Washington, DC

U.S. Office of Personnel Management
Classification Appeal Decision
Under section 5112 of title 5, United States Code

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Carlos A. Torrico
Acting Classification Appeals and FLSA Claims
Program Manager
Agency Compliance and Evaluation
Merit System Accountability and Compliance


05/29/2018

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Date

As provided in section 511.612 of title 5, Code of Federal Regulations (CFR), this decision constitutes a certificate that is mandatory and binding on all administrative, certifying, payroll, disbursing, and accounting officials of the Government.  The agency is responsible for reviewing its classification decisions for identical, similar, or related positions to ensure consistency with this decision.  There is no right of further appeal.  This decision is subject to discretionary review only under conditions and time limits specified in the Introduction to the Position Classification Standards (Introduction), appendix 4, section G (address provided in appendix 4, section H).

As indicated in this decision, our findings show the appellant’s official position description (PD) does not meet the standard of adequacy described in section III.E. of the Introduction.  Since PDs must meet the standard of adequacy, the agency must revise the appellant’s PD to reflect our findings.  The servicing human resources office must submit a compliance report containing the corrected PD within 30 days of the date of this decision to the OPM Agency Compliance and Evaluation (ACE) Washington, DC, office.

Introduction

The appellant’s position is currently classified as Medical Records Technician (OA), GS-675-4, and is located in the Outpatient Medical Records section, Patient Administration Department (PAD), Naval Hospital Pensacola (NHP), Directorate of Administration, U.S. Department of the Navy (DON), in Pensacola, Florida.  The appellant believes her position should be classified as a Medical Records Technician (OA), GS-675-5.  We have accepted and decided this appeal under section 5112 of title 5, United States Code (U.S.C.).

General issues

The appellant makes various statements about her agency’s evaluation of her position and compares her duties to higher-graded medical records technician positions at other hospitals within and outside her agency.  In adjudicating this appeal, our responsibility is to make our own independent decision on the proper classification of her position.  By law, we must make that decision solely by comparing her current duties and responsibilities to OPM position classification standards (PCS) and guidelines (5 U.S.C. 5106, 5107, and 5112).  Since comparison to PCSs is the exclusive method for classifying positions, we cannot compare the appellant’s position to others that may or may not be properly classified, as a basis for deciding her appeal.  Because our decision sets aside all previous agency decisions, the appellant’s concerns regarding her agency’s classification review process are not germane to this decision.

Like OPM, the appellant’s agency must classify positions based on comparison to OPM standards and guidelines.  The agency also has primary responsibility for ensuring that its positions are classified consistently with OPM appeal decisions.  If the appellant considers her position so similar to higher graded positions at other Military Treatment Facilities (MTFs) within her agency, she may pursue the matter by writing to her headquarters agency human resources office.  In doing so, she should specify the precise organizational location, classification, duties, and responsibilities of the positions in question.  If the positions are found to be basically the same as hers, the agency must correct their classification to be consistent with this appeal decision.  Otherwise, the agency should explain to her the differences between her position and the others.  

The appellant believes her official PD, number 16PCA, is not accurate because it does not reflect the face-to-face customer service aspect of her work or the variety of questions and situations encountered when manning the front desk and duty phone.  However, the appellant’s supervisor (Supervisory Medical Records Technician, GS-675-7), organizationally titled Outpatient Supervisor, certified to the accuracy of the appellant’s official PD.  A position is the duties and responsibilities that make up the work performed by the employee.  Classification appeal regulations permit OPM to investigate or audit a position and decide an appeal based on the actual duties and responsibilities currently assigned by management and performed by the employee.  An OPM appeal decision classifies a real operating position and not simply a PD.  This decision is based on the work currently assigned to and performed by the appellant.  Our review disclosed the appellant’s PD is not completely accurate.  Specifically, under the description of Factor 4, Complexity, the appellant’s work does not consist “of some unrelated processes for maintaining of medical records and for establishing eligibility for care and registration as needed” as discussed later in this decision.  Therefore, the appellant’s PD of record does not meet the standard of adequacy as addressed on pages 10-11 of the Introduction, and the agency must revise the PD to reflect our findings.

Position information

The PAD of the NHP is composed of the Inpatient Records, Outpatient Records, Admissions and Medical Boards sections.  It provides administrative support to patients and staff members, promotes favorable healthcare relations between the Command and its beneficiaries, and maintains various Navy Medical Department programs.  The appellant’s position is located in the Outpatient Records section.  The section is directed by the PAD Head, consisting of a Supervisory Medical Records Technician, GS-675-7 (the appellant’s supervisor), and currently six Medical Records Technicians (OA), GS-675-4 (including the appellant).  Although requested, the agency stated it did not have a functional statement specific to the Outpatient Records section.  However, our fact-finding shows the Outpatient Records section is responsible for processing all incoming requests to the facility for release of information in accordance with Privacy Act and Health Insurance Portability and Accountability Act (HIPPA) requirements; registering eligible individuals to receive medical and dental care at the NHP, and performing various duties related to the maintenance and archival of outpatient medical records.  

The appellant’s primary responsibility involves processing and releasing protected health information (PHI) upon request from a variety of customers including, active duty members and their dependents, their authorized representatives, other MTFs, government agencies (e.g., Department of Veterans Affairs or Social Security Administration), and other authorized third parties such as insurance companies and law firms.  Requests are made in person at the customer service front desks, by mail, email, phone or fax.  The record indicates the appellant is assigned to work one of two customer service front desks at least twice a week and as back-up to the front desk once a week.  She is also assigned to answer calls received from the office’s duty phone once a week.  When processing PHI requests, the appellant reviews the request to ensure appropriate authorizations have been received, determines eligibility for release of information, and abstracts medical information from paper and electronic records.  She searches for medical records and information (e.g., prescriptions, diagnostic test results, beneficiary conditions) using the Armed Forces Health Longitudinal Technology Application (AHLTA), the military’s electronic health record and the Composite Health Care System (CHCS), an electronic medical information system used to input, store, revise, and retrieve medical data and results, e.g., laboratory and radiology results.  She also requests medical records from outside providers as necessary, scans medical records and information, and other patient documents into the Health Artifact and Image Management Solution (HAIMS).  Office automation databases (i.e., Access) and word processing programs are used to log, track and account for release of information requests and other information.  

The appellant is also responsible for registering active duty members, their dependents and other beneficiaries (e.g., retired military, civil service employees) for medical and dental care at the NHP.  She does this by verifying beneficiary eligibility using the Defense Enrollment Eligibility Reporting System (DEERS), a Department of Defense (DoD) database of information on uniformed service members (sponsors), their family members and others eligible for TRICARE benefits.  After confirming eligibility, she inputs demographic information, selects Patient Category (PATCAT) codes, and updates and/or corrects registrant information as necessary in CHCS.  Additionally, she resolves customer complaints, referring the more complicated issues to her supervisor and corrects medical records inconsistencies and discrepancies of a technical nature.  When not assigned to the customer front desk she performs the aforementioned duties received from other sources at her desk.

All medical records technicians of the Outpatient Medical Records section are assigned on a rotational basis for transferring Service Treatment Records (STRs) of active duty members who are retiring or separating to the Navy Medicine Records Activity (NMRA), and Non-Service Treatment Records (NSTRs) for medical records for patients not seen for care in two to three years to the National Personnel Records Center (NPRC) for archival.  These duties require identifying and preparing the record (i.e., certifying, indexing and requesting accession numbers), and boxing hardcopy records to be shipped out.  Boxes filled to capacity weigh up to 30 pounds each.

In reaching our classification decision, we have carefully reviewed all information provided by the appellant and her agency.  In reaching our classification decision, we have carefully reviewed all information provided by the appellant and her agency, including the official PD, which although not completely accurate, we have incorporated by reference into this decision.  In addition, to help decide the appeal we conducted separate telephone interviews with the appellant and her supervisor including follow-up requests for additional information from the appellant.

Series, title, and standard determination

The agency has classified the appellant’s position in the Medical Records Technician Series, GS-675, titling it Medical Records Technician (OA).  The parenthetical title (OA) signifying “Office Automation” is added to the title of positions excluded from the Office Automation Clerical and Assistance Series, GS-326, when such positions require significant knowledge of office automation systems and a fully qualified typist to perform word processing duties.  Based on our fact-finding and as stated on the appellant’s PD, we agree with the agency’s conclusion that such skills are needed to perform the work.  The office automation aspect of the appellant’s work is not grade-controlling and, therefore, is not addressed further in our decision.  Therefore, the appropriate title is Medical Records Technician (OA).  The appellant does not disagree with the agency’s title and series determination and we concur.  The grade of positions in the GS-675 series must be evaluated by reference to the grading criteria in the Job Family Position Classification Standard (JFS) for Assistance and Technical Work in the Medical, Hospital, Dental, and Public Health Group, GS-0600.  Our evaluation of the grade level of the position by application of the grading criteria for positions in the GS-675 series follows.

Grade determination

The GS-0600 JFS uses the Factor Evaluation System (FES) in which factor-levels and accompanying point values are assigned for each of the nine factors, with the total then being converted to a grade level by use of the grade-conversion table provided in the JFS.  Under the FES, each factor-level description in a JFS describes the minimum characteristics needed to receive credit for the described level.  Therefore, if a position fails to meet the criteria in a factor-level description in any significant aspect, it must be credited at a lower level unless the deficiency is balanced by an equally important aspect that meets a higher level.  Conversely, the position may exceed those criteria in some aspects and still not be credited at a higher level.  

The appellant disagrees with her agency’s assignment from the GS-0600 JFS of Factor Levels
4-2 for Factor 4, Complexity, and 5-2 for Factor 5, Scope and effect.  Based on the record, email information from the appellant received after the initial filing, and our interview, the appellant concurs with the agency’s assignment of the remaining factors at Levels of 1-3, 2-2, 3-2, 6-2, 7A, 8-2, and 9-1.  After careful review, we concur with the agency’s assignment of Factor Levels 1-3, 2-2, 3-2, 6-2, 7A, 8-2 and 9-1, thus have not specifically addressed them in our discussion below.  Therefore, our evaluation is limited to only those factor levels in dispute.  

Factor 4, Complexity

This factor covers the nature, number, variety, and intricacy of tasks, steps, processes, or methods in the work performed; the difficulty in identifying what needs to be done; and the difficulty and originality involved in performing the work.  

At Level 4-2, work consists of related steps, processes, or standard explanations of methods, such as compiling, recording, and reviewing medical records data.  The employee decides what needs to be done by choosing from a few recognizable alternatives, such as determining the relevance of many facts and conditions of information within the medical record, legal, and regulatory requirements, and other variables.  The employee recognizes inconsistencies in the medical records, and applies prescribed medical records procedures and methods to validate that the record contains factual information.  

A work illustration in the GS-0600 JFS of a Medical Records Technician at Level 4-2, describes a position that reviews, screens, and analyzes all requests for release of medical information.  The employee analyzes each request to ensure that proper authorizations are submitted and determines the originator’s entitlement to information in accordance with the Privacy Act and medical facility regulations.  The employee retrieves records, compiles and collates medical data, and coordinates the release of medical records data with various medical and administrative staff members.  The employee determines easily recognizable inconsistencies in forms completed by the patient that affect entitlement.

At Level 4-3, work consists of different, varied, and unrelated medical record processes and methods, including reviewing the work of other employees to verify compliance with regulatory requirements.  The employee determines the relevance of many facts and conditions such as information contained in the record, legal and regulatory requirements, and other variables, and determines the appropriate action from many alternatives.  The employee identifies and analyzes medical records problems and determines their interrelationships and the appropriate methods and techniques needed to resolve them.  

The appellant’s position meets Level 4-2.  Like this level, the duties performed by the appellant require following related steps and processes such as reviewing, abstracting and compiling of outpatient medical record information.  For instance, because DEERS enrollment is directly tied to TRICARE eligibility, medical care may be denied if the sponsor and family members are not enrolled.  Thus, before registering a beneficiary to receive care at the NHP, the appellant reviews a member’s medical eligibility status in DEERS, and verifies member’s identity by checking proper identification such as a DoD ID and social security number (SSN).  Once eligibility has been established, she compiles and records patient demographic information and assigns a PATCAT code to identify the sponsor (e.g., Army Active Duty) and entitlement (e.g., Family Member) in CHCS.  Also, like Level 4-2, she decides what needs to be done by choosing from a few recognizable alternatives.  For instance, she identifies individuals who although not enrolled in DEERS are still eligible for medical care and uses alternative means to record and confirm their medical eligibility.  For example, in the case of a member having a newborn who has not been issued a SSN and not yet enrolled in DEERS, the appellant may prompt CHCS to assign a pseudonym SSN to allow for patient registration until DEERS enrollment is completed.  Another example relates to military reservists injured in the line of duty.  These individuals do not show as enrolled in DEERS because they are no longer active duty members.  However, the member qualifies for Line of Duty (LOD) care for illness or disease resulting in emergency or urgent care while serving on drill weekends or annual training.  In this case, the appellant requests a letter from the reservists’ command to verify eligibility to receive LOD care at the NHP.

Comparable to Level 4-2, the appellant recognizes inconsistencies in medical records and corrects errors using prescribed methods to properly document medical records in CHCS and ALHTA.  For instance, she ensures changes in family status such as marriage, divorce or a new child are updated and/or corrected in CHCS.  She also identifies and corrects technical errors involving duplicate medical record accounts found in ALHTA using methods to separate and delete additional medical record accounts.  As expected at this level, the procedures for dealing with such situations are relatively limited and well established.  The appellant’s choices consist of determining what entries do not conform to factual data and what needs to be done to meet documentation requirements.  The appellant’s duties favorably compare to the work illustration at Level 4-2.  Like that illustration, in performing release of information duties she reviews the validity of PHI requests, ensuring proper authorization is included (i.e., HIPPA release authorization), searches, retrieves and compiles medical record data from both electronic and paper records, and releases information in compliance with the Privacy Act and HIPPA requirements.  Requests involving subpoena of records without a HIPPA release of information authorization from the requestor are forwarded to the legal department of the NHP for clearance.  

The appellant’s position does not meet Level 4-3.  Unlike Level 4-3, the appellant’s duties do not involve performing different and varied medical processes including reviewing the work of the staff to ensure compliance with regulatory requirements.  Instead, she performs standard medical records technician duties limited to the Outpatient Medical Records section.  The appellant states that she is required to review the work of co-workers through a peer-review process.  Specifically, when reviewing peer release of information files she checks that the information released is limited to what is specifically requested and to the person or entity designated to receive it.  Where clarification is needed regarding the type of information desired, the appellant contacts the requestor.  Thus, her review lacks the complicating factors and subjective judgments associated with more intensive specialized reviews requiring the performance of specialized medical records functions or processes (e.g., coding of patient records) characteristic of Level 4-3.  Further, unlike Level 4-3, the appellant’s duties do not require her to determine the relevance of many facts and conditions contained in the medical record, but rather are typically limited to factual determinations regarding patient care eligibility and release of PHI.  Moreover, unlike Level 4-3, her work does not involve the analysis and interpretation of medical record problems and issues to determine their interrelationships and the appropriate methods and techniques needed to resolve them.  Instead, as previously addressed her work is limited to following established medical records procedures and documentation methods to comply with regulatory requirements.

This factor is evaluated at Level 4-2 and 75 points are assigned.  

Factor 5, Scope and effect

This factor covers the relationship between the nature of the work (i.e., purpose, breadth, and depth of the assignments) and the effect of work products or services both within and outside the organization.  

At Level 5-2, work involves performing assignments according to specific rules or procedures that represent a significant segment of the medical records function for the organization.  Work affects the accuracy, timeliness, reliability, and acceptability of information in the medical records.  

A work illustration in the GS-0600 JFS of a Medical Records Technician at Level 5-2 describes a position that receives and screens all incoming correspondence requesting the release of medical information.  If the information requested is not in the medical record, the employee forwards the request to the appropriate source for a response.  Accuracy and efficiency of the work affects the reliability of services the unit provides.  

At  Level 5-3, work involves performing a variety of specialized medical record tasks, and resolving problems according to established criteria (e.g., processing medical records data that involve inconsistencies, discrepancies, and other non-routine problems), and developing, maintaining, and monitoring special registries that assist physicians in the care and treatment of patients.  Work affects the accuracy, reliability of medical records, which in in turn affect the outcome of research efforts; the outcome of internal and external audits; the quality of information physicians receive on such things as readmission and legal claims; and the quality of patient care rendered.  

The appellant’s position meets Level 5-2.  Like this level, her work involves performing duties of the Outpatient Medical Records section according to specific rules or procedures.  For instance, when releasing PHI she applies patient confidentiality rules and follows system procedures for abstracting medical information from various sources such as ALHTA, CHCS and hardcopy medical files.  The appellant’s work matches the work illustration at Level 5-2.  Like that illustration, when information requested is not in the medical record, the appellant contacts the appropriate requestor for response. Also, like Level 5-2 and its illustration, the accuracy and efficiency of the appellant’s work affects the reliability of services provided by the Outpatient Medical Records section of the NHP.  

The appellant’s position does not meet Level 5-3.  The appellant is not involved in a number of different, varied, and specialized medical record processes typical of Level 5-3, such as maintaining select disease registries that assist physicians in the care and treatment of patients, or carrying out quality assurance, research, or other special project studies.  Rather, as previously described she performs standard and routine outpatient medical record functions in compliance with procedural requirements.  Further, unlike Level 5-3 the appellant’s work does not affect the accuracy, reliability of medical records, which in in turn affect the outcome of research efforts, the outcome of internal and external audits, the quality of information physicians receive on such things as readmission and legal claims, and the quality of patient care rendered.   

This factor is evaluated at Level 5-2 and 75 points are assigned.  

Summary
Factors	Level	Points
1. Knowledge required by the position	1-3	350
2. Supervisory controls	2-2	125
3. Guidelines	3-2	125
4. Complexity	4-2	75
5. Scope and effect	5-2	75
6. & 7. Personal contacts/Purpose of contacts	2A	45
8. Physical demands	8-2	20
9. Work environment	9-1	5
Total		820

A total of 820 points falls within the GS-4 grade level point range (655 to 850) in the grade conversion table of the JFS.  

Decision

The appellant’s position is properly classified as Medical Records Technician (OA), GS-675-4.

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