Requirements Description.docx

Requirements Description

STATEMENT OF WORK –

CLINICAL DOCUMENTATION IMPROVEMENT AND CODING TRAINING FOR THE VISNs 17, 19, 20, 21 AND 22 (HEREBY REFERRED TO AS THE WESTERN STATES NETWORK CONSORTIUM (WSNC)

3 Contract Title American Clinical Documentation Improvement Specialists (ACDIS) and educational program for Clinical Providers, Clinical Documentation Improvement Specialists (CDIS), and Coding Staff.

4 Statement of Need Department of Veterans Affairs, WSNC has a significant need for initial and ongoing training for Clinical Documentation Improvement (CDI) and provider documentation as well as Coding education for Clinical Providers, Clinical Documentation Improvement Specialists (CDIS), Coding Staff and Nursing Informatics Champions.

5 Background This statement of work is for the purchase of training for Clinical Documentation Improvement and Coding training (hereby known as ACDIS educational program) for WSNC. The WSNC Board of Directors is proposing the purchase of an online and face-to face comprehensive CDIS and Coding training curriculum for Clinical Providers, Clinical CDIS Specialists, and Coding Staff.

WSNC is seeking training for a base year with four options years through online comprehensive and face to face training and continuing education for Clinical Providers, Clinical Documentation Improvement Specialists (CDIS) and Coding Staff.

6 Place of Performance

· Department of Veterans Affairs, WSNC:

VISN 17: VA Heart of Texas Network, 2301 East Lamar Blvd., Suite 650, Arlington, TX 76006 VISN 19: VA Rocky Mountain Network, 4100 East Mississippi Ave, Suite 1100, Glendale, CO 80246 VISN 20: VA Northwest Network, 1601 E 4th Plain Blvd., Vancouver, WA 98661 VISN 21: VA Sierra Pacific Network, 201 Walnut Avenue, Mare Island, CA 94592 VISN 22: VA Desert Pacific Network, 300 Oceangate, Suite 700, Long Beach, CA 90802

7 Period of Performance

· Base Period of Performance: 07/01/2025 to 06/30/2026

· Option Year 1: 07/01/2026 to 06/30/2027

· Option Year 2: 07/01/2027 to 06/30/2028

· Option Year 3: 07/01/2028 to 06/30/2029

· Option Year 4: 07/01/2029 to 06/30/2030

8 Scope

· Clinical Documentation Improvement (CDIS) is a process where the health record is manually reviewed either concurrently or retrospectively for ambiguous, conflicting, incomplete, or nonspecific provider documentation. Coding is a process where the health record is reviewed and diagnosis and procedures codes are assigned based on the clinical documentation. A Clinical Documentation Improvement and Coding Program requires specialized training to review health records for completeness, appropriate documentation and correct assignment of diagnosis and procedure codes. Training should include the ongoing access for a period of one year. This will be required to allow staff the ability to take the online CDIS and/or Coding training curriculum on their own time and whenever new staff are hired at the facilities.

· With the purchase of the CDIS and Coding training curriculum, Clinical staff should be able to:

· Understand ICD-10-CM/PCS fundamentals.

· Documentation clarification opportunities for inpatient and outpatient CDIS

· Encourage communication between Clinical and CDIS/Coding staff

· Identify common documentation deficiencies in the medical record

· Identify diagnoses frequently in need of documentation clarification to support accurate code assignment

· Understand MS-DRG assignment and the impact of diagnosis assignment

· Understand inpatient quality measures and the Physician Champion’s role in CDIS

· With the purchase of the CDIS and Coding training curriculum, the attendee (CDIS, Nurse CDIS and Coders) should be able to:

· Understand and apply the ICD-10-CM Official Guidelines for Coding and Reporting from a CDIS perspective

· Identify diagnoses frequently in need of documentation clarification to support accurate code assignment.

· Understand best practices associated with VHA, CMS and TJC compliant query process’s.

· Learn and understand tips for working, communicating and educating Providers to improve clinical documentation.

· How to recognize the important clinical indicators for diagnoses across major body systems

· Understand MS-DRG assignment is calculated and the impact of diagnosis assignment.

· Understand how correct code assignment impacts reimbursement.

· Assessment of documentation workflow practices

· Perform initial medical record audit of provider notes.

· Validate against submitted ICD-10 code(s) on claims.

· Identify documentation deficiencies.

· Identify existing HCC chronic conditions not captured within 12 months.

· Identify opportunities and ensure accuracy and completeness of clinical documentation used for measuring and reporting physician outcomes.

· Identify risks and missed opportunities due to under coding.

· Formal written strategy plan to address documentation deficiencies.

· Formal meeting to review audit findings and strategy plan for the CDIS, Coding and Nursing Informatics Team

9 Specific Requirements

· Implement work plans for CDIS, Nurse CDIS, Coders and Physicians

· Educate CDIS and Nurse CDIS on the importance of concurrent reviews of medical records.

· Validation of diagnosis codes and query processes

· Educate providers on their audit findings related to documentation, coding and billing requirements.

· Educate providers on clinical documentation and coding needs, changes to clinical documentation guidelines, coding and reimbursement issues. Unlimited online attendee access to the web-based CDIS and Coding training curriculum for existing and newly hired staff, for a period of one year.

· Combination of formal classroom education and hands-on training,award CEUs to staff

· Customized specialty education for large and/or small groups

· VA attendees will have access to web-based training curriculum and resources.

· Pocket Guides for Inpatient and Outpatient Coding Rules and Regs

10 Performance Monitoring

· Provide follow-up training to reinforce CDIS and Coding objectives.

· Contractor work will be evaluated upon completion by the VISNs’ Business Implementation Manager (BIM) and VISN’s Business Office Support Service (BOSS) HIMS Management staff, along with assigned COR to ensure contract requirements are completed.

· Process assessment

· Audit monthly patient encounters

· Conduct follow-up review of clinical documentation to ensure proper clinical information is recorded in the patient’s record.

· Identify any CDIS workflow optimizations of care plan or non-face-to-face documentation templates.

· Identify any Coding deficiencies and allow for focused training aimed at improvement of coding accuracy.

· Provide monthly/quarterly leadership reports based on benchmark criteria including but not limiting to an overall increase in the case mix index, decrease in risk of mortality rate compared to expected and a better severity of illness rate that the average for other VA hospitals of similar size.

11 Specific Training Requirements Determine Coding and Clinical Documentation content requirement Topics for Providers, Clinical Documentation Improvement Specialists, and Coders.

· Collaborate with VAMC on specific coding topics. Review providers documentation for presentation.

· Select documentation that is straightforward to complex as examples (No PHI is used) Research coding guidelines.

· Research Clinical Documentation guidelines and education on understanding of clinical indicators.

· VA approved references

· CPT Assistant

· Coding Clinic

· Coder’s Desk Reference and etc…

Research VA Intranet Website

· Coding Council Q/A’s

· Research for VA specific Directives, Handbooks, HIMS Call Minutes and etc…

What is included in the presentation?

· Definitions of anatomy and physiology terms (coders and clinical documentation specialists only)

· Definitions and go over disease processes (coders and clinical documentation specialists only)

· Graphics for specific areas presenting on

· Summarize and provide coding guidelines references from CPT, ICD-10 CM, ICD-10PCS, and HCPCS Books.

· Summarize and provide references from CPT Assistant, Coding Clinic and from the VA Intranet.

· Provide documentation examples and go through each one during presentation along with supplying CPT, ICD-10CM, ICD-10 PCS, HCPCS and codes.

· Discuss any query opportunities from providers examples or in general we may have seen while researching.

· Summarize coding topic/Issues Addressed.

· The coding trainer will send to the VAMC contacts to review before presenting the PowerPoint.

· The coding trainer will make any revisions before final presentation.

· The coding trainer will present and take any questions from VAMC coding staff/providers on the topic.

· The coding trainer will ensure any unanswered questions or additional questions during presentations are followed up on and sent back to the VAMC for clarification.

12 National Archives and Records Administration (NARA) Records Management Language for Contracts Records Management Obligations

· Applicability

· This clause applies to all Contractors whose employees create, work with, or otherwise handle Federal records, as defined in Section B, regardless of the medium in which the record exists.

· Definitions

· “Federal record” as defined in 44 U.S.C. § 3301, includes all recorded information, regardless of form or characteristics, made or received by a Federal agency under Federal law or in connection with the transaction of public business and preserved or appropriate for preservation by that agency or its legitimate successor as evidence of the organization, functions, policies, decisions, procedures, operations, or other activities of the United States Government or because of the informational value of data in them.

· The term Federal record:

· Includes Department of Veteran Affairs records.

· Does not include personal materials.

· Applies to records created, received, or maintained by Contractors pursuant to their Department of Veteran Affairs contract.

· May include deliverables and documentation associated with deliverables.

· Requirements

· Contractor shall comply with all applicable records management laws and regulations, as well as National Archives and Records Administration (NARA) records policies, including but not limited to the Federal Records Act (44 U.S.C. chs. 21, 29, 31, 33), NARA regulations at 36 CFR Chapter XII Subchapter B, and those policies associated with the safeguarding of records covered by the Privacy Act of 1974 (5 U.S.C. 552a). These policies include the preservation of all records, regardless of form or characteristics, mode of transmission, or state of completion.

· In accordance with 36 CFR 1222.32, all data created for Government use and delivered to, or falling under the legal control of, the Government are Federal records subject to the provisions of 44 U.S.C. chapters 21, 29, 31, and 33, the Freedom of Information Act (FOIA) (5 U.S.C. 552), as amended, and the Privacy Act of 1974 (5 U.S.C. 552a), as amended and must be managed and scheduled for disposition only as permitted by statute or regulation.

· In accordance with 36 CFR 1222.32, Contractor shall maintain all records created for Government use or created in the course of performing the contract and/or delivered to, or under the legal control of the Government and must be managed in accordance with Federal law. Electronic records and associated metadata must be accompanied by sufficient technical documentation to permit understanding and use of the records and data.

· Department of Veteran Affairs and its contractors are responsible for preventing the alienation or unauthorized destruction of records, including all forms of mutilation. Records may not be removed from the legal custody of Department of Veteran Affairs or destroyed except for in accordance with the provisions of the agency records schedules and with the written concurrence of the Head of the Contracting Activity. Willful and unlawful destruction, damage or alienation of Federal records is subject to the fines and penalties imposed by 18 U.S.C. 2701. In the event of any unlawful or accidental removal, defacing, alteration, or destruction of records, Contractor must report to Department of Veteran Affairs. The agency must report promptly to NARA in accordance with 36 CFR 1230.

· The Contractor shall immediately notify the appropriate Contracting Officer upon discovery of any inadvertent or unauthorized disclosures of information, data, documentary materials, records or equipment. Disclosure of non-public information is limited to authorized personnel with a need-to-know as described in the contract action. The Contractor shall ensure that the appropriate personnel, administrative, technical, and physical safeguards are established to ensure the security and confidentiality of this information, data, documentary material, records and/or equipment is properly protected. The Contractor shall not remove material from Government facilities or systems, or facilities or systems operated or maintained on the Government’s behalf, without the express written permission of the Head of the Contracting Activity. When information, data, documentary material, records and/or equipment is no longer required, it shall be returned to Department of Veteran Affairs control, or the Contractor must hold it until otherwise directed. Items returned to the Government shall be hand carried, mailed, emailed, or securely electronically transmitted to the Contracting Officer or address prescribed in the contract action. Destruction of records is EXPRESSLY PROHIBITED unless in accordance with Paragraph (4).

· The Contractor is required to obtain the Contracting Officer's approval prior to engaging in any contractual relationship (sub-contractor) in support of this contract requiring the disclosure of information, documentary material and/or records generated under, or relating to, contracts. The Contractor (and any sub-contractor) is required to abide by Government and Department of Veteran Affairs guidance for protecting sensitive, proprietary information, classified, and controlled unclassified information.

· The Contractor shall only use Government IT equipment for purposes specifically tied to or authorized by the contract and in accordance with Department of Veteran Affairs policy.

· The Contractor shall not create or maintain any records containing any non-public Department of Veteran Affairs information that are not specifically tied to or authorized by the contract.

· The Contractor shall not retain, use, sell, or disseminate copies of any deliverable that contains information covered by the Privacy Act of 1974 or that which is generally protected from public disclosure by an exemption to the Freedom of Information Act.

· The Department of Veteran Affairs owns the rights to all data and records produced as part of this contract. All deliverables under the contract are the property of the U.S. Government for which Department of Veteran Affairs shall have unlimited rights to use, dispose of, or disclose such data contained therein as it determines to be in the public interest. Any Contractor rights in the data or deliverables must be identified as required by FAR 52.227-11 through FAR 52.227-20.

· Training. All Contractor employees assigned to this contract who create, work with, or otherwise handle records are required to take Department of Veteran Affairs-provided records management training. The Contractor is responsible for confirming training has been completed according to agency policies, including initial training and any annual or refresher training.

· [Note: To the extent an agency requires contractors to complete records management training, the agency must provide the training to the contractor.]

· Flow down of requirements to subcontractors

· The Contractor shall incorporate the substance of this clause, its terms and requirements including this paragraph, in all subcontracts under this contract action, and require written subcontractor acknowledgment of same.

· Violation by a subcontractor of any provision set forth in this clause will be attributed to the Contractor.