To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 04/10/2025

Basic Requirements:

Citizenship. Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g, this part.)

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 experience that indicates knowledge of medical terminology and general understanding of 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 medical record techniques and procedures. Also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record

Certification. Persons hired or reassigned to MRT (Coder) 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

Grade Determinations: MRT (Coder- Inpatient)

GS-7
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:
1. Skill in applying current coding classifications to a variety of inpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record.
2. Ability to communicate with clinical staff for specific coding and documentation issues such as recording inpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health care documentation and code assignment.
3. Ability to research and solve coding and documentation related issues.
4. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.
5. Ability to abstract, assign, and sequence codes, including complication or CC/MCC, and POA indicators to obtain correct MS-DRG.

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:
1. Ability to analyze the medical 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 medical record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient.
2. Ability to accurately perform the full scope of inpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and inpatient professional services.
3. 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.

References: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.