Medical Records Technician (Coder) job - Department of Veterans Affairs - Augusta, ME

is responsible for performing quality review of patient care documents & assigning codes specific for the type of care provided. Duties include, but are not limited to:

• Assigns codes to documented patient care encounters (inpatient/outpatient) covering the full range of health care services. Patient encounters are often complicated & complex requiring extensive coding expertise. Applies advanced knowledge of medical terminology/anatomy/physiology/disease processes/treatment modalities/ diagnostic tests/medications/procedures as well as the principles/practices of health services & the organizational structure to ensure proper code selection.


• Adheres to accepted coding practices, guidelines & conventions when choosing the most appropriate diagnosis/operation/procedure/ancillary/or Evaluation & Management code to ensure ethical/accurate/complete coding. Also applies codes based on guidelines specific to certain diagnoses/procedures/other criteria (inpatient/outpatient settings) used to classify patients under the Veterans Equitable Resource Allocation program that categorizes all patients into specific classes representing their clinical conditions & resource needs.


• Assists facility staff with documentation requirements to completely/accurately reflect the patient care provided; provides technical support in the areas of regulations & policy/coding requirements/resident supervision/reimbursement/workload/accepted nomenclature/proper sequencing. Insures provider documentation is complete & supports the diagnoses & procedures coded. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation or codes in the electronic patient record.


• Utilizes the facility computer system/software applications to correctly code/abstract/record/transmit data to the national VA database in Austin. Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the organizational database within established timelines. Independently researches references to resolve any questionable code errors; contacts supervisor as appropriate.


• Works within a team and supports the diagnoses & procedures environment; supports peers in meeting goals & deadlines; flexibleand handles multiple tasks; works under pressure; & copes with frequently changing projects & deadlines.


• Codes inpatient professional fee services for identified inpatient admissions in support of the Medical Care Cost Recovery program. Code selection is based upon strict compliance with regulatory fraud & abuse guidelines and organizational specific guidance for optimum allowable reimbursement.


• Establishes the primary & secondary diagnosis & procedure codes for billable outpatient encounters following applicable regulations/instructions/requirements for allowable reimbursement; links the appropriate diagnosis to the procedure &/or determines level of Evaluation & Management service provided. Understands the nuances of the CPT coding system for Third Party Insurance cost recovery & accurately interprets instructional notations; bundles encounters when appropriate; identifies non-billable encounters.


• Codes all Operating Room procedures reported in the Surgical Package of the computerized hospital system; follows coding guidelines & selects proper codes, & ensures all procedures file to the appropriate Patient Care Encounter; adds Anesthesia & Pathology codes for all billable surgical cases.

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WORK SCHEDULE – Monday – Friday 8:00 am to 4:30 pm.