2021 ATTACHMENT 1 PWS HIM CODING FINAL.pdf

ATTACHMENT 1:

PERFORMANCE WORK STATEMENT

DEPARTMENT OF VETERANS AFFAIRS

Veterans Health Administration

Office of Health Information Management

Health Record Coding Services

Date: June 24, 2020

Performance Work Statement

1.0 Background:

The Veterans Health Administration (VHA) currently captures and stores information including diagnoses, treatment, and healthcare providers for all inpatient and outpatient care using the VHA Coding Guidelines and industry standard International Classification of Diseases Clinical Modification, 10th Edition, Current Procedural Terminology, and Healthcare Common Procedure Coding System provided to patients treated at a Veterans Health Administration healthcare facility, and for patients treated at other healthcare facilities at Veterans Affairs expense.

Inpatient information is abstracted and entered in the national encoder product and electronic health record (EHR). The electronic abstract provides a record of inpatient activity, diagnoses, procedures, and surgeries performed from the time of admission to the time of discharge from inpatient care. Coding and abstracting are completed for inpatients treated at any level of a Veterans Affairs facility (hospital, nursing home, domiciliary, observation), and for Veterans receiving care at non-Veterans Affairs facilities at Veterans Affairs expense.

Outpatient information is abstracted and entered in the national encoder product and electronic health record (EHR). Data elements captured include but are not limited to the date and time of service, identification of the healthcare provider, diagnoses, procedures and applicable modifiers for all care provided including ancillary services and procedures. Surgical case coding includes the entry of coded procedures and diagnoses for all surgery cases into the national encoder product and EHR.

A national encoder product is required for all coding and is available at each Veterans Health Administration medical facility. The encoder provides all the tools needed to review, analyze, audit, and code inpatient and outpatient episodes of care. The Veterans Health Administration clinical coding program requires use of the national Veterans Affairs encoder product which includes reports. The encoder product is utilized to manage workflow and expedite the coding process, e.g. as a communication tool, a compliance tool, and to ensure all assigned services are coded within mandated timeframes, etc. Reports are produced and reviewed daily to ensure all assigned cases are coded within established timelines. The encoder software provides coders with current electronic references and support tools. The encoder product is updated and/or modified as needed to meet the data collection needs of the Veterans Affairs.

There are approximately 170 Veterans Health Administration medical facilities and 1,063 community outpatient clinics in all 50 United States, American Samoa, Guam, the Philippines, the Virgin Islands and Puerto Rico. Veterans Affairs Medical Center staff have varying degrees of workload including coding backlogs at varying levels. Many sites may need continued assistance to keep current.

2.0. Purpose:

The purpose of this Blanket Purchase Agreement is to secure services to assign the current appropriate International Classification of Diseases; Current Procedural Terminology; and Healthcare Common Procedure Coding System Level II codes based on electronic health record documentation of outpatient, surgical, and inpatient care and services provided at or under the auspices of a Veterans Health Administration facility, to include all community outpatient clinics, when applicable, and to conduct coding audits of inpatient and outpatient episodes as requested by a Veterans Health Administration facility. The Contractor shall provide all resources necessary to accomplish the deliverables described in the Performance Work Statement except as may otherwise be specified.

3.0. Description of Services:

• The Contractor shall:

1. Assign the current appropriate industry standard codes after careful review of the Health Record documentation for all inpatient, outpatient, surgeries, procedures, and ancillary encounters/services.

2. Furnish validation of the integrity, quality, and assignment of codes to the data contained in the national encoder product and EHR.

3. The latest United States editions of the International Classification of Diseases, Current Procedural Terminology, Health Care Common Procedure System shall be used to provide uniform disease and operation terminology.

4. Code assignment shall be in accordance with The Official Coding Guidelines (current year), published by the cooperating parties: National Center for Health Statistics, Centers for Medicare and Medicaid Services, American Hospital Association, American Medical Association and American Psychiatric Association guidelines. On those occasions when there is a question, Veterans Health Administration Coding Guidelines will take precedence. In the absence of Official Coding Guidelines or VHA Coding guidance, local policies will direct how coding is accomplished. The American Hospital Association Coding Clinic and other publications may be used for training and reference purposes.

5. Quantitative and/or qualitative reviews are required and must be performed by the facility.

6. Ensure that the Contractor’s coders providing services through this Blanket Purchase Agreement and subsequent task orders (herein referred to as Blanket Purchase Agreement) use the facility’s national Veterans Affairs encoder product.

• Contractor is responsible for the management and supervision of its staff.

Contractor is responsible for training its staff on Veterans Affairs policy, guidelines, and procedures.

• The contractor shall adhere to all coding guidelines as approved by the Cooperating Parties (American Hospital Association, American Health Information Management Association, Centers for Medicare and Medicaid Services, and the National Center for Health Statistics), as mandated by Health Insurance Portability and Accountability Act and accepted Veterans Affairs regulations, including the following applicable documents:

1. The Official Guidelines and Reporting as found in the Current Procedural Terminology 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 International Classification of Diseases, a publication of the American Hospital Association, and

3. The current Veterans Health Administration guidelines for coding as found in the Veterans Health Administration Health Information Management Coding Guidelines. These guidelines are updated at least once per year with new codes and guidance to delineate those situations where VHA may not follow the official coding guidelines. The contractor must ensure that they have the current version and the guidance is followed. Note: While Veterans Health Administration does ask for reimbursement from third party payers, the Veterans Health Administration coding policy is to code according to official coding guidelines, except in such cases where VHA has determined differences are required. Internal Veterans Health Administration compliance audits use only this definition when determining if coding is accurate.

4. The National Correct Coding Initiative (NCCI) will be applied to Current Procedural Terminology codes to ensure no unbundling has occurred.

5. Veterans Health Administration Directive 1082 Patient Care Data Capture:

http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=3091

6. Veterans Health Administration Directive 1401 Billing for Services Provided by Supervising Practitioners and Physician Residents:

http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=3221

7. Veterans Health Administration Handbook 1400.01 Resident Supervision:

https://www.va.gov/OPTOMETRY/docs/VHA_Handbook_1400- 01_Resident_Supervision_12-19-2012.pdf

8. Veterans Health Administration Health Information Management Clinical Coding Program Guide:

https://vaww.vha.vaco.portal.va.gov/sites/HDI/HIM/vaco_HIM/subsite5/sub site3/HIM%20Handbooks/Forms/HIM%20Document%20Library.aspx

9. Veterans Health Administration Handbook 1907.01 Health Information Management and Health Records:

http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=3088 http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1821 http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2363 https://www.va.gov/OPTOMETRY/docs/VHA_Handbook_1400-01_Resident_Supervision_12-19-2012.pdf https://www.va.gov/OPTOMETRY/docs/VHA_Handbook_1400-01_Resident_Supervision_12-19-2012.pdf http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=2791

10. Veterans Health Administration Directive 1233 Closeout of Veterans Health Administration Corporate Patient Data Files Including Quarterly Patient Census:

http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=5425

11. HIM and Consolidated Patient Accounts Centers (CPAC) Standard Operating

Procedures:

https://vaww.vha.vaco.portal.va.gov/sites/HDI/HIM/vaco_HIM/subsite5/subsite 3/Coding%20References/Forms/AllItems.aspx?RootFolder=%2Fsites%2FHDI %2FHIM%2Fvaco%5FHIM%2Fsubsite5%2Fsubsite3%2FCoding%20Referen ces%2FCoding%20Resources%2Fcpac&FolderCTID=0x01200078A544A04C D5274BA1F70B598C57B05D&View=%7B60252EDE%2D0E1F%2D4A0E%2

D9C5C%2D02D9C06B32EE%7D

12. Practice Brief Monitoring Coding Accuracy and Productivity:

https://vaww.vha.vaco.portal.va.gov/sites/HDI/HIM/vaco_HIM/subsite5/subsite 3/Practice%20Briefs%20and%20Fact%20Sheets/Practice%20Brief%20Monit oring%20Coding%20Accuracy%20and%20Productivity%20October%202018 %20Updated.docx

13. Other directives that Veterans Affairs may issue from time to time.

• All written deliverables will be phrased in layperson language. Statistical and other technical terminology will not be used without providing a glossary of terms.

• Upon request of the Contracting Officer, the contractor shall remove any contract staff that do not comply with Veterans Health Administration policies or meet the competency requirements for the work being performed.

• The Contractor shall abide by the American Health Information Management Association (AHIMA) established code of ethical principles as stated in the Standards of Ethical Coding published by AHIMA.

• All coding and auditing activities shall be performed remotely and will reference Veterans Affairs’ electronic health record documentation.

• The Contractor shall provide all labor, materials, transportation, and supervision necessary to perform coding and 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, Current Procedural Terminology Assistant, Centers for Medicare and Medicaid Services /American Medical Association, Ambulatory Patient Classifications ) in a simulated Medicare payment environment.

• Communication:

1. The Contractor shall specify a contact person and phone number who is available for personal contact, at a minimum, during regular business hours of the Veterans Affairs facility that owns the work, for the duration of the work.

2. The Contractor shall maintain weekly communication with the Health Information Management Manager, Contracting Officer’s Representative or http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=2419 https://vaww.vha.vaco.portal.va.gov/sites/HDI/HIM/vaco_HIM/subsite5/subsite3/Practice%20Briefs%20and%20Fact%20Sheets/Practice%20Brief%20Monitoring%20Coding%20Accuracy%20and%20Productivity%20October%202018%20Updated.docx https://vaww.vha.vaco.portal.va.gov/sites/HDI/HIM/vaco_HIM/subsite5/subsite3/Practice%20Briefs%20and%20Fact%20Sheets/Practice%20Brief%20Monitoring%20Coding%20Accuracy%20and%20Productivity%20October%202018%20Updated.docx https://vaww.vha.vaco.portal.va.gov/sites/HDI/HIM/vaco_HIM/subsite5/subsite3/Practice%20Briefs%20and%20Fact%20Sheets/Practice%20Brief%20Monitoring%20Coding%20Accuracy%20and%20Productivity%20October%202018%20Updated.docx https://vaww.vha.vaco.portal.va.gov/sites/HDI/HIM/vaco_HIM/subsite5/subsite3/Practice%20Briefs%20and%20Fact%20Sheets/Practice%20Brief%20Monitoring%20Coding%20Accuracy%20and%20Productivity%20October%202018%20Updated.docx other designee (i.e., coding supervisor/team leader) regarding progress, workload status and/or problems.

3. The Contractor shall make every effort to ensure that issues raised by the local facility are addressed within the timeframe specified to in the task order or agreed to with the facility Contracting Officer’s Representative.

4. The Contractor shall ensure that communications that contain Personally Identifiable Information, Personal Health Information and/or individually identifiable health information/record are encrypted to prevent inappropriate/unauthorized access or disclosure. The Veterans Affairs facility Contracting Officer’s Representative will advise the contractor of the encryption to be used.

• Contract coders shall obtain clarification through Query process conflicting, ambiguous, or non-specific information appearing in the health record as directed by the facility.

• Quality Assessment of Health Information Services:

1. The Contractor shall possess all licenses, permits, accreditation and certificates as required by law.

2. The Contractor shall perform the required work in accordance with The Joint

Commission, Veterans Health Administration, and other regulatory standards.

The Joint Commission standards may be obtained from:

The Joint Commission

One Renaissance Blvd Oakbrook Terrace, IL 60181

• Exclusions and Sanction Certification: The Contractor shall provide annual written certification to the Contracting Officer which certifies that all employees, sub- Contractors, and their employees have been checked to ensure that all agents providing services under this Blanket Purchase Agreement have been found not to be listed on the List of Parties Excluded from Federal Programs and the Health and Human Services/Office of the Inspector General Cumulative Sanction Report. The annual certification shall be provided within three weeks after award and within three weeks after the exercise of any options periods (if applicable).

• The Contractor shall be responsible to train new contract staff (including subcontractors, if applicable) on Veterans Affairs policy and procedures and ensure completion of any Veterans Affairs mandatory training, security clearances, or other tasks required for Contractor staff to perform the services outlined in this PWS.

• The contractor staff shall sign confidentiality statements as required. Any person, who knowingly or willingly discloses confidential information from the Veterans Affairs, may be subject to fines.

• Health Insurance Portability and Accountability Act regulations require Veterans Health Administration to execute Health Insurance Portability and Accountability Act compliant Business Associate Agreements with appropriate parties that collect, receive, use, or disclose Veterans Health Administration Protected Health Information to perform activities, functions, or services for Veterans Health Administration. Attachment 3.

4.0. Specific Mandatory Tasks and Deliverables:

The Contractor shall provide the specific deliverables described below by the timeframes specified or as stated on individual task orders.

The Contractor shall not commence performance on the tasks in this Performance Work Statement until the Contracting Officer has conducted a kickoff meeting or has advised the contractor that a kickoff meeting is waived.

4.1 Task One - Coding Services:

A. The Contractor shall use skills, training, and knowledge of International

Classification of Diseases, Current Procedural Terminology, and Healthcare Common Procedure 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/EHR data elements in accordance with Veterans Health Administration Handbooks, Guides 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 facility task order Contracting Officer.

D. The Contractor shall use the 1995 or 1997 Evaluation and Management guidelines as documented in the facility policy. Individual facilities may also require the Evaluation and Management calculator contained within the encoder software.

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 EHR, 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 national encoder product and EHR communication tools to provide billing staff with a standardized reason why they believe an outpatient encounter cannot be billed. Encounters believed to be not billable will be marked with the appropriate reason in the national encoder product/EHR. Reasons may include but are 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 Current Procedural Terminology Assistant, as specified by the Veterans Affairs Administration Center.

H. 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.

I. The Contractor shall utilize the standardized reasons in the encoder application to communicate specific document information to Billing.

J. The Contractor shall utilize the national encoder product and EHR, if necessary, to reflect code changes and names(s) of provider(s).

K. If requested by the facility, the Contractor may place a local coder on-site if available in accordance with the task order when the coder lives in the area of a Veterans Affairs facility requesting work. No travel costs will be charged in this scenario.

L. The Contractor shall ensure that individual coders are clearly identified on all work;

any paper documents shall clearly identify the individual coder.

M. When assigning multiple Current 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.

N. The Contractor shall identify those encounters, if any, where documentation does not substantiate an appropriate code(s).

O. The contractor shall identify duplicate encounters or encounters created in error because the patient was not seen.

P. The Contractor shall code based on reading and reviewing the documentation in the electronic health record. The contractor shall complete data entry into the encoder as part of this Contract. Completion of source documents in lieu of using the national encoder product may be arranged only upon agreement between the facility task order Contracting Officer and the contractor for a contingency plan when the national encoder is down.

Q. The Contractor shall coordinate with the local Contracting Officer’s Representative for implementation of contingency plans for data entry when required.

R. The contractor shall assign modifiers as appropriate to override Correct Coding Initiative edits.

S. For Inpatient Episodes/Admission Services:

1. Accurately abstract inpatient information and enter into the national encoder minimizing national data acceptance errors and following facility policy for corrective action. Opening and transmitting inpatient episodes will follow local facility protocol.

T. The Contractor shall review documentation to determine and provide additional information such as the referring providers name, stop and start times for anesthesia, etc. as outlined in SOP with CPAC in coding case comments.

U. The Contractor shall re-review any coded data when questioned by Veterans Affairs staff and assigned to VHA HIM coding using appropriate status 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 Current Procedural Terminology, Healthcare Common Procedure Coding System or International Classification of Diseases diagnosis codes that should have been coded and were not,

3. Inappropriate Current Procedural Terminology, Healthcare Common Procedure Coding System or International Classification of Diseases codes

4. Unbundled codes

5. Inaccurate Diagnosis Related Groups assignments

6. 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.

V. 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.

W. Inpatient Facility coding:

1. All data must be accepted by Veterans Health Administration Corporate Data

Warehouse within 5 calendar days from the date of patient discharge, including any error. corrections must be re-transmitted and accepted. The only exceptions are Patient Treatment File discharges from Contract or Community Nursing Home and non-Department of Veterans Affairs Purchased Care patient files.

2. 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.

3. 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.

4. Non- Veterans Affairs purchased care coding utilizes the non-Veterans Affairs invoice, as well as submitted clinical documentation if received.

X. Inpatient Professional Encounters/Services coding:

1. Inpatient Professional Encounters/Services coding is to be completed within five (5) calendar days of the date coding is assigned.

2. Identify and link Current Procedural Terminology/Healthcare Common

Procedure Coding System and International Classification of Disease codes, identify the provider, and the date(s) of service.

3. Contractor may be required to create the Inpatient Professional Service encounter in the Patient Care Encounter application in order to code the service.

Y. Outpatient Coding:

1. All coding is to be completed within five (5) 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. Assign or validate diagnostic and procedural codes reflective of documentation;

correct outpatient encounter, if necessary, to reflect code changes and name(s) of provider(s).

3. 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.

Z. 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 of surgery.

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. Anesthesiology visits for surgery performed in the Operation Room may require coders to create encounters for the services if they do not exist.

5. Instructions for surgery coding are contained in the official coding guidelines and 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 task order will specify the period of performance for all audit services.

B. External audits provide validation of the integrity, quality, and assignment of codes to the data contained in the national encoder product and EHR 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 and Guides, Health Information Management Consolidated Patient Agreement Center Service Level Agreement, Veterans Health Administration Coding Guidelines, etc. as well as each facility’s policies prior to commencement of an audit. References will be provided by the facility as needed, see referenced Practice Brief Monitoring Coding Accuracy and Productivity.

C. To ensure the review findings have value to the facility, the VHA standard reporting tool provided will be utilized for the audit. 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 EHR, the medical center will overnight the documentation to the vendor.

D. 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

E. 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 task order, 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 of 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.

F. Outpatient, Inpatient Professional, Surgery, and Inpatient facility Audits:

1. Audit includes Evaluation and Management, Current Procedural Terminology procedures, Healthcare Common Procedure Coding System 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 Current Procedural Terminology 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 Current Procedural Terminology/Healthcare Common Procedure 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.

G. The Contractor shall provide a final written report to the facility Contracting Officer’s Representative within 10 calendar days. The report 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 must include, at a minimum, the record ID, breakdown of record type (i.e., outpatient, inpatient), breakdown by code (Current 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.

H. The Contractor shall document in writing all records reviewed and provide such documentation to the facility Contracting Officer’s Representative with the final report.

I. 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.

J. 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

6. Education Plan

4.3 Task Three - Training Workshop:

A. At the task order level, the Contractor shall provide, at a minimum, a two-hour educational session based on facility needs for Veterans Health Administration coding staff, Veterans Integrated Service Network/Veterans Affairs Medical Center management officials, physicians/clinicians, sub-specialties providers or other staff.

The Contractor is required to develop specific coding education utilizing actual health records and identified coding issues specific to the Veterans Health Administration coder and/or Veterans Affairs facility, and based on Veterans Health Administration guidelines, regulations, and local policy. This can be done either on site or remote at the discretion of the facility.

B. Task Three Deliverable:

1. Training Workshop

2. Sign-In sheet and Completion Listing

3. Summary of Coding issues Addressed

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 unless otherwise indicated on the individual task order. 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 National Health Information

Management Contracting Officer’s Representative and the Blanket Purchase Agreement Contracting Officer, listing all work referred to the contractor based on a Contractual agreement made through this Blanket Purchase Agreement. 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 Officer

6.0 Schedule of Deliverables:

The contractor shall meet the Delivery Schedule for each deliverable specified below:

Task Deliverables Deliverable Objective Delivery Due

4.1 Task One –

Coding Services

1. Inpatient Facility Coding Within five (5) calendar days of the date coding is assigned.

2. Inpatient Professional Encounter/Services Coding

Within five (5) calendar days of the date of coding is assigned.

3. Outpatient Coding Coding completed within five (5) calendar days of the date coding is assigned.

4. Surgery Coding Completed immediately after the procedure when possible and no later than one week from the date coding is assigned.

4.2 Task Two -

External Audit

1. Project Plan with description of sample size determination

At the time of proposal submission.

2. Audit: Inpatient Facility (Diagnosis Related Group) Coding

Complete within the performance period stated on the facility task order.

3. Audit: Inpatient professional encoder coding including surgery coding

Complete within the performance period stated on the facility task order.

4. Audit: Outpatient encounter coding

Complete within the performance period stated on the facility task order.

5. Final Report of audit results

Complete within the performance period stated on the facility task order.

6. Education Plan Provide at the exit conference.

4.3 Task Three -

Training Workshop

1. Training Workshop (2-hour minimum)

Provide remotely or on site; date to be determined by/coordinated with the facility.

2. Sign-In sheet and Completion Listing

Within 7 calendar days of the end of training.

3. Summary of Coding issues Addressed

No less than 7 calendar days prior to scheduled training workshop date.

5.0 Reporting

Requirements

1. Monthly Progress Report

Within 7 calendar days of the end of the month.

2. Quarterly Reports Within 7 calendar days of the end of the quarter.

7.0 Quality Control and Performance Metrics:

The Health Information Management Manager or Veterans Affairs appointed designee will validate the contractor’s work to confirm that Contractual coding and auditing meets accuracy and policy requirements. The Contractor is responsible for continuous quality control of their own work product using quality control methods such as auditing.

Coding accuracy will be determined by the number of correct codes compared to total number of codes, correct Diagnosis Related Group 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 cancellation of this Blanket Purchase Agreement. The designated contacts for the facility and the contractor will discuss any questions regarding coding or expected work.

The Contractor shall have in place the following Coding Quality Control/Performance Process whereby the contractor shall: Meet the expected turnaround time as stated herein or as included on the task order. Work is considered completed when it is received back at the Veterans Affairs facility with data entry done via the encoder or the documentation is at the Veterans Affairs facility.

The Contractor must perform on-going quality assessments on a representative sample and provide results in a manner agreed upon by the facility, at a minimum of monthly, to the Veterans Affairs facility Contracting Officer’s Representative to ensure that the 95% accuracy rate is met. Data elements include International Classification of Diseases and Current Procedural Terminology codes, Diagnosis Related Groups, and data items abstracted and entered by the Blanket Purchase Agreement coder. The contractor shall track results by coder to assure appropriate follow-up and training.

The contractor shall monitor to ensure that the 95% quality standard is met on an on-going basis. If monitoring demonstrates that work has fallen below the quality standard, the Contractor must develop a corrective action plan and include it with the report, at a minimum of monthly, to the Contracting Officer’s Representative. Reports to the facility and National Contracting Officer’s Representative shall be accurate and completed within the specified timeframe.

VHA Facility staff must perform a random audit of contractor’s audit results. The Contractor will be notified of VHA audit results by the facility and will be required to respond to/dispute findings in writing and correct any associated coding errors within 5 calendar days of notification. If requested by facility, the Contractor will develop and implement a corrective action plan to address deficiencies. A copy of the corrective action plan will be submitted to the Contracting Officer’s Representative for concurrence within 5 calendar days.

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 in accordance with the Blanket Purchase Agreement terms and conditions. A timeframe for resolution will be agreed upon at the task order level.

8.0 General Information:

The Contractor shall provide all resources necessary to accomplish the deliverables described in the Performance Work Statement, except as may otherwise be specified.

A. Assign appropriate International Classification of Diseases, Current Procedural

Terminology and Healthcare Common Procedure Coding System Level II codes based on health 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 national encoder product and EHR.

C. Any changes to the Performance Work Statement shall be authorized and approved only through written correspondence from the Contracting Officer. A copy of each change will be kept in a project folder along with all other products of the project.

Costs incurred by the contractor through the actions of parties other than the Contracting Officer shall be the responsibility of the Contractor.

8.1 Personnel:

The Contractor personnel shall possess expertise in health record coding and auditing.

These skilled experienced professional and/or technical personnel are essential for successful contractor accomplishment of the work to be performed under this PWS.

The Contractor shall utilize only employees, sub-contractors or agents who are physically located within a jurisdiction subject to the laws of the United States. The Contractor will ensure that it does not use or disclose Protected Health Information received from Covered Entity in any way that will remove the Protected Health Information from such jurisdiction. The Contractor will ensure that its employees, sub- Contractors and agents do not use or disclose Protected Health Information received from Covered Entity in any way that will remove the Protected Health Information from such jurisdiction. Personnel providing direct Coding and Auditing services must be a U.S. citizen.

The Contractor personnel shall maintain training requirements necessary for continued access to VA information systems throughout the period of performance. Contractor personnel shall possess knowledge of VA requirements for access to information systems per the requirements in section 19 and applicable documents and ensure only approved methods for accessing VA information systems are used for contract performance.

8.1.1 Personnel Replacement:

Any personnel the contractor offers as substitutes shall meet the security requirements and qualifications as outlined in the Performance Work Statement.

All personnel substitutions shall be submitted to the Contracting Officer’s Representative prior to making any change in personnel. The Contractor shall submit evidence of completed mandatory training, security documents, and any other information requested by the Contracting Officer’s Representative.

Substitute personnel shall not commence work until all necessary security and training requirements are met.

8.2 Contractor Personnel:

The Contractor shall:

A. Have the ability to read and interpret health record documentation in order to identify all diagnoses and procedures that affect the current outpatient encounter visit, ancillary, inpatient professional fees and surgical episodes.

B. Meet the education and experience (in para. 8.3) in the industry standard code sets and guidelines for International Classification of Diseases, Current Procedural Terminology, and Healthcare Common Procedure Coding System.

C. Apply knowledge of current Diagnostic Coding and Reporting Guidelines for outpatient services.

D. Apply knowledge of Diagnostic, Procedure, Professional, and Surgical coding guidelines for inpatient services.

E. Apply knowledge of Current Procedural Terminology format, guidelines, and notes to locate the correct codes for all services and procedures performed during the encounter/visit and sequence them correctly.

F. Apply knowledge of procedural terminology to recognize when an unlisted procedure code must be used in Current Procedural Terminology.

G. Code in accordance with Correct Coding Initiative Bundling Guidelines.

H. Use the Healthcare Common Procedure Coding Systems, where appropriate.

I. 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.

8.3. Coder/Auditor Education and Experience:

The Contractor shall provide experienced, competent, credentialed personnel to perform coding and/or auditing activities.

A. Contract coders shall have a minimum of two years’ experience in International

Classification of Diseases, Current Procedural Terminology, and Healthcare Common Procedure Coding System coding and completed the baseline International Classification of Diseases,10th edition requirements listed below or as required to hold a current/active credential;

B. Audit reviewers must have at least three years of training experience in reviewing records in large tertiary care hospital, and outpatient health care organizations having all subspecialties and primary care, as well as three years of education and training experience and completed the baseline International Classification of Diseases, 10th edition requirements listed below or as required to hold a current/active credential:

C. Contract coders/validation staff shall 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 (International Classification of Diseases, Current Procedural Terminology, and Healthcare Common Procedure Coding System).

1. Coders/auditors shall 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 Blanket Purchase Agreement, a certified coder/auditor is someone with one of the following active credentials listed below. Other credentials shall not be accepted.

a. Personnel with responsibilities for International Classification of Diseases 10th edition code determination/application activities shall hold a current/active American Health Information Management Association or American Academy of Professional Coders credential.

b. Personnel shall have successfully completed the required baseline International Classification of Diseases, 10th edition, Clinical Modification/Procedure Coding System continuing education units (CEUs) required by their credentialing organization as follows: American Health Information Management Association requires Registered Health Information Technician 6 CEUs; Registered Health Information Administrator 6 CEUs; Clinical Documentation Improvement Practitioner 12 CEUs; Certified Coding Specialist -P 12 CEUs; Certified Coding Specialist 18 CEUs; and Certified Coding Associate 18 CEUs.

c. Certification as an…