36C25821Q0033.pdf

PAGE 1 OF1. REQUISITION NO.

2. CONTRACT NO. 3. AWARD/EFFECTIVE DATE 4. ORDER NO. 5. SOLICITATION NUMBER 6. SOLICITATION ISSUE DATE

a. NAME b. TELEPHONE NO. (No Collect Calls) 8. OFFER DUE DATE/LOCAL

TIME

9. ISSUED BY CODE 10. THIS ACQUISITION IS UNRESTRICTED OR SET ASIDE: % FOR:

SMALL BUSINESS

HUBZONE SMALL

BUSINESS

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

WOMEN-OWNED SMALL BUSINESS

(WOSB) ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

8(A)

NAICS:

SIZE STANDARD:

11. DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

SEE SCHEDULE

12. DISCOUNT TERMS

13a. THIS CONTRACT IS A

RATED ORDER UNDER

DPAS (15 CFR 700)

13b. RATING

14. METHOD OF SOLICITATION

RFQ IFB RFP

15. DELIVER TO CODE 16. ADMINISTERED BY CODE

17a. CONTRACTOR/OFFEROR CODE FACILITY CODE 18a. PAYMENT WILL BE MADE BY CODE

TELEPHONE NO. DUNS: DUNS+4:

PHONE: FAX:

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER

18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW IS CHECKED

SEE ADDENDUM

19. 20. 21. 22. 23. 24.

ITEM NO. SCHEDULE OF SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

(Use Reverse and/or Attach Additional Sheets as Necessary)

25. ACCOUNTING AND APPROPRIATION DATA 26. TOTAL AWARD AMOUNT (For Govt. Use Only)

27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA ARE ARE NOT ATTACHED.

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA ARE ARE NOT ATTACHED

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN _______________ 29. AWARD OF CONTRACT: REF. ___________________________________ OFFER COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DATED ________________________________. YOUR OFFER ON SOLICITATION DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY (BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED SET FORTH HEREIN IS ACCEPTED AS TO ITEMS:

30a. SIGNATURE OF OFFEROR/CONTRACTOR 31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER)

30b. NAME AND TITLE OF SIGNER (TYPE OR PRINT) 30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER (TYPE OR PRINT) 31c. DATE SIGNED

AUTHORIZED FOR LOCAL REPRODUCTION (REV. 2/2012)

PREVIOUS EDITION IS NOT USABLE Prescribed by GSA - FAR (48 CFR) 53.212

7. FOR SOLICITATION

INFORMATION CALL:

STANDARD FORM 1449

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS 119

36C25821Q0033 12-09-2020

Nakia Vance 602-795-4275 12-23-2020 4:00pm PST

Department of Veterans Affairs 777 E. Missouri Ave Ste 300

Phoenix, AZ 85014 AZ 85014

X 100

X

Y

541511

$30 Million

N/A

X

Department of Veterans Affairs Phoenix VA Healthcare System 644 E. Indian School Rd

Phoenix AZ 85012

Department of Veterans Affairs NCO22-Gilbert Network Contracting 777 E. Missouri, Suite 300 Phoenix AZ 85014

This is accomplished through the Tungsten Network located at:

http://www.fsc.va.gov/einvoice.asp This is mandatory and the sole method for submitting invoices.

See CONTINUATION Page

This requirement is for Health Information Management Service (HIMS) Medical Coding Support. This service will be performed at the Phoenix VA Health Care System (PVAHCS).

100% VOSB set a side

See CONTINUATION Page

X X

James Moran

VA-VHA-2020-F44EFB70

VOSB

36C25820Q0348

Table of Contents

SECTION A

A.1 SF 1449 SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

SECTION B - CONTINUATION OF SF 1449 BLOCKS

B.1 CONTRACT ADMINISTRATION DATA

B.2 STATEMENT OF WORK

B.3 PRICE/COST SCHEDULE

ITEM INFORMATION

B.4 DELIVERY SCHEDULE

SECTION C - CONTRACT CLAUSES

C.1 52.212-4 CONTRACT TERMS AND CONDITIONS—COMMERCIAL ITEMS (OCT

2018)

C.2 VAAR 852.212-70 PROVISIONS AND CLAUSES APPLICABLE TO VA

ACQUISITION OF COMMERCIAL ITEMS (APR 2020)

C.3 52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998)

C.4 52.217-8 OPTION TO EXTEND SERVICES (NOV 1999)

C.5 52.217-9 OPTION TO EXTEND THE TERM OF THE CONTRACT (MAR 2000) ...48

C.6 52.212-5 CONTRACT TERMS AND CONDITIONS REQUIRED TO IMPLEMENT

STATUTES OR EXECUTIVE ORDERS—COMMERCIAL ITEMS (AUG 2020)

SECTION D - CONTRACT DOCUMENTS, EXHIBITS, OR ATTACHMENTS

D.1 BUSINESS ASSOCIATE AGREEMENT

BUSINESS ASSOCIATE AGREEMENT BETWEEN THE DEPARTMENT OF

VETERANS AFFAIRS VETERANS HEALTH ADMINISTRATION, , AND

D.2 WAGE DETERMINATION

SECTION E - SOLICITATION PROVISIONS

E.1 ADDENDUM TO FAR 52.212-2 EVALUATION – SIMPLIFIED ACQUISITION

PROCEDURES

E.2 52.204-24 REPRESENTATION REGARDING CERTAIN TELECOMMUNICATIONS

AND VIDEO SURVEILLANCE SERVICES OR EQUIPMENT (AUG 2020)

E.3 52.204-16 COMMERCIAL AND GOVERNMENT ENTITY CODE REPORTING

(JUL 2016)

E.4 52.212-3 OFFEROR REPRESENTATIONS AND CERTIFICATIONS—

COMMERCIAL ITEMS (AUG 2020)

SECTION B - CONTINUATION OF SF 1449 BLOCKS

B.1 CONTRACT ADMINISTRATION DATA

1. Contract Administration: All contract administration matters will be handled by the following individuals:

a. CONTRACTOR:

b. GOVERNMENT: Contracting Officer 36C258

Department of Veterans Affairs

777 E. Missouri Ave Ste 300

Phoenix, AZ 85014 AZ 85014

2. CONTRACTOR REMITTANCE ADDRESS: All payments by the Government to the contractor will be made in accordance with:

[] 52.232-33, Payment by Electronic Funds Transfer—System For Award Management, or

[X] 52.232-36, Payment by Third Party

3. INVOICES: Invoices shall be submitted in arrears:

a. Quarterly []

b. Semi-Annually []

c. Other [X] Monthly

4. GOVERNMENT INVOICE ADDRESS: All Invoices from the contractor shall be submitted electronically in accordance with VAAR Clause 852.232-72 Electronic Submission of Payment Requests.

This is accomplished through the

Tungsten Network located at:

http://www.fsc.va.gov/einvoice.asp

This is mandatory and the sole method for submitting invoices.

ACKNOWLEDGMENT OF AMENDMENTS: The offeror acknowledges receipt of amendments to the Solicitation numbered and dated as follows:

AMENDMENT NO DATE

B.2 STATEMENT OF WORK

1. Title: Health Information Management Service (HIMS) Coding Support for the Phoenix VA Healthcare System in Phoenix, Arizona and their associated Community Based Outpatient Clinics.

2. 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). 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.

Beginning September 1, 1999, CPT-4 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.

VA medical centers (VAMCs) have varying degrees of coding backlogs that require assistance to remain current. 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.

The Department of Veterans Affairs, Veterans Health Administration uses the International Classification of Diseases, 10th Edition, Clinical Modification/Procedure Coding System (ICD-10 CM/PCS). The International Classification of Diseases, 10th Edition Clinical Modification is used for diagnosis coding; International Classification of Diseases, 10th Edition, Procedure Coding System for inpatient procedure coding.

Common Procedural Terminology is used for outpatient procedures.

3.0. Purpose: The purpose of this contract is to secure services to assign the current appropriate International Classification of Diseases; Common Procedural Terminology; and Healthcare Common Procedural Coding System Level II codes based on 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 Based 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 Statement of Work except as may otherwise be specified.

Any changes to the Statement of Work 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.

4.0. Description of Services:

A. 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. Outpatient encounters include but are not limited to scheduled clinic appointments with physicians as well as other healthcare providers, ambulatory surgery/ procedures, radiology, laboratory and other ancillary services.

2. Furnish validation of the integrity, quality, and assignment of codes to the data contained in the outpatient Patient Care Encounter, inpatient Patient Treatment File, and non-Veterans Affairs database and the Integrated Billing package, or that the record contains the correct Centers for Medicare and Medicaid Services (CCM) coder comment regarding the “reason not coded.”

Note: Contractor shall validate any order for test procedures in health information documentation to validate medical necessity.

3. Not use “incident to rules.”

4. Use the latest United States editions of the International Classification of Diseases, Current Medical Information and Terminology, of the American Medical Association and the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association shall be used to provide uniform disease and operation terminology, which is complete and scientifically accurate.

5. Assign codes in accordance with National Center for Health Statistics, Centers for Medicare and Medicaid Services, American Hospital Association, American Medical Association and American Psychiatric Association guidelines, as appropriate. On those occasions when there is a question, Veterans Health Administration Coding Guidelines take precedence. Local policies will direct how coding is accomplished and what quantitative and/or qualitative reviews are performed by the facility. The American Hospital Association Coding Clinic and other publications may be used for training and reference purposes.

6. Ensure that the contractor’s coders providing services through contract use the national Veterans Affairs encoder product. All coding must be completed through the encoder product. The national Veterans Affairs encoder is a single transparent interface with the Veteran Affairs’ electronic health record system Veterans Health Information Systems and Technology Architecture and the Graphical User Interface version of Veterans Health Information Systems and Technology Architecture. All coding is required to be done via the national Veterans Affairs encoder; no other system shall be used or interfaced with the Veterans Affairs systems.

7. Ensure complete electronic data entry into the VISTA system at each individual facility. Entry is to include CPT codes; modifiers; service-connected determination, when applicable; and diagnostic/procedure codes for the encounter or occasion of service into the appropriate VHA encoder software suite. It is to include associating the provider with the CPT code, when applicable. When documentation does not support a diagnosis code, procedure code, or CPT code, a secure compliance e-mail shall be sent to the provider requesting such documentation as appropriate. A suspense date of three days shall be set for reply & follow-up. When paper- based documents are provided by the VA, Contractor shall document codes and related information completely.

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

Contractor is responsible for training its 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 SOW.

1. Contractor shall maintain records that document competence/performance levels of employees working on this contract in accordance with The Joint Commission’s (TJC) standards as well as regulatory body requirements.

2. Contractor will provide annual competence assessment reports on each employee to the respective facility COR.

C. The 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-9- CM/PCS, and ICD-10-CM/PCS) (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:

1. The Official Guidelines and Reporting as found in the Common 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, Health Information Management, and Department of Veterans Affairs. This workbook is updated at least once per year with new codes and guidance. 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 only according to coding guidelines. Our own compliance audits use only this definition when determining if any encounter or Patient Treatment File is coded correctly.

4. The Correct Coding Initiative the Common Procedural Terminology Evaluation and Management codes assure documentation substantiates the code level assigned.

5. Veterans Health Administration Directive 2009-002

Patient Care Data Capture:

http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub

_ID=1821

6. Veterans Health Administration Directive 2011-006 Revised Billing Guidance for Services provided by Supervising Practitioners and resident:

http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2363

7. Veterans Health Administration Handbook 1400.01 Resident Supervision:

http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=2847

8. CMS Ruling – Documentation Requirements for VA Teaching Hospitals

(PVAHCS)

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

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

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

F. The 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 American Health Information Management.

G. All coding and auditing activities shall be performed remotely and will utilize Veterans Affairs’ electronic health record.

H. The contractor shall provide all labor, equipment, 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, Common Procedural Terminology Assistant, Centers for Medicare and Medicaid Services /American Medical Association, Ambulatory Patient Classifications) in a simulated Medicare payment environment. This includes having the appropriate reference material and using the VHA encoder software and Pro Fee Compliance Suite.

I. 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 each facility for the duration of the work.

2. The contractor shall maintain weekly communication with the Health Information

Management Manager, Contracting Officer’s Representative or other designee (i.e., coding supervisor/team leader) regarding progress, workload status and/or problems.

3. The contractor shall provide a weekly and/or monthly report (electronically) of completed cases to their respective facilities.

4. The contractor shall make every effort to ensure that issues raised by the facility are addressed within the timeframe specified with the facility’s Contracting Officer’s Representative.

5. 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.

J. Contract coders shall code in accordance with all Common Procedural Terminology / Common Procedural Coding Systems coding rules such as Correct Coding Initiative Bundling Guidelines, and use the Healthcare Common Procedural Coding Systems, level II codes, where appropriate.

K. Contract coders shall 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.

L. Contract coders shall clarify conflicting, ambiguous, or non-specific information appearing in the record by consulting with their supervisor, if necessary, discuss with the local Veterans Affairs contact.

M. The contractor shall code using the appropriate Common Procedural Terminology for inpatient professional services or nursing home professional services.

N. 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

O. Exclusions and Sanction Certification: The contractor shall provide annual written certification to the Contracting Officer’s Representative (COR) which certifies that all employees, Sub-Contractors, and their employees have been checked to ensure that all agents providing services under this contract 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).

P. 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.

Q. 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.

5.0 Specific Mandatory Tasks and Deliverables

5.0 Phoenix Healthcare System Requirements (PVAHCS)

The contractor shall provide the specific deliverables described below by the timeframes specified or as stated.

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

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; shall include required encoder/ Veterans Health Information Systems and Technology Architecture data elements in accordance with Veterans Health Administration Handbooks and protocols. 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 Contracting Officer.

D. The contractor shall use the 1997 Evaluation and Management guidelines as specified in the facility policy.

E. Veteran’s 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 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 the area of 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).The contractor shall identify duplicate encounters or encounters created in error because the patient was not seen.

Q. 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, Contracting Officer and the contractor.

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

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

T. 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.

U. 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.

V. 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 Z00.00

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. Veterans Affairs reserves the right to validate all coding, audit results and/or accuracy statistics submitted.

W. 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 and shared with the contractor at the time of award. Inpatient Facility coding:

1. 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.

8. Estimated monthly deliverables 260 PTF’s

X. Inpatient Professional Encounters/Services coding:

A. Inpatient Professional Encounters/Services coding is to be completed within seven (7) calendar days of the date coding is assigned.

2. Veteran’s 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 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.

8. Estimated monthly deliverables 500 Inpatient Professional Encounter/Services.

AA. 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 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.

6. Estimated monthly deliverables 2,500 Outpatient Encounters; Estimated monthly deliverables 100 Surgery Case coding.

BB. 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.

Task Two – External Auditing Service:

A. The facility 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 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 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 each 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, the project plan at a minimum should include:

1. Specific timelines for completing the audit: 3 annual audits

2. Timeframe for the facility reports: 1st, 2nd Qtr and 3rd Qtr

3. Number of reviewers

G. If a sample size or the number of records to be audited is not stated the contractor shall develop a sample size that assures a 95% confidence level of accuracy for each of the auditing tasks, and may include inpatient hospitalizations, outpatient visits, and non-Veterans Affairs records. The contractor shall submit a proposal with 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 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.

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 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 identifies 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, Coding Supervisor, 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.

I. 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.

J. 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 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.

K. The contractor shall provide a final written report to the facility Contracting Officer’s Representative within 15 business days following the review(s).

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

M. 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.

N. Task Two Deliverables:

O. Project Plan with description of sample size determination

1. Audit: Inpatient facility (Diagnosis Related Group) coding

2. Audit: Inpatient professional encounter coding including surgery coding

3. Audit: Outpatient encounter/services coding

4. Report on audit results

5. Education Plan

Estimated Deliverables:

Deliverable Schedule Estimated

Inpatient Coding Monthly 260 PTF’s

Inpatient Professional Fee Coding

Monthly 500 encounters

Outpatient Encounters Monthly 2,500 encounters

Surgery Case Coding Monthly 100 cases

External Audit Outpatient:

Includes Outpatient, Professional

Fee and Surgery Case Coding

Quarterly 225 encounters

External Audit Inpatient Quarterly 80 PTF’s

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 7 calendar days of the date coding is assigned to the contractor by the facility.

2. Inpatient Professional Encounter/Services Coding

Within 7 calendar days of the date coding is assigned to the contractor by the facility.

3. Outpatient Coding Within 7 calendar days of the date coding is assigned to the contractor by the facility.

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 at the facility: Tri-annually during the 1st, 2nd & 3rd Qtrs.

3. Audit: Inpatient professional encoder coding including surgery coding

Complete within the performance period stated at the facility.

4. Audit: Outpatient encounter coding

Complete within the performance period stated at the facility.

5. Final Report of audit results

Within 15 business days of audit completion.

6. Education Plan Within 7 calendar days of audit completion.

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.

5.1 Phoenix VA Healthcare System Requirements (PVAHCS)

Contractor shall provide the specific service and deliverables described below within the timeframes identified or as agreed upon.

A. Task One: A kick-off meeting shall be held within ten (10) business days of contract award as agreed upon between Contracting and the Contractor. At the kick-off meeting, the Contractor shall present the details of its intended approach, work plan and project schedule to include deliverable dates as applicable for review and approval by the facility. Work will not commence until the facility approves the approach and/or methodology, work plan and schedule. The Contractor shall also complete standard administrative tasks as stated in this

SOW.

Deliverable 1.1: A project work plan in Microsoft Project or the VA approved project management software Primavera for Task 3 or Word document for Task 2 and briefing in Microsoft PowerPoint within ten (10) business days from date of award.

Deliverable 1.2: The Contractor shall complete and submit to the local COR a Staff Roster within five (5) business days from date of award.

Deliverable 1.4: All mandatory training shall be completed and documented as appropriate within twenty (20) business days from date of award. Contractor is expected to be pro-active during the initial and following processes to gain computer access for all staff in a timely manner. If performance on this order crosses the anniversary date for recurring annual training requirements, such training must be completed within twenty (20) business days of the anniversary date. Training completed by individual staff within the same fiscal year as otherwise required for this deliverable will be accepted as long as appropriate documentation is submitted.

Contractor shall submit electronically to the local COR within twenty-five (25) business days of award – or in the case of staff added after performance begins, twenty-five (25) business days of their on-board date – a complete status of training for all staff.

B. Task Two - Coding Services: Contractor shall use skills and knowledge of current ICD-CM, CPT- 4, HCPCS Level II and other generally accepted available resources to review medical record documentation and providers’ scope of practice to assign diagnostic and procedural codes at an accuracy rate no less than 95%. The Contractor shall code Outpatient Encounters including Radiology, Lab or other Ancillary/Specialty Services, Surgical, Inpatient Professional Services; and Inpatient Episodes/Admission Services as specified.

1. The Contractor shall abstract identified data items and either enter the data into the local VISTA system, encoder program, or write the information on source documents as agreed with the local facility. It will be assumed that the episode of care is billable. If after thorough review of the documentation, missing elements of documentation a claim should not be submitted due to lack of documentation, missing elements of documentation, student documentation, no treatment, etc., the contract staff may select a predetermined coder comment available within the encoder software to communicate to the Billing Staff that the encounter should not be billed. Coding an episode of care includes answering any follow-up questions regarding the episode, including questions that may arise during the completion of an encounter or re-coding as necessary.

2. Contractor shall provide all labor, materials, and supervision necessary to perform coding and abstracting using either the 1995 or 1997 Evaluation and Management guidelines on encounters and standard industry guidelines, e.g. Coding Clinics and CPT Assistant, as specified by the facility. Contractor shall adhere to all coding guidelines as approved by the Cooperating Parties and accepted VA regulations.

3. Utilize encoder and reference materials to assign and/or validate diagnostic and procedural codes reflective of documentation.

4. Utilize PCE/PTF/Surgery or other databases, if necessary, to reflect code changes and names(s) of provider(s).

5. Review and determine whether documentation is accurate and complete to support services.

6. The contractor shall ensure that individual coders are clearly identified on each and every document they have coded when using paper documents.

7. When assigning multiple CPT codes, the Contractor shall verify that they are not components of a larger, more comprehensive procedure that can be described with a single code.

8. The Contractor…