Medical Records Technician (Coder)
The Medical Record Technician (Coder) position is in the Health Information Management (HIM) section at the Minneapolis VA Health Care System. The MRT (Coder) is responsible for the technical duties related to abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided. Current clinical classification systems include the International Classification of Diseases - Clinical Modification, ICD-10-CM, CPT, and the HCPCS.Responsibilities
Duties include but are not limited to:
- Reviews and analyzes clinical medical record documentation for patient care episodes for all specialties from CPRS and/or VISTA Imaging to determine the reason for the episode, conditions addressed and all procedures performed. Develops skill and knowledge of health record coding.
- Selects and assigns codes from the current version of one or more coding systems appropriate for the type of care provided.
- Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate and complete coding.
- Gains knowledge of regulatory and policy requirements affecting coded information. Ensures resident supervision guidelines are met when applicable.
- Reviews record documentation to abstract other required data. Enters information into appropriate software package.
- Reviews all coding edits returned in encoder product and revises coding. Reviews coverage determination issues regarding medical necessity of specific procedures and diagnostic tests.
- Ensures all documentation is present, accurate, complete and in an appropriate format. Ensures that documentation meets Joint Commission and VA requirements. Identifies problems in documentation.
- Reviews documentation regarding conditions that have been adjudicated as a service connection (SC) condition or for special treatment authorities related to exposures or experiences and forwards to Utilization Review.
- Utilizes the facility computer systems and software applications to code, abstract, record and transmit data to the national VA database. Corrects any identified data errors or inconsistencies. Researches references to resolve code errors.
- Uses a variety of MS Windows based application; MS Outlook, MS Excel, MS Word; competent in use of the health record applications and encoder product suite.
- Communicates and interacts appropriately with a variety of staff from other areas/services. Follows appropriate channels and communication methods.
- Completes work within established timeframes to ensure reimbursement and workload credit are received.
- Works within a team environment.
- Participates in regular meetings and attends training and education seminars.
- Abides by the American Health Information Management's established code of ethical principles.
Financial Disclosure Report: Not required Travel Required
Not requiredSupervisory status No Promotion Potential 8