Medical Records Technician (Coder-Outpatient)

This position is located in the Health Information Management (HIM) section at the Anchorage VA Medical Center. MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers.Total Rewards of a Allied Health Professional Duties may include, but are not limited to: Completes diagnostic and procedural coded data are necessary for research, epidemiology, outcomes and statistical analysis, financial and strategic planning, reimbursement, evaluation of quality of care, and communication to support the patient's treatment. Diagnoses and procedures will be coded utilizing the current edition of International Classification of Diseases (ICD) Clinical Modification (CM), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS). NOTE: Coders will follow current published ICD-10-CM Official Guidelines for Coding and Reporting, CPT Guidelines, as well as other established industry standard coding guidance such as the American Medical Association (AMA) CPT Assistant and the American Hospital Association's (AHA) Coding Clinic. Selects and assigns codes from the current version of several coding systems to include ICD, CPT, and/or HCPCS. Assigns codes to documented patient care encounters (outpatient and/or inpatient professional services) covering the full range of health care services provided by the VAMC. Applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs. Monitors ever-changing regulatory and policyrequirements affecting coded information for the full spectrum of services provided by the VAMC. Performs a comprehensive review of the electronic health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. Assists facility staff with documentationrequirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations. Ensures provider documentation is complete and supports the diagnoses and 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 health record. Searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the electronic health record. Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA databases. Corrects any identified data errors or inconsistencies in a timely