Medical Records Technician (Coder-Outpatient and Inpatient)

Basic requirements

• U.S. citizenship requirement applies, with limited exceptions for non-citizens under VA policy.
• One year of creditable experience in medical terminology, anatomy, physiology, pathophysiology, medical coding, and health record structure and format; or
• An associate degree in health information technology/management or a related field with at least 12 semester hours in HIM/HIT coursework; or
• Completion of an AHIMA-approved or comparable intensive coding program of about one year or more; or
• Equivalent combinations of education and experience.
• Certification must include one of the following:
  • Apprentice/Associate level certification through AHIMA or AAPC
  • Mastery level certification through AHIMA or AAPC
  • Clinical Documentation Improvement certification through AHIMA or ACDIS

Grade-specific qualifications

• GS-5: One year of experience at the next lower grade level or a qualifying bachelor's degree.
• GS-6: Ability to analyze records, apply ICD-CM/PCS and CPT guidelines, understand HIPAA and other confidentiality requirements, and work with classification systems such as ICD-CM, ICD-PCS, CPT, and HCPCS.
• GS-7: Ability to code across inpatient and outpatient specialty care areas, communicate with clinical staff, research and resolve coding/documentation issues, and sequence codes accurately.
• GS-8: Ability to perform full-scope outpatient and inpatient facility coding, interpret complex health record documentation, and apply judgment when guidelines are incomplete or unclear.