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P D # 881500
Navajo Area I H S
Area Standard Position Description
Medical Record Technician (Coder)
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
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
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.
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
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
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.
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.
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
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
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
Thorough knowledge of medico-legal aspects of health information
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
Knowledge of specialized procedures and methods to correct and
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
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
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
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
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.