duties**:
This position is in the Health Information Management Service (HIMS) at the VA Western New York Health Care System (VAWNYHCS). MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings.
- Applies knowledge of medical record content, medical terminology, anatomy & physiology, diseases processes, and official coding guidelines to assign codes to the most basic and routine outpatient services.
- Selects and assigns codes from the current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
- With instruction from a senior coder, lead coder or supervisor learns to select diagnosis, operation, or procedure codes based on the accepted coding practices, guidelines, conventions and policy.
- Reviews record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data with guidance and instruction from supervisor, lead coder or senior coder to develop knowledge of the organization and structure of an electronic patient record.
- Coding and documentation questions from providers are referred to lead coder or supervisor for resolution or guidance.
- Establishes the primary and secondary diagnosis and procedure codes for outpatient encounters for one specialty or subspecialty following applicable regulations, instructions, and requirements for allowable reimbursement; links the appropriate diagnosis to the procedure and/or determines level of E/M service provided. Uses knowledge of the CPT and HCPCS coding systems for Third Party Insurance cost recovery; receives guidance from experienced coder to interpret instructional notations or to bundle encounters or to identify non-billable encounters.
- Codes less complex Operating Room procedures reported in the Surgical Package of the VistA hospital system; applies ICD and CPT coding systems and guidelines and selects proper codes using the current code set and the encoder product suite; ensures all procedures file to the appropriate Patient Care Encounter (PCE); adds Anesthesia and Pathology codes to the PCE encounter for all billable surgical cases.
- Codes diagnoses from paper forms for VA registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc.
- Understands the CPT coding system for Third Party Insurance cost recovery and interprets instructional notations; bundles encounters when appropriate; identifies non-billable encounters. HCPCS codes are used per guidelines.
- Codes Operating Room procedures reported in the Surgical Package of the VistA hospital system; applies ICD and CPT coding systems and guidelines and selects proper codes using the current code set and the encoder product suite; ensures all procedures file to the appropriate Patient Care Encounter (PCE); adds Anesthesia and Pathology codes to the PCE encounter for all billable surgical cases.
- Reviews and codes assigned fee service Care in the Community patient encounters (outpatient) using the paper or electronic documentation obtained from non-VA facilities such as Community Hospitals, Emergency Rooms, military facilities, etc.
- Understands the nuances of the CPT coding system for Third Party Insurance cost recovery and accurately interprets instructional notations; bundles encounters when appropriate; identifies non-billable encounters. HCPCS codes are used per guidelines.
- Codes all Operating Room procedures reported in the Surgical Package of the VistA hospital system; applies ICD and CPT coding systems and guidelines and selects proper codes using the current code set and the encoder product suite; ensures all procedures file to the appropriate Patient Care Encounter (PCE); adds Anesthesia and Pathology codes to the PCE encounter for all billable surgical cases.
- Reviews and codes assigned Fee Service patient encounters (outpatient) using the paper or electronic documentation obtained from non-VA facilities such as Community Hospitals, Emergency Rooms, military facilities, etc.
- Conducts re-reviews of codes abstracted for outpatient encounters identified by the VERA committee to determine if based on the documentation the specific VERA coding requirements were followed; corrects coding as needed to ensure proper patient classification in the VERA program.

**Work Schedule**: Monday - Friday 7:00am - 3:30pm EST

**Remote**:This is a remote position

**Functional Statement #**: PD21Q25A

**Relocation/Recruitment Incentives**: Authorized

**Permanent Change of Station (PCS)**:Not authorized

**Fi**nancial Disclosure Report**: Not required

**Requirements**:
**Conditions of Employment**:

- Selective Service Registration is required for males born after 12/31/1959.
- Must be proficient in written and spoken English.
- You may be required to serve a probationary period.
- Subject to background/security investigation.
- Selec