US Department of Veterans Affairs
Baltimore, MD, USA
Medical Records Technician (Coder-Outpatient and Inpatient) This position is in the Coding Section at the VA Maryland Health Care System (VAMHCS). The Medical Records Technician (Coder) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided. This is considered the full performance level for this assignment. Coders at this level perform either inpatient or outpatient coding duties, or a combination of inpatient and outpatient coding duties. Major duties may include: Identifies the principal diagnosis and principal procedure (when applicable) for every inpatient discharge; also identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG). Upon patient admission to the Community Living Center/Nursing Home Care Unit, codes the admission diagnosis for use by unit staff. All diagnoses and...