Qualifications

Basic Requirements:

• Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy
• Experience: One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a health records
• OR Education: An associate's degree from an accredited college or university recognized by the U.S. Department of Education with a major field of study in health information technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management (e.g., courses in medical terminology, anatomy and physiology, medical coding, and introduction to health records)
• OR Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding
• The training program must have led to eligibility for coding certification/certification examination, and the sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor, or comparable international accrediting authority at the time the program was completed
• OR Experience/Education Combination: Equivalent combinations of experience and education are qualifying
• The following educational/ training substitutions are appropriate:(a) Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, and one year above high school, with a minimum of 6 semester hours of health information technology courses
• (b) Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service, under close medical and professional supervision, may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures
• Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder)
• Certification
• Persons hired or reassigned to Medical Record Technician (Coder - Outpatient) positions in the GS-0675 series in VHA must have either of the following certifications/credentials: Apprentice/Associate Level Certification through AHIMA or AAPC Mastery Level Certification through AHIMA or AAPC Clinical Documentation Improvement Certification through AHIMA or ACDIS English Language Proficiency: LPMHCs must be proficient in spoken and written English in accordance with VA Handbook 5005, Part II, chapter 3, section A, paragraph 3.j
• Grandfathering Provision: All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series, and grade held, including positive education and certification that are part of the basic requirements of the occupation
• Grade Determinations: Medical Records Technician (Coder-Outpatient) GS-8 (Full Performance Level) Experience
• One year of experience equivalent to the next lower grade level
• Demonstrated KSAs
• In addition to the experience above, the candidate must demonstrate the following KSAs: Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation
• This includes the ability to read and understand the content of the health record, the terminology, the significance of the findings, and the disease process/pathophysiology of the patient
• Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and/or inpatient professional fee services coding
• Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity, and the ability to use judgment in completing assignments using incomplete or inadequate guidelines Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.