SSN 230209 - NCCI.pdf

Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative Program (NCCI)

Sources Sought Notice (SSN) 230209

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THIS IS NOT A REQUEST FOR PROPOSAL or SOLICITATION AND DOES NOT

COMMIT CMS TO AWARD A CONTRACT NOW OR IN THE FUTURE

Introduction:

The Centers for Medicare & Medicaid Services (CMS) is hereby conducting market research to determine the availability and capability of potential small businesses (e.g., 8(a), service-disabled veteran owned small business, HUBZone small business, small disadvantaged business, veteran-owned small business and woman-owned small business) that can provide the services identified in the attached National Correct Coding Initiative Program (NCCI) Draft Statement of Work (SOW) (see Attachment 1) in support of CMS, and specifically Centers for Program Integrity (CPI), Audits and Vulnerabilities Group (AVG).

The information obtained through this market research will assist the CMS in determining the appropriate acquisition procedures for obtaining the NCCI services described in the attached SOW. This market research will help CMS plan their acquisition strategy and aid in its determination as to whether it is appropriate to set-aside this work for small businesses or for a specific socio-economic category of small businesses such as 8(a), small disadvantaged, women-owned, veteran-owned, service-disabled-veteran-owned, or HUBZone small business.

Contractors must be free of conflicts of interest or be able to prepare an Organizational Conflict of Interest (OCI) mitigation plan to address any actual, potential, or apparent organizational conflicts of interest that could arise.

Contractors must be registered in the System for Award Management (SAM) database located at https://www.sam.gov/SAM/ prior to award, during performance, and through final payment of any contract resulting from this Notice. Contractors may obtain information on SAM registration by visiting: https://www.acquisition.gov.

This announcement is a Sources Sought Notice (SSN) for planning purposes only. This is not an invitation for bid, request for quote or other solicitation and in no way obligates the Government to award a contract. CMS will not entertain questions regarding this market research.

Background:

The NCCI program promotes program integrity (PI) and compliance through guidance, edits, and other methodologies that reduce improper payments in the Medicare and Medicaid program. The NCCI program is administered by the CMS, Center for Program Integrity. As the largest payer for health care services, the CMS-administered programs are a target for improper payments and schemes to defraud federal health care programs of billions of dollars annually.1 Accurate coding and reporting of services by providers and suppliers is a critical aspect of assuring proper payments in Medicare and Medicaid. To address this requirement, CMS developed and

1 See the Department of Health and Human Services Agency Financial Report, https://www.hhs.gov/sites/default/files/fy-2021-hhs-agency-financial-report.pdf.

https://www.acquisition.gov/ https://www.hhs.gov/sites/default/files/fy-2021-hhs-agency-financial-report.pdf

Pg.2 implemented the NCCI program to promote national correct coding methodologies and to reduce improper coding that can lead to improper payment in the Medicare and Medicaid programs. In August 1994, CMS awarded the first NCCI contract and NCCI edits have been in place in the CMS claims processing system since January 1, 1996 for Medicare Part B. The NCCI program has since been expanded to include Medicaid under section 6507 of the Patient Protection and Affordable Care Act (PPACA).

The NCCI program includes three types of edits: Procedure to Procedure (PTP), Medically Unlikely Edits (MUEs), and Add-On Code (AOC) edits:

• PTP edits - prevent inappropriate payment of services that should not be reported together. Each edit has a Column One and Column Two Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) code. If a provider reports the two codes of an edit pair for the same beneficiary on the same date of service, the Column One code is eligible for payment but the Column Two code is denied unless a clinically appropriate NCCI PTP-associated modifier is also reported.

• MUE edits - prevent payment for an inappropriate number/quantity of the same service on a single day. An MUE for a HCPCS/CPT code is the maximum number of Units of Service (UOS) under most circumstances reportable by the same provider for the same beneficiary on the same date of service.

• AOC edits - consist of a listing of HCPCS and CPT AOC with their respective primary codes. An AOC is eligible for payment if and only if one of its primary codes is also eligible for payment.

Claims are denied by NCCI edits based on a determination of inappropriate coding, not on the basis of medical necessity. Correct coding is a separate activity from medical review in that no further clinical judgment is needed to deny a claim; therefore, the denial can be automated.

Certain edits also include indicators that certain edits may or may not be bypassed with a modifier.

More detailed information about the Medicare and Medicaid NCCI Programs including public documents and edit files, are available at:

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html and https://www.medicaid.gov/medicaid/program-integrity/national-correct-coding-initiative-medicaid/index.html.

Overview of the Requirements

The purpose of this contract is to maintain and further expand all of the NCCI correct coding edits and other methodologies to ensure that consistent coding and adjudication of Medicare and Medicaid claims lead to consistent payments to providers in accordance with the payment policies of those programs; and enable CMS and states to meet the Medicaid program requirements as outlined in section 6507 of the PPACA.

CMS seeks a Contractor to achieve the following outcomes through performance of the tasks outlined in the attached Draft Statement of Work (SOW):

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html https://www.medicaid.gov/medicaid/program-integrity/national-correct-coding-initiative-medicaid/index.html https://www.medicaid.gov/medicaid/program-integrity/national-correct-coding-initiative-medicaid/index.html

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• Maintain PTP, AOC, and related edits, including updates to current edits with approved recommended changes or comments, and incorporation of (CPT) and (HCPCS) additions, deletions, and revisions;

• Maintain MUEs (i.e., units of service edits) to reduce coding and clerical errors, including updates to the current edits with any recommended changes or comments incorporating CPT and HCPCS additions, deletions, and revisions;

• Evaluate clinical and claim information to ensure that NCCI accurately reflects CMS payment and coverage policy decisions; and

• Assist CPI and states to meet the requirements of section 6057 of the Patient PPACA, which expands NCCI methodologies to Medicaid.

Contractor support includes, but is not limited to:

• Providing continuous maintenance of the current NCCI PTP, AOC and MUE edit programs and to further develop, improve and expand those programs in order to prevent improper payments;

• Providing continuous maintenance of the NCCI Coding Policy Manuals and the NCCI Correspondence Language Manuals or their successors, and to develop, improve and expand the content and/or format in order to support the edits and guidelines promulgated by NCCI;

• Providing timely and accurate answers to inquiries received from email, correspondence, fax, NCCI mailbox, etc. about the NCCI program, while tracking this activity through an internal inquiry log that is directly accessible to CMS to monitor existing edits to identify inaccuracies or changes, making any necessary corrections upon approval from CMS;

• Providing appropriate surveillance of health care coding systems for the purpose of recommending necessary additions, deletions and changes to the NCCI edit programs;

• Assisting CMS in identifying opportunities to create new programs, approaches and strategies to reduce Medicare and Medicaid coding variation and associated payment variation, ensure correct, consistent coding and associated payments in accordance with Medicare and national Medicaid policies, and to reduce overpayments associated with inappropriate coding;

• Establishing and maintaining databases directly accessible to CMS to support deliverables related to the requirements of this contract and to provide an audit trail pertaining to all decisions relating to the edits and records of the status of all edits at any point in time;

• Establishing and providing quarterly edit files compatible with CMS requirements for transmission of the data to the claims processing systems; and

• Establishing and providing an audit trail of supporting records to support NCCI Workgroup (WG) decisions and actions for use in responding to queries or other administrative needs.

mailto:NCCIPTPMUE@cms.hhs.gov

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Instructions for Responding:

Responses to this notice shall demonstrate the respondent’s capability to perform the services outlined in the Draft SOW. In addition, CMS is interested in implementing new and innovative approaches for performing NCCI activities. Respondents are encouraged to submit suggestions for innovative techniques and approaches as appropriate for the NCCI requirement. Responses based upon anticipated teaming arrangements and Joint Ventures are acceptable. The capability of each team member (prime contractor and subcontractors) shall be demonstrated relative to the anticipated functions/roles to be performed by each. Potential small businesses shall demonstrate their knowledge, expertise and experience with the SOW requirements in all of the numbered points below, including:

(1) interpreting HCPCS/CPT codes and coding conventions;

(2) working with national medical specialty societies;

(3) working with Medicare Part B claims processing systems;

(4) working with Medicaid payment policies and other federal Medicaid requirements

(5) performing and interpreting data analysis of the Medicare Part B claims

(6) maintaining current certification as a Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist (CCS), Certified Professional Coder (CPC), or equivalent

(7) performing database design, reporting, data analysis and data extraction

(8) maintaining and directing an effective internal corporate Quality Control and Quality

Assurance Program, preferably in the health insurance/health care industry.

Please address each requirement outlined above in order. Reference the Draft SOW for definitions and clarification of terms. CMS will take all information received under consideration when finalizing the strategy for procuring services for the NCCI.

Respondents shall also submit the following business information in their response:

1. Unique Entity Identifier Number

2. Company Name

3. Company Address

4. Company Point of Contact, phone number and email address

5. Type of company under North American Industry Classification System (NAICS)

541990- All Other Professional, Scientific, and Technical services. Size Standard $17.0 Million (i.e., small business, 8(a), woman-owned, veteran-owned, etc.) as validated via the System for Award Management (SAM). Additional information on NAICS codes can be found at www.sba.gov.

6. Corporate structure (e.g. corporation, LLC, sole proprietorship, partnership, limited liability partnership, professional corporation, etc.).

7. Do you have a Government approved accounting system? If so, please identify the Agency that approved the system.

8. Current contracting vehicles (e.g. GSA, BPAs, IDIQ etc.) appropriate to this Sources Sought the company is part of that is applicable and relevant.

9. Point of Contact, phone number and email addresses of at least two individuals who can

Pg.5 verify the demonstrated capabilities identified in the responses.

Teaming Arrangements: All teaming arrangements shall also include the above-cited information and certifications for each entity on the proposed team. Specifically, the capability statement must address how much effort would be performed by any proposed team member. Note that any resulting small business set-aside would require that at least 50% of the cost of contract performance for personnel be expended for employees of the concern (see FAR 52.219-14, Limitations on Subcontracting).

Submission Requirements:

All capability statements shall be submitted via email to the point of contact listed below. The title of the email shall read “Response to NCCI SSN 230209.” Responses must be submitted no later than 10:00 am, local time, Baltimore, MD, August 4, 2022. Responses shall be limited to 10 single-sided pages, not including the required business information and cover page. Pages should be single-spaced, minimum 11-point Times New Roman font with a minimum of one-inch margins on all sides.

Responses should be sent electronically to Megan Anuszewski, Contract Specialist, at Megan.Anuszewski@cms.hhs.gov with a courtesy copy to Jennifer Kuhn, Contracting Officer, at Jennifer.Kuhn@cms.hhs.gov.

Disclaimer and Important Notes:

This notice does not obligate the Government to award a contract or otherwise pay for the information provided in response. The Government reserves the right to use information provided by respondents for any purpose deemed necessary and legally appropriate. Any organization responding to this notice should ensure that its response is complete and sufficiently detailed to allow the Government to determine the organization’s qualifications to perform the work. Respondents are advised that the Government is under no obligation to acknowledge receipt of the information received or provide feedback to respondents with respect to any information submitted. No reimbursement will be made for any costs associated with providing information in response to this Notice. Respondents will not be notified of the results of this evaluation.

After a review of the responses received, a pre-solicitation synopsis or a solicitation may be published on beta.SAM.gov. However, responses to this notice will not be considered adequate responses to any solicitation CMS may choose to issue.

Confidentiality:

No proprietary, classified, confidential, or sensitive information should be included in your response. The Government reserves the right to use any non-proprietary technical information in any resultant solicitation(s).

Protection of Privileged or Confidential Commercial or Financial Information mailto:Megan.Anuszewski@cms.hhs.gov mailto:Jennifer.Kuhn@cms.hhs.gov https://beta.sam.gov/

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The Freedom of Information Act (FOIA), 5 U.S.C. § 552, provides individuals with a right to access certain records in the possession of the Federal government, subject to certain exemptions. Exemption 4 of the FOIA permits information to be withheld that is in the nature of "trade secrets and commercial or financial information obtained from a person and privileged or confidential." The term "person" refers to a wide range of entities, including corporations, banks, state governments, agencies of foreign governments, and Native American tribes or nations, who provide information to the government. Information that does not qualify withholding under the Exemption will be disclosed.

CMS may invoke Executive Order 12600 in accordance with FOIA Regulation 45 C.F.R. §

5.42. Information provided by entities to CMS in response to this notice may be subject to FOIA disclosure requirements unless protected under Exemption 4 of the Freedom of Information Act. Should entities wish to protect any trade secret or confidential information under Exemption 4, they should mark their submission accordingly citing applicable redactions and non-disclosure rationale. Pre-disclosure redactions and non-disclosure rationale shall be sent via e-mail to the requesting contracting officer with a copy to the CMS FOIA Office at 12600@cms.hhs.gov.

If an entity’s submission is not marked and CMS receives a FOIA request related to this notice, the CMS Contracting Officer will notify the entity. The entity will have 10 working days to object to the release of any part of their information submitted to CMS citing relevant case law. Final determination on the applicability of Exemption 4 of the FOIA are made on a case-by-case basis by CMS.

The statutory language of the FOIA is codified at 5 U.S.C. § 552(b). Additional information and resources, including the 9 FOIA Exemptions and HHS FOIA Regulation, and examples, can be found on the HHS FOIA Website.

ATTACHMENTS

Attachment 1: Draft Statement of Work https://uscode.house.gov/view.xhtml?req=(title:5%20section:552%20edition:prelim)%20OR%20(granuleid:USC-prelim-title5-section552)&f=treesort&edition=prelim&num=0&jumpTo=true https://www.archives.gov/federal-register/codification/executive-order/12600.html https://www.govinfo.gov/content/pkg/CFR-2019-title45-vol1/xml/CFR-2019-title45-vol1-part5.xml#seqnum5.42 https://www.govinfo.gov/content/pkg/CFR-2019-title45-vol1/xml/CFR-2019-title45-vol1-part5.xml#seqnum5.42 mailto:12600@cms.hhs.gov https://www.cms.gov/Regulations-and-Guidance/Legislation/FOIA https://www.hhs.gov/foia/index.html