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P D # 881500
Navajo Area I H S
Area Standard Position Description

Medical Record Technician (Coder)
G S-675-08

I. INTRODUCTION

This position is located in the Medical Records Department of an Indian Health Care Facility within the Navajo Area.

The incumbent performs highly technical and specialized functions for an outpatient and inpatient Medical Record. The incumbent reviews, analyzes, and codes diagnostic and procedural information that determines, Medicare, Medicaid and Private Insurance payments. The primary function of this position is to perform I C D-9-C M and C P T coding for reimbursement. The coding function is a primary source for data and information used in a health care today, and promotes provider/patient continuity, accurate, data base information, and the ability to optimize reimbursement. The incumbent is responsible for the accuracy and timely completion of the health record. The coding function is a primary resource for allocation for N A I H S / I H S.

II. MAJOR DUTIES AND RESPONSIBILITIES

25% C P T Coding:

Selects the correct principal diagnosis and operation/procedure. When multiple diagnoses and procedures are listed, assures the surgical procedure is related to the proper diagnosis. Assures maximum allocation under Diagnostic Related Group (D R G), Ambulatory Patient Group (A P G) system by properly sequencing diagnosis and procedures in order of severity of illness treated.

Performs utilization reviews and D R G assignments utilizing an encoder, analyzing inpatient and outpatient records for reimbursement and complete abstraction of services rendered to obtain optimal results.

Provides technical assistance with processing and maintaining C P T coding, abstraction of the complete chart (inpatient/outpatient) and compliance enforcement of all regulatory requirements. Reviews, analyzes, C P T coding, abstracts and compiles data, maintains and identifies potential risk areas in inpatient and outpatient medical records. All information will be for manual data analysis for the Business Office, Compliance Officer, Medical Records and Administration.

Searches and abstracts all C P T coding, operative and therapeutic and all other pertinent data from the medical records in order to identify, encode and document appropriate patient care and other information necessary for reporting purposes (Compliance Program).

Conducts a thorough review of all abstraction and search of records and guidelines in order to select the most accurate and descriptive codes in accordance with C P T / H C P C S coding system. Code selection involves discriminating between several different codes, which can overlap in scope, encompass multiple diagnoses, treatments or operations; and include special codes to denote causes of accidents/injury or adverse effects.

Keeps abreast of Coding trends.

30% I C D-9-C M Coding:

The incumbent assigns and sequences I C D-9-C M/C P T / H C P C S codes to diagnosis and procedure from documented information. Assures the final diagnoses and operative procedures as stated by the physician are valid and complete. Abstracts all necessary information from the medical records to identify secondary complications and co-morbid conditions.

Abstracts all necessary information and assigns codes (I C D-9, C P T & H C P C S), which most accurately describe each documented diagnosis, surgical procedure and special therapy or procedure according to established guidelines and practices.

Assures that the diagnosis responsible for length of stay is appropriately identified and that the secondary diagnoses are sequenced properly in order to assure maximum allocation under the Diagnostic Related Group (D R G) system. If there are questions/problems with documentation the provider is notified immediately.

The incumbent determines the final diagnoses and procedures stated by the physician are valid and complete. The incumbent corrects sequence (in consultation with the attending physicians as necessary) that complies with the I H S Uniform Hospital Discharge Data Set definitions in preparation for itemizing and billing.

Works with automated record systems, data entry and encoder software. Generates billing data forms on all third party covered patients.

Uses coding conventions, techniques, coding rules and H C F A regulations. Keeps up-to-date with current codes and trends.

25% Analysis/Performance Improvement

Quantitative analysis – Performs a comprehensive review for the record to assure the presence of all component parts such as; patient and record identification, signatures and dates where required, and the presence of all reports which appear to be indicated by the nature of the treatment rendered.

Qualitative analysis – Evaluates the record for documentation consistency and adequacy. Ensures that the final diagnosis accurately reflects the care and treatment rendered. Reviews the records for compliance with established third party reimbursement agencies and special screening criteria.

Medico-legal requirements – Makes final determination that the record is complete, accurate, and reflects sufficient data to justify the diagnosis and warrant treatment and end results, without infringing on decisions concerning a physician’s clinical judgement.

Identifies inconsistencies or discrepancies within the medical record and discusses with the appropriate medical, nursing, or healthcare providers for corrective action, without infringing on decisions concerning clinical judgement.

INFORMATION MANAGEMENT 20%

R P M S

Is responsible for data entry of all inpatient clinical record information into the R P M S system for transmission to the Navajo Area Office. Corrects error listings and reports pertaining to inpatient coding. Incumbent generates management reports and clinical reports as requested.

Mix Index:

On a monthly basis submits a case mix index report as required by clinical Director for statistical purposes used as a gage for national comparison. Technician will abstract length of stay, D R G and weight and post on daily discharge listing by wards, posts by months. Total all discharges by ward and total all weights and divide total discharge by weight to get total case mix index.

Pre-Certification/Pre-Admission Reviews:

The incumbent in conjunction with the Utilization/Review Coordinator has responsibility for the coordination and management of the reimbursement system to ensure quality care in the most cost-efficient manner. Working with various departments identifying problems and suggesting methods to maximize reimbursements. Other duties of this function are as follows:

Admission Reviews: The incumbent determines form available, documentation and patient’s information, the medical necessity of admission to an acute care facility, as related to private insurance companies criterion.

Continued Stay Review: The incumbent reviews, at required intervals, available documentation to verify (assure) continued need for hospitalization as related to private insurance companies criterion.

Pre-Admission Review: The employee reviews all identified/referred Pre-Admission patients and process them as required by their private insurance companies, that is, obtain pre-certification approval code numbers and length of stay.

Professional Review: The employee coordinates discrepancies and correspondents with professional organization representatives including Insurance companies to assure documentation and coding are accurate and complete and meet requirement set forth in review guidelines.

The incumbent creates and maintains records and logs, which reflect, accountability for all coding processed. Patient billing files will be established for Billing.

Orients and trains new employees, practitioners and other hospital staff to their specialized medical record functions.

Incumbent may lead medical clerks during evening and weekend rotation shifts as assigned. Reports are given to Medical Record supervisor via a completed report at the end of the work shift.

III. FACTOR LEVELS

FACTOR 1 – Knowledge Required by the Position Factor Level 1-5 750 points.

Advanced knowledge and understanding of medical science and medical terminology, that is, symptoms, tests, diagnostic rationale, and treatment protocols.

Thorough knowledge of anatomy and physiology.

Advanced knowledge of I C D-9 and C P T 4 coding procedure, Uniform Hospital Discharge Date definitions regarding diagnostic and procedural sequencing.

Extensive knowledge and ability of medical record documentation requirements and record management system.

Ability to effectively communicate orally and in writing. Ability to prepare and write sufficient reports and other materials

Ability to make presentation to other staff members, conduct briefings and training classes.

Ability to communicate and work effectively with providers.

Extensive knowledge of official coding conventions and rules established by the American Medical Association (A M A), and the Health Care Finance Administration (H C F A) for assignment of diagnostic and procedural codes.

Thorough knowledge of medico-legal aspects of health information management.

Thorough knowledge of the Privacy Act of 1974 and Freedom of Information Act regulations and requirements regarding responsibilities for patient confidentiality. Knowledge of the laws and regulations on the confidentiality of medical records and the procedures for informed consent for release of information from the record.

Knowledge of the Resource Patient Management System (R P M S). Keeps abreast of current changes in government regulations, collection laws, F T C ruling, third party payer procedures and internal procedures. Knowledge and ability to generate management reports.

Knowledge of the rules and regulations pertaining to a compliance program and various aspects of compliance issues, specifically coding and billing issues and its relation to I H S.

Extensive knowledge of J C A H O, HCFA, H C P C S, Medicare/Medicaid and other regulatory agencies to ensure the record complies with requirements of regulatory agencies.

Ability to establish Performance Improvement functions, tracking, and reporting outcomes and conclusions/follow up both verbally and in written text.

Knowledge and ability to code complicated medical records having diagnostic, surgical, and therapeutic procedures on specific D R G’s (Diagnostic Related Group) that are identified as difficult to classify.

Knowledge of specialized procedures and methods to correct and amend records.

Knowledge and skill of computer application. Ability to operate computerized data entry and information processing systems. Skill in data collection to compile and organize information for reporting and presentation.

FACTOR 2 – Supervisory Controls Factor Level 2-3 275 points. The incumbent works independently under general supervision of the Supervisor or designee. The supervisor defines overall program goals and priorities. Employee works on own initiative and independently, prioritizes work and resolves problems within the scope of Service Unit policies.

The incumbent coordinates unusual situations that do not have clear precedents with the supervisor.

The Supervisor places considerable reliance upon the technician’s knowledge of medical records.

The supervisor reviews the work for results achieved, technical soundness, and conformity to medical record policy and requirements.

FACTOR 3 – Guidelines Factor Level 3-3 275 points. Guidelines include: Encoder, I C D-9-C M, C P T-4, H C P C S and other coding classification systems, R P M S users guide, P D R, the Privacy Act, medical dictionaries, I H S and Service Unit manuals, J C A H O and S U Business Office Compliance Plan, Health Records guidelines, written and oral policies and procedures. These guides are general in nature and do not cover all areas of the work performed by the medical record technician, such as cases involving new diseases, treatments, or experimental drugs.

The incumbent uses judgment to adapt and interpret guidelines for application to specific cases or problems using discretion and initiative in deciding on the right course of action to correct deficiencies and improve reliability of information in the records. This may require developing approaches and work methods within the framework established by higher level authority, devising procedures to use when applying new regulatory requirements, or adapting to new computer technology.

FACTOR 4 – Complexity Factor Level 4-3 75 points. The work involves highly complex Medical Record processes and procedures. The Technician performs periodic reviews of other employees’ work to confirm conformance to policies, regulations and Medical Records Standards. Furthermore, the employee carries out specialized assignments such as setting up special registries, assisting with a wide range of quality assurance/P I studies, providing problem-solving services in specific areas of medical records/research activities, coding complicated medical records, or making recommendations to improve procedures for compiling and retrieving medical record information. The decisions about what needs to be done requires the Technician to determine the relevance of many facts and conditions which meet coding standards, H C F A Utilization Reviews, J C A H O, Compliance, legal and regulatory standards. Uses a complex body of specialized subject matter knowledge, interviewing, interpreting and investigation techniques to assure that accurate information is abstracted in an effective and efficient manner.

The work involves analyzing and interpreting conditions and elements to correct complicated inconsistencies or discrepancies in the Medical Records.

FACTOR 5 – Scope and Effect Factor Level 5-3 150 points. The Medical Record function of this position is an integral portion of the operation of the hospital. Because information in the medical record is the basis for reimbursement as well as clinical decision-making, coding entries must be complete and accurate. The amount of reimbursement depends on the correct coding of diagnoses and procedures and appropriate D R G assignment. The work typically has a direct effect on medical record keeping and a direct impact on the accuracy, documentation, timeliness, reliability and acceptability of information in the medical record services.

Work has considerable impact on the accreditation status of the hospital, quality of patient care, reliability of research data and the maximization of Third-Party reimbursement.

The coding function is a primary source used in health care today, and promotes provider/patient continuity, accurate data, statistic information, and the ability to optimize reimbursement.

FACTOR 6/7 – Personal Contacts/Purpose of Contacts Factor Level 2B 75 points. Contacts are with health care practitioners, medical records staff, and various departments within the agencies. Other contacts include private health providers, consultants, visitors, patients, and their family members, Federal and State Agencies.

The purpose of the contacts is to exchange factual information and to coordinate work efforts and solve technical problem pertaining to key entry, coding or to issues pertaining to the Compliance plan of the Service Unit. Resolves issues pertaining to services rendered to Indian Beneficiaries and Non-Beneficiaries. Issues pertaining to the Compliance Program of Navajo Area.

FACTOR 8 – Physical Demands Factor Level 8-1 5 points. The work is sedentary, however, there may be some walking, standing, carry of light items such as manuals or bundles of forms within the work area with the majority of time spent at the computer terminal entering medical and coding data that require intense concentration. The visual demand is intensive and the usage of video display terminals (C R T) have been known to have adverse health effects and discomforts such as eye strain, headaches, poor concentration and irritability. The extensive use of the keyboard for long periods can cause shoulder, arms and wrist strain and prevention should be taken with wrist supports and routine exercises.

FACTOR 9 – Work Environment Factor Level 9-1 5 points. The work is performed is an office setting with adequate lighting, heating and ventilation. Work environment involves some discomfort due to long hours sitting while performing abstracting, coding and key entering of medical information with some walking within the hospital.

Total Points: 1610 = G S-8

III. OTHER SIGNIFICANT FACT

Incumbent may be required to work on a rotational basis for shift, weekend and holiday duty as needed and assigned.

The Privacy Act of l974 mandates that the incumbent shall maintain complete confidentiality of all administrative, medical and personnel records and all other pertinent information that comes to his/her attention or knowledge. The Privacy Act carries both civil and criminal penalties for unlawful disclosure of records. Violations of such confidentiality may be cause for adverse action.