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Performance Work Statement for Coding Support1. Title of Project: Health Information Management Service (HIMS) Coding Support2. Background: The Veterans Health Administration (VHA) currently captures and stores information including diagnoses, treatment, and providers for all inpatient and outpatient care provided to patients treated at a VA healthcare facility, and for patients treated at other healthcare facilities at VA expense. All VA facilities store this information in an integrated computer system called Veterans Health Information Systems and Technology Architecture (VistA). Each facility has its own VistA database and selected data from the local databases is uploaded into various national systems. Inpatient information is stored in the Patient Treatment File (PTF), which was developed in 1983. PTF is a computerized abstract of each patient discharge and contains over 100 different data items which describe the characteristics of the patient and the reason for the hospital stay. PTFs are completed for inpatients treated at any level of a VA facility (hospital, nursing home, domiciliary, observation), and for patients receiving care at non-VA facilities at VA expense. The PTF software package is subject to change with additions, modifications, deletions, etc. of the transaction types and data fields or replacement to meet data collection needs. See Attachment A for current PTF transaction types. Outpatient information is entered through VistA Patient Care Encounter (PCE), Event Capture (EC) or Appointment Manager (AM) software modules. Coded data for all professional services inpatient or outpatient are captured through PCE. Some of the data elements captured are the date and time of service, identification of the provider, diagnoses and procedures for all care provided including ancillary services, minor and major procedures, and diagnostic studies. The value of coded data to managers and researchers depends on how accurately it portrays the actual clinical events that take place in the medical center. Data validity begins with practitioners providing timely and complete medical record documentation including an accurate recording of all diagnoses and procedures. Beginning September 1, 1999, Current Procedural Terminology (CPT) procedure coding and inpatient Diagnosis Related Groups (DRGs) became a basis for facility and professional charges for bills submitted to third party carriers. Coders are held responsible for the accuracy of these codes and compliance with federal legislation and VHA guidelines. The facility has varying degrees of coding backlogs. Episodes of care to be coded include outpatient encounters, ancillary services, major or minor surgery episodes, diagnostic studies, inpatient PTF, and/or inpatient professional services.3. Scope of Work: The purpose of this contract is to obtain services to assign Classification of Diseases (ICD), CPT-4, and Healthcare Common Procedural Coding Systems (HCPCS) Level II codes based on medical record documentation of outpatient and inpatient care provided at or under the auspices of a Veterans Health Administration facility and perform coding audits. The Contractor shall provide all resources necessary to accomplish the deliverables described in the statement of work (SOW), except as may otherwise be specified. a. Assign ICD, CPT-4, and HCPCS Level II codes based on medical record documentation of outpatient and inpatient care provided at or under the auspices of a Veterans Health Administration facility b. Furnish validation of the integrity, quality, and assignment of codes to the data contained in the outpatient Patient Care Encounter (PCE), inpatient Patient Treatment File (PTF), the non-VA database and the integrated billing package.c. Contract performance periods will consist of a base year and four additional option years. 4. Description of Services: 4.1 Task One - Coding Services: A. The contractor shall use skills, training, and knowledge of International Classification of Diseases, Common Procedural Terminology, and Healthcare Common Procedural Coding System Level II code sets and guidelines and other generally accepted available resources to review health record documentation and providers scope of practice to assign diagnostic and procedural codes at a minimum 95% accuracy rate and within required performance timelines. B. The contractor shall code Outpatient Encounters including Radiology, Lab or other Ancillary Services, Surgical to include pathology and anesthesia services, Inpatient Professional Services; and Inpatient Episodes/Admission Services as specified under each individual task order; shall include required encoder/ Veterans Health Information Systems and Technology Architecture data elements in accordance with Veterans Health Administration Handbooks and protocols as specifically outlined in the task order. Other identified cases to be coded include but not limited to: Veteran Tortfeasor Claims; Veteran Workers Compensation, Humanitarians, beneficiaries of the Military Health System (TRICARE is the healthcare program servicing military beneficiaries), Civilian Health and Medical Program of the Department of Veterans Affairs, Ineligibles, Fugitive Felon, Prosthetics, non-Veterans Affairs Fee Services, and New Insurance/Late Checkout. C. New Insurance/Late Check Out encounters may not have been coded due to new insurance identified or late check-out and were not identified in the daily coding reports. New Insurance/Late Check Out encounters shall be coded within the turnaround time stated in the local policy or approved by the Contracting Officer. D. The contractor shall use the 1995 or 1997 Evaluation and Management guidelines as specified in the facility policy. E. Veterans Health Administration provides a wide variety of primary and specialty care services in the outpatient setting. Inpatient admissions include those for acute care/specialty care, observation, and admissions to the Community of Living nursing care, and domiciliary units to include non-Veterans Affairs Fee services. F. The contractor shall abstract other identified data items and enter the data into the local Veterans Health Information Systems and Technology Architecture system, encoder program, or write the information on source documents as agreed with the local facility. This information shall include a decision as to whether or not an encounter is billable, based on non-compliance with documentation and resident supervision guidelines. Coders will utilize the Case Comment communication tool to provide billing staff with a standardized reason (case comment) why they believe an outpatient encounter cannot be billed. Encounters believed to be not billable will be marked with the appropriate Case Comment. Case Comments may include but is not limited to Agent Orange exposure or Ionizing Radiation, telephone care, non-billable provider, insufficient documentation, or other types of care that cannot be billed. Contractor shall be available to answer any follow up questions regarding the episode and provide references in support of their code selection. Contractor will also record episodes as required.G. The contractor shall provide all labor, materials, transportation, and supervision necessary to perform coding and abstracting using either the 1995 or 1997, per VA Medical Center policy, the Evaluation and Management guidelines on encounters and standard industry guidelines, e.g., Coding Clinics and Common Procedural Terminology Assistant, as specified by the Veterans Affairs Administration Center. H. The contractor shall adhere to all coding guidelines as approved by the Cooperating Parties and accepted Veterans Affairs regulations. I. The contractor shall utilize Veterans Health Administration national encoder, industry standard guidelines, Veterans Health Administration and local policies, and other generally accepted contractor supplied reference materials to assign and/or validate diagnostic and procedural codes reflective of documentation. J. The contractor shall utilize the standardized Case Comments in the encoder application to communicate specific document information to Billing. K. The contractor shall utilize Patient Care Encounter / Patient Treatment File / Surgery or other database, if necessary, to reflect code changes and names(s) of provider(s). L. The contractor shall review and determine whether documentation is adequate to support billable services. M. If requested by the facility, the contractor may place a local coder on-site if available in accordance with the contract when the coder lives in a Veterans Affairs facility requesting work. No travel costs will be charged in this scenario. N. The contractor shall ensure that individual coders are clearly identified on all work; any paper documents shall clearly identify the individual coder. O. When assigning multiple Common Procedural Terminology codes, the contractor shall verify that they are not components of a larger, more comprehensive procedure that can be described with a single code.P. The contractor shall identify those encounters, if any, where documentation does not substantiate an appropriate code(s). Q. The contractor shall identify duplicate encounters or encounters created in error because the patient was not seen. R. The contractor shall code based on reading and reviewing the documentation in the health record including the Computerized Patient Record System and Veterans Health Information Systems and Technology Architecture Imaging. The contractor shall complete data entry into the encoder application that is integrated with the Veterans Health Information Systems and Technology Architecture system as part of this Contract. Completion of source documents in lieu of Veterans Health Information Systems and Technology Architecture entry may be arranged only upon mutual agreement between the facility task order Contracting Officer and the contractor. S. The contractor shall coordinate with the local Contracting Officer s Representative for implementation of contingency plans for data entry when required. T. The contractor shall assign modifiers as appropriate to override Correct Coding Initiative edits. U. For Inpatient Episodes/Admission Services: 1. Complete all Patient Treatment File Transactions (e.g., 101, 401, 501, 601, and 701/702) in accordance with Veterans Health Administration Handbooks, 1907.03 HIM Clinical Coding Program Procedures and 1907.04 Patient Treatment File Coding Instructions.2. Opening and transmitting Patient Treatment Files will follow local facility protocol. V. The contractor shall review documentation to determine why an ancillary or other diagnostic test was ordered and assign an International Classification of Diseases diagnosis code, as appropriate based on date of service, to that test. Contractor shall add the referring providers name in coding case comments.W. The contractor shall re-review any coded data when questioned by Veterans Affairs staff due to a billing edit, when a denial is received, or when a retrospective review is completed, to either make changes or substantiate the coding with appropriate coding rules and references. This service is included in the price of the work. The contractor shall use the following during re-review processes: 1. Those codes that were coded and not supported in the documentation, violate a coding rule 2. Those Common Procedural Terminology or International Classification of Diseases diagnosis codes that should have been coded and were not, 3. Inappropriate Common Procedural Terminology or International Classification of Diseases codes 4. Unbundled codes 5. Ancillary encounters with only a diagnosis of V72.5 or V72.6 6. Inaccurate Diagnosis Related Groups assignments 7. All other data elements incorrectly entered by the Contract coder, or not entered when appropriate, e.g., coder case comment, provider, adequacy of documentation. Note: All subsequent reviews completed after the initial review work will be forwarded to the contractor s designated contact person for resolution. The contractor along with the VA facility shall jointly determine a communication mechanism whereby the contractor shall access daily unless otherwise indicated on the task order. Veterans Affairs reserves the right to validate all coding, audit results and/or accuracy statistics submitted.X. The contractor shall provide to the facility COR a weekly status report, citing number coded, date to be coded, number remaining to be coded, number of suspended encounters, and any issues needing resolution. The date due, format, and method is to be determined by the facility COR. 1. Inpatient Facility coding: Inpatient facility coding is to be completed within seven (7) calendar days from the date coding is assigned. 2. Per VHA Directive 2011-025, all Patient Treatment File data must be accepted by the Austin Information Technology Center and/or Veterans Health Administration Corporate Data Warehouse no later than seven (7) calendar days from the data of patient discharge. The only exceptions are Patient Treatment File discharges from Contract or Community Nursing Home and non-Department of Veterans Affairs Purchased Care patient files. Error corrections must be re-transmitted by the closeout deadline. 3. Inpatient facility coding is performed on all inpatient episodes of care, to include Observation and non- Veterans Affairs care under Veterans Affairs auspices, regardless of billable status. Applicable coding guidelines will be followed. 4. All inpatient facility coding will be entered into the Patient Treatment File utilizing the encoder software. 5. The Veterans Health Administration Handbook 1907.04 establishes procedures and covers the responsibilities and requirements for the appropriate use of the Patient Treatment File and provides specific instructions for completing each Patient Treatment File transaction (e.g., admission transaction (101), Patient Movement Transaction (501), Surgical Transaction (401), etc.). 6. A Present on Admission field entry is required for patients that are admitted to certain levels of care. The Present on Admission field is not required for Community Living Center and Domiciliary patients. The Present on Admission provides information on whether a diagnosis was present at the time of a patient's admission. The indicator is required to be assigned to all diagnosis codes involving inpatient admission. Each diagnosis, principal and secondary, and external causes of injury are required to have a Present on Admission indicator appended. 7. Non- Veterans Affairs purchased care Patient Treatment File coding utilizes the non-Veterans Affairs invoice, as well as submitted clinical documentation if received. Y. Inpatient Professional Encounters/Services coding: 1. Inpatient Professional Encounters/Services coding is to be completed within seven (7) calendar days of the date coding is assigned. 2. Veterans Health Administration Directive 2009-002 Patient Care Data Capture: It is Veterans Health Administration policy to capture and report inpatient billable professional services and inpatient professional mental health services to support the continuity of patient care, resource allocation, performance measurement, quality management, provider productivity, research, and third-party payer collections. This directive requires the capture of defined inpatient professional mental health services regardless of the third-party billing status. 3. Mental Health Inpatient Professional Services are inclusive of daily evaluation and management, therapy sessions, consultations, etc. For purposes of patient care data capture, mental health services include inpatient professional services performed by a psychiatrist with the credentials of Medical Doctor or Doctor of Osteopathic Medicine , psychologist with the credentials of Doctor of Philosophy or Doctor of Psychology, master level social workers, or physician extender with the credentials of Nurse Practitioner, Clinical Nurse Specialist or Physician Assistant in an inpatient setting, location of the service notwithstanding. 4. Evaluation and Management services are used to capture the provider s professional encounters/services performed in an inpatient setting. The Diagnostic Coding and Reporting Guidelines for Outpatient Services (Hospital-Based and Physician Office) should guide coders when coding inpatient diagnoses for physician professional services. Use the 1995 or 1997 Evaluation and Management guidelines as specified in the facility policy. 5. Identify and link Current Procedural Terminology and International Classification of Disease codes, identify the provider, and the date(s) of service. 6. Guidelines for capturing the inpatient professional encounter/services are contained within the current Veterans Health Administration Coding Guidelines. 7. Contractor may be required to create the Inpatient Professional Service encounter in the Patient Care Encounter application in order to code the service. Z. Outpatient Coding: 1. All coding is to be completed within seven (7) calendar days of the date coding is assigned. 2. Outpatient encounters include face-to-face encounters and other occasions of service that are captured within the Patient Care Encounter. These services are captured through completion of electronic encounter forms; review of documentation by qualified coding staff; and automated data capture within radiology and laboratory Veterans Health Information Systems and Technology Architecture packages. 3. Applicable coding guidelines will be followed; outpatient coding guidelines are contained with the current Veteran Health Administration Coding Guidelines. Use the 1995 or 1997 Evaluation and Management guidelines as specified in the facility policy. 4. Assign or validate diagnostic and procedural codes reflective of documentation; correct the Patient Care Encounter, if necessary, to reflect code changes and name(s) of provider(s). 5. Typically outpatient coding does not require the coder to create encounters. Most outpatient encounters are initiated at the location of the visit, at time of patient check-in, and when the provider completes the visit at patient check-out and or completion of the encounter form. AA. Surgery case coding to include anesthesia and pathology: 1. Surgical coding must be completed immediately after the procedure when possible and no later than one week from the date coding is assigned. 2. Surgery case coding includes the entry of coded procedures and diagnoses for all surgery cases. It is necessary to assign or validate diagnostic and procedural codes reflective of documentation for all cases in the surgery package. 3. Assign and enter the diagnostic codes and procedural codes with associated modifiers reflective of documentation using the encoder into the surgery package. 4. Validate that all cases successfully pass from the Surgery Package to Patient Care Encounter using the Patient Care Encounter Filing Status Report. 5. Assign and enter associated billable anesthesia and pathology services related to the surgery using the encoder into the Patient Care Encounter. 6. Anesthesiology visits for surgery performed in the Operation Room may require coders to create encounters for the services as they may not already exist in Patient Care Encounter. 7. Instructions for surgery coding are contained in the Veterans Health Administration Coding Guidelines. CC. Task One Deliverables: 1. Inpatient Facility Coding 2. Inpatient Professional Encounter/Services Coding 3. Outpatient Coding 4. Surgery case coding to include pathology and anesthesia services. 4.2 Task Two External Auditing Service: A. The facility will specify the period of performance for any audit services at least 30 days prior to commencement of said audit. B. External audits provide validation of the integrity, quality, and assignment of codes to the data contained in the Patient Care Encounter and inpatient Patient Treatment File at each medical center as evidenced by proper documentation of the care or service provided to the patient. External Audits of coded data will be performed on any of the Veterans Health Administration required coding activities (e.g., inpatient, outpatient, surgery). These audits will be performed separate from normal coding activities and will conform to the task order as developed by the site. These audits will address accuracy of coded data, health record documentation issues, to include recommended remediation of specific documentation deficiencies, process improvement and identify educational needs. Audit accuracy expectations are 95% and above. C. The contractor shall be responsible for reviewing all national coding guidelines, Veterans Health Administration Handbooks, Health Information Management Consolidated Patient Agreement Center Service Level Agreement, Veterans Health Administration Coding Guidelines, etc. as well as the facility s policies prior to commencement of an audit. References will be provided by the facility as needed. D. To ensure the review findings have value to the facility, the facility will specify the data collection elements to be captured for the audit. The contractor may submit a suggested data collection tool; any changes must be mutually agreed to/approved by the facility Contracting Officer. E. All reviews will utilize electronic auditing of the Computerized Health Record System whenever possible. Veterans Affairs and Non-Veterans Affairs records may be either scanned documents or hardcopy. The reviews will be conducted by remote data view and remote image view. Should the information not be contained in the Computerized Health Record System or Veterans Health Information Systems and Technology Architecture, the medical center will overnight the documentation to the vendor. F. A detailed project plan may be requested by a facility should the audit require a significant level of effort and expertise. If the plan elements are not spelled out in the task order, the project plan at a minimum should include: 1. Specific timelines for completing the audit 2. Timeframe for the facility reports 3. Number of reviewers G. If a sample size or the number of records to be audited is not stated in the task order the contractor shall develop a sample size that assures a 95% confidence level of accuracy for each of the auditing tasks specified on the contract, and may include inpatient hospitalizations, outpatient visits, and non-Veterans Affairs records. The contractor shall submit with the proposal for each task order a detailed description of how they arrived at the sample size. At a minimum the sample size must include a review of the coding activities as specified on the task order and may include any or all the following: inpatient hospitalizations, ambulatory surgery, diagnostic tests (endoscopy, bronchoscopy, cardiac catheterization, Percutaneous Transluminal Coronary Angioplasty, pulmonary function, radiology, laboratory, etc.), primary care, mental health, medicine sub-specialty, surgery, observation, neurology, and non-Veterans Affairs records. The facility may also provide a list of specific records to audit. H. Outpatient, Inpatient Professional, Surgery, and Inpatient facility Audits: 1. Audit includes Evaluation and Management, Common Procedural Terminology procedures, and International Classification of Diseases diagnosis codes. Encounters/quarter are identified by billed episode and then audited against these three criteria. If the encounter does not have a Common Procedural Terminology procedure code associated with the visit, then that data point is not audited. 2. Use the 1995 or 1997 Evaluation and Management guidelines as specified in the facility policy. Review the Evaluation & Management code to determine if correct and identify the reason(s) if not. 3. Determine the accuracy and sequencing of the diagnoses coded and identify the reason(s) if not. 4. Determine the accuracy of Common Procedural Terminology/Healthcare Common Procedural Coding System codes and modifiers and the reason(s) if not accurate. 5. Inpatient review criteria may include: principal and secondary diagnosis code (accuracy, omission, etc.), Diagnosis Related Groups accuracy, correct Present on Admission assignment. 6. The contractor shall have a methodology for resolving coding questions by reviewers and ensuring inter-reviewer consistency and reliability. 7. The contractor shall review findings with Chief, Health Information Management, facility Contracting Officer s Representative, management, and other designated medical center personnel. Any discrepancies identified during this process must be resolved prior to final written report. 8. The contractor shall be responsible for conducting at a minimum an exit conference with management officials at the discretion of the medical center to be coordinated with the Contracting Officer s Representative at the facility. I. Reports on findings will be prepared to allow use by medical center staff in re-reviews, education or to provide management updates. Final report elements may be specified in the individual task order or developed with assistance from the facility Contracting Officer s Representative. Documentation of audit findings will be as requested by the facility and may include record ID, breakdown of record type (i.e., outpatient, inpatient), breakdown by code (Common Procedural Terminology, International Classification of Diseases, Evaluation and Management, modifier, etc.) of total number of codes reviewed; number of correct codes, accuracy rate, Diagnosis Related Groups reviewed (# correct; accurate); any code changes/errors and reason/reference for error; identified weaknesses and recommendation for correction. Also include any documentation issues/deficiencies and recommendation for improvement/remediation. J. The contractor shall provide a final written report to the facility Contracting Officer s Representative within 15 business days following the review(s). K. The contractor shall document in writing all records reviewed and provide such documentation to the facility Contracting Officer s Representative with the final report. L. Education Plan: To be included in the audit process, weaknesses identified during the audit shall be used to provide a facility specific education/training plan, based on Veterans Health Administration coding and documentation regulations and guidelines, and local policy to present to Veterans Integrated Service Network/Veterans Affairs Medical Center management officials, physicians/clinicians, sub-specialties if needed, and for Veterans Health Administration coding staff to include any recommended remediation. Plan shall be submitted to the local Contracting Officer s Representative within seven (7) calendar days following the audit. M. Task Two Deliverables: 1. Project Plan with description of sample size determination 2. Audit: Inpatient facility (Diagnosis Related Group) coding 3. Audit: Inpatient professional encounter coding including surgery coding 4. Audit: Outpatient encounter/services coding 5. Report on audit results 5.0 Reporting Requirements: A. The contractor shall provide the facility Contracting Officer s Representative with monthly progress reports commensurate with the length of the project. The progress report shall cover all work completed during the preceding reporting period. This report shall also identify project activity, issues and resolutions, escalation process for outstanding issues, and remediation for any issues that cause the project to be delayed (both anticipated and unanticipated). The report format will be determined at the task order level. B. The contractor shall provide a quarterly report to the Contracting Officer s Representative listing all work referred to the contractor based on a Contractual agreement made through this contract. The report shall identify the reporting quarter and include the facility/Veterans Integrated Service Network name, type of work (coding/auditing); purchase/task order number; purchase/task order amount, and name of the facility Contracting Officer s Representative. The contractor may propose modifications to the reporting requirements to the National Contracting Officer s Representative and the Blanket Purchase Agreement Contracting Officer. C. Deliverables: 1. Monthly Progress Report to facility Contracting Officer s Representative 2. Quarterly Report to National Health Information Management Contracting Officer s Representative and Blanket Purchase Agreement Contracting Officer6. Schedule of Deliverables: The contractor shall meet the Delivery Schedule for each deliverable specified below:Task DeliverablesDeliverable ObjectiveDelivery DueCoding ServicesInpatient Facility CodingWithin 7 calendar days of the date coding is assigned. Inpatient Professional Encounter/Services CodingWithin 7 calendar days of the date coding is assigned. Outpatient CodingWithin 7 calendar days of the date coding is assigned. Surgery CodingCompleted immediately after the procedure when possible and no later than one week from the date the coding is assigned.7. General Requirements:a. All written deliverables shall be phrased in layperson language. Statistical and other technical terminology shall not be used without providing a glossary of terms.b. The latest United States editions of the International Classification of Diseases (ICD), Current Medical Information and Terminology (CMIT) and Current Procedural Terminology (CPT) of the American Medical Association (AMA) and the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association (APA) shall be used to provide uniform disease and operation terminology which is complete and scientifically accurate. c. Code assignment shall be in accordance with National Center for Health Statistics (NCHS), Centers for Medicare and Medicaid Services (CMS), American Hospital Association (AHA), AMA and APA guidelines, as appropriate. On those occasions when there is a question, VHA guidelines take precedence. Local policies will direct how coding is accomplished and what quantitative and/or qualitative reviews are performed by the facility. The AHA Coding Clinic and other publications may be used for training and reference purposes. d. Contractor shall ensure that its staff members providing services under this statement of work (SOW) and pursuant agreement use VA encoder software. e. Contractor shall adhere to all coding guidelines as approved by the Cooperating Parties [The four organizations that make up the Cooperating Parties for the ICD-CM: American Hospital Association (AHA), American Health Information Management Association (AHIMA), Centers of Medicare and Medicaid Services (CMS) and National Center for Health Statistics (NCHS)] and accepted VA regulations, including:1. The Official Guidelines and Reporting as found in the CPT Assistant, a publication of the American Medical Association for reporting outpatient ambulatory procedures and evaluation and management services.2. The current Official Guidelines for Coding and Reporting in the Coding Clinic for ICD, a publication of the American Hospital Association.3. VHA guidelines for coding as found in the Handbook for Coding Guidelines current edition, Health Information Management, Department of Veterans Affairs. This workbook is updated at least once per year with new codes and guidance. Contractor shall ensure it has the current version and the guidance is followed. Note: While VHA does ask for reimbursement from third party payers, the VHA coding policy is to code only according to coding guidelines. Our own compliance audits use only this definition when determining if any encounter or PTF is correctly coded. 4. The Correct Coding Initiative. The CPT Evaluation and Management codes assure documentation substantiates the code level assigned.5. VHA Directive Patient Care Data Capture 2006-0266. VHA Directive Resident Services Billing 2005-0547. VHA Handbook Resident Supervision 1400.18. Other directives that VA may issue from time to time. f. Upon request of the Contracting Officer, the Contractor shall remove any Contractor staff that do not comply with VHA policies or meet the competency requirements for the work being performed.g. Contractor shall abide by the American Health Information Management Association established code of ethical principles as stated in the Standards of Ethical Coding, published by AHIMA. h. All coding and auditing activities shall utilize VA s electronic health record. i. Contractor shall provide all labor, materials, transportation, and supervision necessary to perform coding validation reviews for inpatient, observation, diagnostic tests, ambulatory surgery/medicine procedures and outpatient (clinic) data collection, evaluating the completeness and accuracy of coding diagnoses and procedures in accordance with official coding guidelines (Coding Clinics, CPT Assistant, HFCA/AMA, Ambulatory Patient Classifications [APC]) in a simulated Medicare payment environment.j. Communication: Contractor shall specify a contact person and phone number who is available for personal contact at a minimum during regular business hours of the particular facility that owns the work, for the duration of the work. Contractor shall maintain frequent communications with the HIMS Manager or other designated medical center employee (i.e., coding supervisor/team leader) regarding progress, workload status and/or problems. The contractor shall make every effort to ensure that issues raised by the local facility are addressed in a timely manner. k. Contract coders shall code in accordance with CCI Bundling Guidelines, and use the (HCPCS), where appropriate. Contract coders must exclude coding information such as symptoms or signs characteristic of the diagnoses, findings from diagnostic studies, or localized conditions, which have no bearing on current management of the patient or as appropriate. Contract coders must clarify conflicting, ambiguous, or non-specific information appearing in the record by consulting with their supervisor who will, if necessary, discuss with the local VA contact.l. Contractor is responsible for becoming familiar with guidelines on billing within the Veterans Health Administration (VHA). Information may be found at http://vaww1.va.gov/cbo/rcbillingguide.doc.m. The Contractor shall not use "incident to" rules. n. Contractor shall code using CPT for inpatient professional services or nursing home professional services. o. The Contractor shall ensure that its staff members providing services under this contract are trained and capable of using VHA encoder software (Nuance).p. The Contractor shall follow local Standard Operating Procedures (SOPs) as provided to them.q. Nurse Practitioner (NP), Physician Assistants (PA) and Clinical Nurse Specialists (CNS) are licensed independent practitioners and should be listed as a primary provider when there is no physician involvement refer to VHA Coding Guidelines and attached directives.r. Contractor shall ensure primary and secondary providers are properly selected and sequenced. Note- a licensed independent practitioner is always to be listed as primary, refer to Patient Care Data Capture, VHA Directive 2009-002.s. Contractor shall ensure all diagnosis and procedure codes are properly sequenced and linked.t. The Contractor shall review, correct, and re-file any rejected encounters. Recoded encounter will be re-filed, and the contractor shall monitor to ensure the VA is not charged for recoded encounters. The Contractor shall not validate any encounters already validated by VA staff, unless the encounter is in a reject/recode status indicating review of provider, comments, and/or recoding is necessary. u. Contractor shall not unbundle codes. When assigning multiple CPT codes verify codes are not components of a larger, more comprehensive procedure that can be described with a single code, refer to CMS/CCI edits.v. Contractor shall assign code modifiers in accordance with coding guidelines.w. The Contractor shall assign the VA specific GR modifier when a resident is involved in care provided, refer to VHA Directive 2005-054.x. Contractor shall identify and thoroughly review all documentation within the electronic medical record including addendums, separate notes, and reports entered by one or more providers to ensure complete capture and coding of services provided for each assigned encounter. VISTA Imaging and/or Remote Data must be reviewed to ensure all areas within CPRS are reviewed. Encounters without documentation will be suspended for further follow up.y. Contractor shall enter all required comments for the encounter into the system. All comments necessary for claims processing including, but not limited to, (RD) referring or ordering provider, date of injury (DOI), presenting diagnosis for Emergency Department (ED) visit, rehab (PT, OT, ST) visit information, refer to CCM Comments list (ATTACH). 999 will only be utilized when there is not any other appropriate predefined comment available.z. The Contractor shall use 1995 or 1997 Evaluation and Management guidelines as appropriate, refer to VHA Coding Guidelines.aa. Contractor shall abide by VHA Office of Academic Affiliations, Resident Supervision guidelines for services provided by resident physicians: The primary provider for all encounters is the attending/supervising practitioner. Four types of documentation of resident supervision are allowed (1) Attending progress note (2) Attending addendum, (3) Co-signature, or (4) Resident documentation of attending supervision/identification of supervising attending. Requirements are based on the visit type and graduated levels of supervision required; refer to VHA Handbook 1400.01 Resident Supervision (July 2005) for further details. If resident supervision documentation guidelines are not met, coding is to be completed, the primary provider is listed as the resident, and the CCM Comment of Resident Supervision Not Met is to be selected, allowing a facility charge to be billed. Fellows are considered Residents for billing purposes. Residents Moonlighting in the ED are independent licensed providers and do not require attending supervision.bb. Contractor shall review encounters assigned for Combat Veteran status and Service-Connected treatment. Encounters with treatment for a listed service-connected condition will be coded and the CCM Comment of Needs Service-Connected Determination is to be selected. Refer to CCM Comments for other eligibility related issues that may affect the claims process.cc. Contractor shall add the referring or ordering provider in the CCM comment section of Nuance for all ancillary services, procedures, and consults. Contractor shall also indicate in the CCM comments, by adding an N or E , whether the patient is New or Established within the specialty when coding a Consult, which will be cross- walked to an E/M code by billing when required. dd. Contractor shall ensure all encounter flags are in an acceptable (OK or REV) status upon completion.ee. Contractor is required to maintain records that document competence/performance levels of employees working on this contract, as set by The Joint Commission and other regulatory body requirements. Contractor shall provide a current copy of competence assessment checklist and annual performance evaluation to the COR for each employee working on this contract at the end of each year s performance. Contractor must keep abreast of regulation changes that affect required coded information, including Centers for Medicare and Medicaid System (CMS), the Office of Inspector General and others as appropriate. ff. All deliverables, associated working papers, and other material deemed relevant by VA generated by the contractor in the performance of this contract are the property of the United States Government. All individually identifiable health records shall be treated with the strictest confidentiality. Access to records shall be limited to essential personnel only. Records shall be secured when not in use. At the conclusion of the contract all copies of individually identifiable health records shall be destroyed, with a statement verifying destruction or returned to the VA. The contactor shall comply with the Privacy Act, 38 USC 5701, 38 USC 7332 and the Health Insurance Portability and Accountability Act (HIPAA) regulations. Contractor must certify that all employees working on this contract have received HIPAA training. Contractor shall be responsible for ensuring the confidentiality of all patient information and shall be held liable in the event of any breach of confidentiality.gg. Access requirements to VA information system by contractors and contractor personnel shall meet or exceed those requirements as described in VHA Directives. Access shall be granted to non-VA users only if the purpose of access meets criteria of the Privacy Act, HIPAA, and confidentiality regulations.hh. Contractor s employees shall be required to sign access forms before starting work under this contract that require them to abide by the VA computer access security and confidentiality agreement. Contractor staff must sign-on to system at a minimum of once each 30-day period to maintain access.ii. Quality Assessment of Health Information Services: 1. The Contractor shall furnish certification of Indemnification And Medical Liability Insurance in accordance with VAAR 852.237-7 to the Contracting Officer Representative (COR), before commencing work under this contract, that coverage required has been obtained and such policy shall state "This Policy May Not be Changed or Cancelled Without Written Notice to the VA. Said policy must bear an appropriate "loss payable clause" to the United States as its interest may appear. Such evidence of insurance is not waived. 2. The Contractor shall possess all licenses, permits, accreditation and certificates as required by law. The Contractor shall perform the required work in accordance with The Joint Commission (JC), Veterans Health Administration (VHA), and other regulatory standards. JC standards may be obtained from: The Joint CommissionOne Renaissance BlvdOakbrook Terrace, IL 60181jj. Exclusions and Sanction Certification: The Contractor shall provide annual written certification to the COR which certifies that all employees, subcontractors, and employees have been checked to ensure that all agents providing health care services under this contract have been found not to be listed on the List of Parties Excluded from Federal Programs and the HHS/OIG Cumulative Sanction Report. The certification shall be provided within three weeks after award and within three weeks of the contract s annual anniversary date for each period the contract remains effective. kk. If the Contractor should find it necessary to reassign a staff member from working for a facility, the contractor shall make arrangements for there to be a minimum of two week overlap when both the old and new staff member shall be working the facility s account, unless there is a mutual agreement between the Contractor and facility that the overlap is not necessary. ll. Contractor is responsible for the management of its staff, and the Contractor is responsible for training its staff on VA policy and procedures.mm. Contractor staff shall sign confidentiality statements as required. Any person, who knowingly or willingly discloses confidential information from the VA, may be subject to fines.nn. Moving work outside of the United States border (offshore) is prohibited.8. Quality Control:a. Contractor shall ensure assigned encounters are completed within 7 business days. National Closeout requirements of 14 days from ambulatory date of service or 7 days for inpatient discharge must be met, unless otherwise specified by assigning facility, refer to VHA Handbook 1907.01, Health Information Management and Health Records and VHA Handbook 1907.03 HIM Clinical Coding Program Procedures. When the contractor cannot meet this deadline due to unforeseen circumstances, contractor shall notify VAMC facility.b. The Contracting Officer s Representative will validate the contractor s work to confirm that contractual coding meets accuracy requirements. The contractor is responsible for its own work as outlined in this Quality Control section. Coding accuracy will be determined by the number of correct codes compared to total number of codes, correct DRG assignment, and correct review and data entry of identified data items. The contractor must maintain a 95% accuracy level. Failure to meet the required level of accuracy may result in termination of the task order. The designated points of contact for the facility and the contractor will discuss any questions regarding coding or expected work. c. Turnaround times are identified in this PWS. Work is considered completed when it is received back at the VA facility with data entry done via the encoder or the documentation is at the VA facility. When the Contractor cannot meet this deadline, they must inform the VA facility contact person on or before the 5th business day. Work completed after the expected turnaround time set by the facility shall be subject to a 10% reduction in the negotiated price for the batch sent. d. The Contractor shall have in place the following Coding Quality Control/Performance Process whereby the Contractor shall: 1. Perform on-going quality assessments of not less than 5% of all coded data elements and provide weekly results to the VA facility to ensure that the 95% accuracy rate is met. Data elements include ICD codes, CPT codes, DRGs, and data items abstracted and entered by the contract coder. Contractor shall track results by coder to assure appropriate follow-up. 2. If monitoring demonstrates that work has fallen below the quality standard, the contractor shall develop a corrective action plan and include it with the data. 3. If for any reason services cannot be delivered on time, the contractor shall notify the facility Contracting Officer s Representative as soon as possible but no later than three (3) days prior to the due date and provide a written explanation citing reasons for the delay and overall impact, a plan to resolve the reason for the delay, and a firm commitment of when the work shall be completed. The facility Contracting Officer s Representative will review the document collaboratively with the impacted office and issue a response. A timeframe for resolution will be agreed upon at the task order level.Quality StandardsTaskAcceptable LevelIncentiveCoding Services95% Accuracy, entered within 7 daysPossible termination of task orderAudit Services, monthlyProvided within 15 daysPossible termination of task order9. Contractor Experience Requirements: a. The Contractor must provide experienced, competent, credentialed personnel to perform coding and/or auditing activities. These are defined as key personnel and are those persons whose credentials were submitted. The Contractor agrees that the key personnel shall not be removed, diverted, or replaced from work without approval of the CO and COR. b. Any personnel the Contractor offers as substitutes shall have the ability and qualifications equal to or better than the key personnel replaced. Requests to substitute personnel shall be approved by the COR and the CO. All requests for approval of substitutions in personnel shall be submitted to the COR and the CO within 30 calendar days prior to making any change in key personnel. The request shall be written, and the Contractor shall provide a detailed explanation of the circumstances necessitating the proposed substitution. The Contractor shall submit complete documentation of the qualifications for the proposed substitute and any other information requested by the COR needed to approve or disapprove the proposed substitution. The COR will evaluate such requests. The CO will notify the Contractor of approval or disapproval thereof in writing.c. Required Knowledge and Skills of Contract Coders: 1) Contract Coders shall possess the ability to:o Read and interpret health record documentation to identify all diagnoses and procedures that affect the current outpatient encounter visit, ancillary, inpatient professional fees, and surgical episodes.o Apply knowledge of current Diagnostic Coding and Reporting Guidelines for outpatient services.o Apply knowledge of CPT format, guidelines, and notes to locate the correct codes for all services and procedures performed during the encounter/visit and sequence them correctly.o Apply knowledge of procedural terminology to recognize when an unlisted procedure code must be used in CPT.o Code in accordance with CCI Bundling Guidelines.o Use the Healthcare Common Procedural Coding Systems (HCPCS), where appropriate.o Exclude from coding information such as symptoms or signs characteristic of the diagnoses, findings from diagnostic studies or localized conditions that have no bearing on current management of the patient.d. Required Contract Coder Education and Experience: o Contract coders must have a minimum of two years experience in the area that they will be coding. o Contract coders/validation staff must possess formal training in anatomy and physiology, medical terminology, pathology and disease processes, pharmacology, health record format and content, reimbursement methodologies and conventions, rules, and guidelines for current classification systems (ICD-CM, HCPCS and CPT).o Coders must be credentialed and have completed an accredited program for coding certification, an accredited health information management or health information technician. For the purpose of this contract, a certified coder is someone with one of the following active credentials. Other credentials shall not be accepted.American Health Information Management Association (AHIMA) credentials as a Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), and Certified Coding Specialist Physician (CCS-P), or American Academy of Professional Coders (AAPC) as a Certified Professional Coder (CPC) or Certified Professional Coder Hospital (CPC-H),o Supervisory Coders must have a minimum of three years experience in coding.o Credentialed Coders must have a minimum of two years experience in coding.
252-NETWORK CONTRACT OFFICE 12 (36C252)
Chicago VARO
53214
GREAT LAKES ACQUISITION CENTER 115 S 84TH ST MILWAUKEE WI 53214
Donald J St. Onge, Contract Specialist, Phone 414-844-4828, Email Donald.St.Onge@va.gov
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