Washington D.C.
U.S. Office of Personnel Management
Classification Appeal Decision
Under section 5112 of title 5, United States Code
Patient Administration Department
Director for Administration
Navy Medicine Readiness and
Training Command
Bureau of Medicine and Surgery
U.S. Department of the Navy
Lemoore, California
GS-0675-04
Damon B. Ford
Acting Classification Appeals and FLSA Claims Program Manager
Agency Compliance and Evaluation
Merit System Accountability and Compliance
06/09/2020
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 discussed in this decision, our findings show the appellants’ 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 appellants’ PD to reflect our findings. The servicing human resources office must submit a compliance report containing the corrected PD and Standard Form (SF) 50s showing the personnel action taken. The report must be submitted within 30 days from the effective date of the personnel action to the Office of Personnel Management (OPM), Agency Compliance and Evaluation, Washington, DC, office.
Introduction
The appellants[1] occupy an identical additional position (hereinafter referred to as “position”) classified as Medical Records Technician, GS-0675-04, and are assigned to the Outpatient Administration Division, Patient Administration Department, Director for Administration, Navy Medicine Readiness and Training Command, Bureau of Medicine and Surgery, U.S. Department of the Navy (Navy), in Lemoore, California. They request their position be classified at the GS-05 grade level. We have accepted and decided this appeal under section 5112 of title 5, United States Code (U.S.C.).
General issues
The appellants assert they perform work similar to higher-graded positions at other Navy medical facilities. In adjudicating this appeal, our responsibility is to make our own independent decision on the proper classification of their position. By law, we must make that decision solely by comparing their current duties and responsibilities to OPM position classification standards (PCS) and guidelines (5 U.S.C. 5106, 5107, and 5112). Since comparison to standards is the exclusive method for classifying positions, we cannot compare the appellants’ position to others, which may or may not be classified correctly, as a basis for deciding their appeal.
Like OPM, the appellants’ agency must classify positions based on comparison to OPM PCSs and guidelines. The agency also has primary responsibility for ensuring that its positions are classified consistently with OPM appeal decisions. If the appellants consider their position so similar to others that they warrant the same classification, they may pursue the matter by writing to their headquarters’ human resources office. In doing so, they 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 theirs, the agency must correct their classification to be consistent with this appeal decision. Otherwise, the agency should explain to them the differences between their position and the others.
In their appeal request to OPM, the appellants assert the language in their official PD, number PM0H122001, supports evaluation of their position to a higher factor level by comparison to the relevant PCS. A PD is the official record of the major duties and responsibilities assigned to a position by a responsible agency official; i.e., a person with authority to assign work to a position. A position is the work that makes up the duties and responsibilities performed by an employee. Classification appeal statutes and regulations permit OPM to investigate or audit a position and decide an appeal based on the duties assigned by management and performed by the employee. We classify a real operating position and not simply the PD. Therefore, this decision is based on the actual work assigned to and performed by the appellants.
Position information
The appellants and first-level supervisor certified to the accuracy of the appellants’ official PD. However, in OPNAV Notice 5400, dated October 15, 2019, from the Chief of Naval Operations, Naval Health Clinic Lemoore (formerly called a “Hospital”) was officially renamed Navy Medicine Readiness and Training Command effective the above date. Therefore, because the PD is outdated by still identifying the facility as a “Hospital”, we find it does not meet the standard of adequacy addressed on pages 11-12 of the Introduction, and the agency must revise the PD to reflect the current name and setting of the organization.
Treatment and services provided by the medical facility include, but are not limited to, general surgery, immunizations, mental health, obstetrics and gynecology, occupational health, audiology, optometry, orthopedics, podiatry, substance abuse rehabilitation program, and urgent care. The appellants perform work in the records room and are directly supervised by the Supervisory Medical Records Administration Specialist, GS-0669-09. They generally agree with the accuracy of the work percentages identified by their PD, which describes spending 65 percent of the time on maintaining and updating health records; 25 percent on requesting records from military and civilian medical facilities; five percent on ensuring health records are pulled, sorted, and delivered to medical clinics; and five percent on other tasks.
The appellants perform the full variety of technical duties associated with the maintenance, retention, and disposal of outpatient medical records for dependents of active duty military personnel, as well as retirees and their dependents eligible for care. Medical records are arranged into four parts: (1) Part 1 is a record of preventive medicine and occupational health (e.g., immunization, visual, and audiogram records); (2) Part 2 is a record of medical care and treatment; (3) Part 3 is a record of physical qualifications and administrative forms (e.g., living will or medical power of attorney); and (4) Part 4 is a record of ancillary studies, inpatient care, and miscellaneous forms (e.g., laboratory reports). Forms are arranged chronologically by date of most recent action. The appellants implement their unit’s quality assurance process, reviewing records annually for accuracy, completeness, and compliance with requirements of Chapter 16, Health Records, of the Navy’s Manual of the Medical Department (MANMED) and the Standard Operating Procedures For: Medical Records Room. They ensure records are accurate, complete, and legible and that forms are filed in correct order; verify the Privacy Act statement and other forms are signed; and note any errors or discrepancies in the record. They mark the record review as complete by filling out the numbers of the current year along the right side of the medical jacket. They replace the existing jacket if it has deteriorated or been damaged. The appellants also report “good catches” to the supervisor, e.g., if they find a patient’s document incorrectly placed in another patient’s folder, which could be a potential violation of the Health Insurance Portability and Accountability Act if unresolved. Medical records are then filed by social security numbers according to a terminal digit, color-coded, and blocked filing system.
The appellants also perform duties related to the release and transfer of information contained in medical records. They process requests to transfer medical records from patients, physicians, and other sources, reviewing requests to ensure appropriate forms are completed, locating relevant information by searching medical records, and responding appropriately. Their work requires knowledge of the policies and procedures governing the release of medical records. In addition, the appellants regularly use a variety of computer systems and software such as Defense Enrollment Eligibility Reporting System, Composite Health Care System (CHCS), Armed Forces Health Longitudinal Technology Application, Health Artifact Image Management Solution, and the Military Health System GENESIS.
In reaching our classification decision, we carefully considered all information provided by the appellants and their agency including their official PD which, although not completely accurate, we have incorporated by reference into this decision. In addition, to gain more information about their work, we conducted a telephone audit with the appellants and telephone interviews with their current and previous first-level supervisors.
Series, title, and standard determination
The agency classified the appellants’ position to the GS-0675 Medical Records Technician Series, titling it Medical Records Technician, and applied the Job Family Position Classification Standard (JFS) for Assistance and Technical Work in the Medical, Hospital, Dental, and Public Health Group, GS-0600. The appellants do not contest the series, title, or standard determination and, based on careful analysis of the record, we concur.
Grade determination
The GS-0600 JFS is written in the Factor Evaluation System (FES) format, under which factor levels and accompanying point values are assigned for each of the nine factors. The total is converted to a grade level by use of the grade conversion table provided in the JFS. Under the FES, each factor-level description provides the minimum criteria needed to receive credit for the described level. 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 an equally important aspect that meets a higher level balances the deficiency. Conversely, the position may exceed those criteria in some aspects and still not be credited at a higher level.
In their appeal to OPM, the appellants only disagreed with the agency’s evaluation of Factors 4 (Complexity) seeking assignment of Level 4-3, and Factor 8 (Physical Demands) requesting assignment of Level 8-2. The agency subsequently agreed with the appellants’ proposed evaluation of Level 8-2 for Factor 8. We have reviewed the agency’s crediting of Levels 1-3 for Factor 1 (Knowledge Required by the Position), 2-2 for Factor 2 (Supervisory Controls), 3-2 for Factor 3 (Guidelines), 5-2 for Factor 5 (Scope and Effect), 2-a for Factors 6 and 7 (Personal Contacts and Purpose of Contacts), 8-2 for Factor 8, and 9-1 for Factor 9 (Work Environment), and concur and have credited the position accordingly. Therefore, our evaluation focuses on the remaining factor, i.e., Factor 4.
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.
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 issues and determines their interrelationships and the appropriate methods and techniques needed to resolve them.
The appellants’ position fully meets Level 4-2. Like this level, their work consists of steps, processes, or standard explanations of methods relating to the maintenance, retention, and disposal of outpatient medical records. The appellants are responsible for reviewing medical records for accuracy, completeness, and overall compliance with MANMED, Chapter 16, and their unit’s standard operating procedures (SOP). The work entails ensuring documents are appropriate, complete, legible, and filed in chronological order; jackets are undamaged and labeled with current and proper identification marks; records are filed appropriately on the shelf for quick retrieval when required; etc. They also file loose documents (“chits”), verifying patient information in CHCS and other electronic medical information systems to ensure documents are filed to the appropriate patient record. This and other work meet Level 4-2, where work requires deciding what needs to be done by choosing from a few recognizable alternatives such as determining the relevance of many facts and conditions within a specific patient record to legal and regulatory requirements. The appellants’ position is also characteristic of the work illustration at Level 4-2 in the GS-600 JFS, which describes a medical records technician position that reviews, screens, and analyzes requests for release of medical information. The employee analyzes requests to ensure proper authorizations are submitted and determines the originator’s entitlement to information in accordance with the Privacy Act and medical facility regulations. The records technician in the Level 4-2 illustration retrieves records, compiles and assembles 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. Similarly, the appellants recognize clear-cut inconsistencies in their review of requests for release of medical information and individual patient records. When identifying situations failing to conform to prescribed standards, they determine what needs to be done to meet requirements by correcting or acquiring the necessary information (e.g., missing signature) as expected at Level 4-2.
The appellants’ position does not meet Level 4-3. In addition to performing the full range of duties related to the maintenance, retention, and disposal of medical records, they archive records of patients who have not received services at the medical facility in the past two years. After the appellants review records to be archived for accuracy, completeness, and overall compliance with MANMED, Chapter 16, and the unit’s SOPs, the records supervisor likewise reviews the medical record prior to it being boxed and mailed to the records center for storage. Unlike Level 4-3, the appellants’ work does not consist of different, varied, and unrelated medical record processes and methods, including reviewing the work of other employees to verify compliance with regulatory requirements. The appellants assert they review the work of other employees inside and outside of the medical facility to ensure documents in a medical record are correct. In considering this level, a distinction must be made between reviewing documents and expressly reviewing the work performed by record technicians and other employees as envisioned at Level 4-3. We conclude the appellants perform the former, rather than the latter, type of “review.” They conduct a review to ensure documents are accurate and complete for the purpose of maintaining and retaining medical records in accordance with prescribed requirements. Unlike Level 4-3, there is no evidence the appellants are delegated responsibility for reviewing the work performed by record technicians and other employees to ensure the work they perform complies with regulatory requirements nor are they delegated the requisite authority to take appropriate steps to correct employee performance when the work being reviewed fails to comply with requirements.
Furthermore, the appellants are required to follow relatively straightforward processes and procedures requiring they make factual determinations rather than subjective evaluations or intensive analyses characteristic of Level 4-3. For example, their unit’s SOPs provide instructions for actions including, but not limited to, transferring medical records; requesting medical records from other facilities, civilian medical facilities, or the National Personnel Records Center; and making copies of medical records. Operating procedures are detailed; for example, the guidance instructs the following when requesting records from a civilian medical facility:
Patient needs to fill out and sign current DD FORM 2870; AUTHORIZATION FOR DISCLOSURE OF MEDICAL OR DENTAL INFORMATION. Fax or mail the request to the civilian hospital. Upon receipt of the document, file in medical record. (ENCL 5).
In contrast to Level 4-3, the appellants’ work does not require the evaluation of many facts and conditions regarding the maintenance, retention, and disposal of outpatient records. When reviewing a record, they must be able to recognize, identify, and correct instances when records are filed to the incorrect part, not in chronological order, missing signatures or other required information, illegible, etc. They consult with the supervisor in unusual situations, e.g., if unable to identify the correct placement of a document in the record or illegible documents require rescanning by another department at the medical facility. Unlike Level 4-3, the appellants’ work does not require identifying and analyzing medical record problems and issues, determining their interrelationships, and identifying the appropriate methods and techniques required to resolve them. The GS-0600 JFS provides an illustration of this type of work at Level 4-3, which describes a medical records technician position performing the full variety of medical records duties in a medical facility. The employee in the Level 4-3 illustration analyzes emergency room medical trauma records for pertinent information related to the type of injury or extent of disability, diagnosis, medication prescribed, and procedures performed for inclusion in the Trauma Registry database. The employee also develops accurate and meaningful statistical data; identifies, analyzes, and resolves medical record problems and issues; and the resolutions reached serve as the basis for quality assurance action plans. The Level 4-3 illustration contrasts with the smaller-scaled and limited records review actions performed by the appellants in the records room. Their work lacks the complicating factors and subjective judgments associated with the larger and more intensive specialized records review actions illustrated at Level 4-3.
Level 4-2 is credited for 75 points.
| Summary | ||
| Factor | 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 and Purpose of Contacts | 2-a | 45 |
| 8. Physical Demands | 8-2 | 20 |
| 9. Work Environment | 9-1 | 5 |
| Total | 820 |
A total of 820 points falls within the GS-04 range (655-850) on the grade conversion table provided in the GS-0600 JFS.
Decision
The appellants’ position is properly classified as Medical Records Technician, GS-0675-04.
[1] The appellants’ designated representative originally filed this appeal on behalf of three employees: [name], [name], and [name]. However, [name] retired effective December 31, 2019, thus is no longer assigned to the appealed position. Therefore, she is not covered by this decision and we have cancelled her appeal.