36C26118Q0219-00002005.pdf

Statement of Work for Contract Coding VA Central California Health Care System

1. Purpose: Health Information Management Service (HIMS) Coding Support The purpose of this contract is to assign ICD-10-CM/PCS, CPT-4 and HCPCS Level II codes based on medical record documentation of any of the following: prescriptions, surgical episodes, inpatient facility and professional services, and outpatient care provided at the VA Central California Health Care System (VACCHCS). This is to supplement current VA inpatient and outpatient coding staff.

This is a non-personal services contract and the Government shall not exercise any supervision or control over the contract service providers performing the services herein. Such contract service providers shall be accountable solely to the Contractor who, in turn is responsible to the Government.

2. Background:

The Under Secretary for Health directed that as of October 1, 1996, VHA facilities were to begin collecting and reporting coded diagnostic, procedural and practitioner data for all ambulatory care encounters. While VHA facilities had been electronically reporting information about each outpatient visit to the national Outpatient Clinic System (OPC), the new requirement forced a major shift in the way VHA medical centers collected and stored ambulatory care information.

Outpatient information is entered through the VistA Patient Care Encounter (PCE).

Facilities now report patient identity, date and time of service, practitioners (by HCFA Individual Provider Taxonomy type code), place of service, active problem(s) ICD-10-CM/PCS codes) and service(s) (CPT codes) for every ambulatory encounter and/or ancillary service.

The value of PCE data to managers and researchers depends on how accurately it portrays the actual clinical events that take place in the medical center. Data validity begins with practitioners accurately recording diagnoses and procedures. That information must be accurately entered into the facility’s computer system (VistA).

Beginning September 1, 1999, CPT-4 procedure coding is used as a basis for facility and professional charges for bills submitted to third party carriers. Coders are held responsible for the accuracy of codes and compliance with federal legislation and VHA guidelines.

The Department of Veterans Affairs Central California Health Care System (VACCHCS) a level 1C facility, is an integrated health care delivery system, offering a comprehensive array of medical, surgical, rehabilitative, mental health and extended care to veterans in central California.

The health system is comprised of a medical center in Fresno; ;3 outpatient clinics in Merced, Tulare and Oakhurst.

3. Scope of Work: The purpose of this CONTRACT is to obtain services to assign, ICD-10- CM/PCS CPT-4, and HCPCS Level II codes based on medical record documentation of outpatient and inpatient care provided at or under the auspices of a Veterans Health Administration facility and perform coding audits. The Contractor shall provide all resources necessary to accomplish the deliverables described in the statement of work (SOW), except as may otherwise be specified.

• Assign ICD-10-CM PCS,CPT-4, and HCPCS Level II codes based on medical record documentation of outpatient and inpatient care provided at or under the auspices of a Veterans Health Administration facility

• Furnish validation of the integrity, quality, and assignment of codes to the data contained in the outpatient Patient Care Encounter (PCE), inpatient Patient Treatment File (PTF), the non-VA database and the integrated billing package

4. Performance Period: April 1, 2018 – March 31, 2023

a. Order Periods:

Ordering Period 1: April 1, 2018 – March 31, 2019 Ordering Period 2: April 1, 2019 – March 31, 2020 Ordering Period 3: April 1, 2020 – March 31, 2021 Ordering Period 4 April 1, 2021 – March 31, 2022 Ordering Period 5: April 1, 2022 – March 31, 2023

5. Type of Contract: The Government intends to award a firm fixed price indefinite delivery indefinite quantity (IDIQ) contract.

6. Place of Performance: All work shall be performed at the Contractor’s facility unless otherwise specified and mutually agreed to by the Contractor and COR. In the instance where the Contractor is required to work at the Government site, that work shall not take place on Federal holidays unless directed by the Contracting Officer.

7. Key Assumptions:

a. Industry standard coding guidelines shall be followed.

b. All patient encounters shall be properly coded whether the encounter is billable or not.

Note: Only 20%-30% of VA encounters are billable.

c. Both physician and non-physician providers are employed by the VA Medical Center.

d. As a federal facility, providers must have valid licenses; however, VHA does not require providers to be licensed by the state in which they work.

e. VA does not currently bill Medicare or Medicaid, nor participate in any outside managed care agreements. VA billing consists of charges to private insurance carriers, including those that are Medicare supplemental policies.

f. VA is authorized to charge "reasonable charges" by amended statutory provisions - PL 105-33 amended 38 U.S.C. 1720.

g. The Contractor shall provide for its staff laptops, reference material, software/encoder tools for conducting reviews and developing training materials. Contractor staffs shall be proficient in the use of the laptops, reference materials, software/encoder tools and provide with their proposal evidence of use of an encoder.

h. VHA policies and procedures shall be followed. If the Contractor is uncertain concerning a policy, the Contractor shall consult with the VISN/VAMC for clarification.

i. Failure of the Contractor to maintain the required 95% accuracy level may result in termination for cause of the contract.

8. General Requirements:

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

b. The latest United States editions of the International Classification of Diseases (ICD), Current Medical Information and Terminology (CMIT) and Current Procedural Terminology (CPT) of the American Medical Association (AMA) and the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association (APA) shall be used to provide uniform disease and operation terminology which is complete and scientifically accurate.

c. Code assignment shall be in accordance with National Center for Health Statistics

(NCHS), Centers for Medicare and Medicaid Services (CMS), American Hospital Association (AHA), AMA and APA guidelines, as appropriate. On those occasions when there is a question, VHA guidelines take precedence. Local policies will direct how coding is accomplished and what quantitative and/or qualitative reviews are performed by the facility. The AHA Coding Clinic and other publications may be used for training and reference purposes.

d. Contractor shall ensure that its staff members providing services under this statement of work (SOW) and pursuant agreement (CONTRACT) use VA encoder software.

e. Contractor shall adhere to all coding guidelines as approved by the Cooperating Parties

[The four organizations that make up the Cooperating Parties for the ICD-10-CM/ ICD- 10-CM/PCS/PCS: American Hospital Association (AHA), American Health Information Management Association (AHIMA), Centers of Medicare and Medicaid Services (CMS) and National Center for Health Statistics (NCHS)] and accepted VA regulations, including:

1. The Official Guidelines and Reporting as found in the CPT Assistant, a publication of the American Medical Association for reporting outpatient ambulatory procedures and evaluation and management services,

2. The current Official Guidelines for Coding and Reporting in the Coding Clinic for ICD, a publication of the American Hospital Association, and

3. VHA guidelines for coding as found in the Handbook for Coding Guidelines V7.0 April 3, 2007, Health Information Management, Department of Veterans Affairs. This workbook is updated at least once per year with new codes and guidance.

Contractor shall ensure it has the current version and the guidance is followed. Note:

While VHA does ask for reimbursement from third party payers, the VHA coding policy is to code only according to coding guidelines. Our own compliance audits use only this definition when determining if any encounter or PTF is correctly coded.

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

5. VHA Directive Patient Care Data Capture 2006-026

6. VHA Directive Resident Services Billing 2005-054

7. VHA Handbook Resident Supervision 1400.1

8. Other directives that VA may issue from time to time.

f. Upon request of the Contracting Officer, the Contractor shall remove any Contractor staff that do not comply with VHA policies or meet the competency requirements for the work being performed.

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

h. All coding and auditing activities shall utilize VA’s electronic health record.

i. Contractor shall provide all labor, materials, transportation, and supervision necessary to perform coding validation reviews for inpatient, observation, diagnostic tests, ambulatory surgery/medicine procedures and outpatient (clinic) data collection, evaluating the completeness and accuracy of coding diagnoses and procedures in accordance with official coding guidelines (Coding Clinics, CPT Assistant, HFCA/AMA, Ambulatory Patient Classifications [APC]) in a simulated Medicare payment environment.

j. Communication: Contractor shall specify a contact person and phone number who is available for personal contact at a minimum during regular business hours of the particular facility that owns the work, for the duration of the work. Contractor shall maintain frequent communications with the HIMS Manager or other designated medical center employee (i.e., coding supervisor/team leader) regarding progress, workload status and/or problems. The contractor shall make every effort to ensure that issues raised by the local facility are addressed in a timely manner.

k. Contract coders shall code in accordance with CCI Bundling Guidelines, and use the

Healthcare Common Procedural Coding Systems (HCPCS), where appropriate.

Contract coders must exclude coding information such as symptoms or signs characteristic of the diagnoses, findings from diagnostic studies, or localized conditions, which have no bearing on current management of the patient or as appropriate.

Contract coders must clarify conflicting, ambiguous, or non-specific information appearing in the record by consulting with their supervisor who will, if necessary, discuss with the local VA contact.

l. Contractor is responsible for becoming familiar with guidelines on billing within the

Veterans Health Administration (VHA). Information may be found at http://vaww1.va.gov/cbo/rcbillingguide.doc.

m. The Contractor shall not use "incident to" rules.

n. Contractor shall code using CPT for inpatient professional services or nursing home professional services.

o. Quality Assessment of Health Information Services:

1. The Contractor shall possess all licenses, permits, accreditation and certificates as http://vaww1.va.gov/cbo/rcbillingguide.doc required by law. The Contractor shall perform the required work in accordance with The Joint Commission (JC), Veterans Health Administration (VHA), and other regulatory standards. JC standards may be obtained from:

The Joint Commission One Renaissance Blvd Oakbrook Terrace, IL 60181

p. Exclusions and Sanction Certification: The Contractor shall provide annual written certification to the COR which certifies that all employees, subcontractors, and employees have been checked to ensure that all agents providing health care services under this contract have been found not to be listed on the List of Parties Excluded from Federal Programs and the HHS/OIG Cumulative Sanction Report. The certification shall be provided within three weeks after award and within three weeks of the CONTRACT’s annual anniversary date for each period the CONTRACT remains effective.

q. If the Contractor should find it necessary to reassign a staff member from working for a facility, the contractor shall make arrangements for there to be a minimum of two week overlap when both the old and new staff member shall be working the facility’s account, unless there is a mutual agreement between the Contractor and facility that the overlap is not necessary.

r. Contractor is responsible for the management of its staff, and the Contractor is responsible for training its staff on VA policy and procedures.

s. Contractor staff shall sign confidentiality statements as required. Any person, who knowingly or willingly discloses confidential information from the VA, may be subject to fines.

9. Specific Mandatory Tasks and Associated Deliverables:

Contractor shall provide the specific service and deliverables described below by the within the timeframes identified or as agreed to on individual task orders.

Task One: The Contractor shall provide a work plan, briefing, and kick-off meeting for the government, which presents the Contractor’s plan for completing the task order. The plan shall illustrate this SOW and describe in further detail the approach to be used for each aspect of the task order as defined in its technical quotation. The Contractor shall schedule a kick-off meeting to be held within ten (10) business days of task order award or as agreed upon between local Contracting Officer and 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 VISN/VAMC. Work will not commence until the VISN/VAMC approves the approach and/or methodology, work plan and schedule. The Contractor shall also complete standard administrative tasks (e.g., background investigation forms, staff roster, mandatory training) as noted in the deliverable descriptions below.

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: Contractor shall submit to the local COR within five (5) business days after award a full and complete list of names, Social Security Numbers, and home addresses of Contractor personnel for the Background Investigation requirement.

Deliverable 1.3: 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. 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 under separate orders 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.

Task Two - Coding Services: Contractor shall use skills and knowledge of ICD-10-CM, ICD- 10-CM/PCS, 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 Services, Surgical, Inpatient Professional Services; and Inpatient Episodes/Admission Services as specified.

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

Deliverable Objective Delivery Due

Inpatient Facility Coding Within 7 calendar days of the date coding is assigned.

Inpatient Professional Encounter/Services Coding

Within 7 calendar days of the date of coding is assigned.

Outpatient Coding Coding completed within 7 calendar days of the date coding is assigned.

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

• 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. This information shall include a decision as to whether or not an episode is billable, based on the documentation and VHA billing guidelines, and the type of insurance coverage of the patient. The reason not billable shall include, at a minimum, treatment for a Service Connected (SC) condition, treatment related to Agent Orange (AO) exposure or Ionizing Radiation (IA), lack of attending documentation in a circumstance that requires it, telephone care, non-billable provider, or other types of care that cannot 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 a claim as well as developing responses to denials for payment or re-coding as necessary.

• Contractor shall provide all labor, materials, transportation 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 VAMC. Contractor shall adhere to all coding guidelines as approved by the Cooperating Parties and accepted VA regulations.

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

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

• Review and determine whether documentation is adequate to support billable services.

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

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

• 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.

• 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.

• Contractor shall code based on reading and reviewing the documentation in the medical record including the Computerized Patient Record System (CPRS). The contractor shall complete data entry into the VistA system as part of this contract. Completion of source documents in lieu of VistA entry may be arranged only upon mutual agreement between the facility and the contractor.

• The Contractor shall assign modifiers as appropriate to override Correct Coding Initiative edits.

• For Inpatient Episodes/Admission Services:

o Complete all PTF Transition Types (101, 401, 501, 601, 701/702 and 801) in accordance with VHA Handbooks, 1907.03 HIM Clinical Coding Program Procedures and 1907.04 Patient Treatment File (PTF) Coding Instructions o Opening and re transmitting PTFs shall follow local facility protocol.

• Contractor shall review documentation to determine why an ancillary or other diagnostic test was ordered and assign an ICD-9/ICD-10 diagnosis code to that test.

• Contractor shall have the ability to perform concurrent inpatient coding for within 48 hours.

• Contractor shall re-review any coded data when questioned by VA during the VA pre-bill process or when a denial is received to either make changes or substantiate the coding with appropriate coding rules and references. This service shall be included in the price of the work. Contractor shall use the following procedures and definitions during re-review processes:

o Include all CPT codes, and a maximum of four ICD-9/ICD-10 or ICD-10 codes as applicable in the denominator for the audit percent. Include Modifiers 24, 25, 50, 51, 52, 53, 57, 58, 59, 78 and 79 in the denominator. Modifier 91 is required for labs. Other modifiers will not be counted for the accuracy rate. Note: Modifier 26 is required for inpatient professional fee billing by third parties, however, it will not be counted here as it is a requirement by the insurance carrier only, not VHA.

o Count each one of the following as an error:

1. Codes that were coded and not supported in the documentation, violate a coding rule; and/or

2. CPT or diagnosis codes that should have been coded and were not; and/or

3. Inappropriate CPT or ICD 9/10 codes;

4. Unbundled codes;

5. Ancillary encounters with only a diagnosis of V72.5 or V72.6;

6. Inaccurate DRG assignments;

7. All other data elements incorrectly entered by the contract coder, or not entered when appropriate, e.g. reason not billable, provider, adequacy of documentation.

Note: All re-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 it daily unless otherwise indicated on the task order. VA reserves the right to validate all audit results and/or accuracy statistics submitted. The vender will perform all re-review work at no additional cost to the VA.

Deliverable 2: Coded Outpatient Encounters including Radiology, Lab or other Ancillary Services, Surgical, Inpatient Professional Services; and Inpatient Episodes/Admission Services encounters, as specified under each individual task order, including required VistA data elements in accordance with VHA Handbooks and protocols as specifically outlined in the task order.

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

Deliverable Object Delivery Due

Project Plan with description of sample At the time of proposal submission.

size determination Audit: Inpatient Facility Coding Complete within the performance period stated on the facility task order.

Audit: Inpatient professional encoder coding including surgery coding

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

Audit: Outpatient encounter coding Complete within the performance period stated on the facility task order.

Final Report of audit results

Within 15 business days of audit completion.

Education Plan Within 7 calendar days of audit completion.

Task Three – External Auditing Services:

• External Audits of coded data shall be performed on any of the VHA required coding activities (e.g., inpatient, outpatient, ancillary). VHA uses the national coding guidelines, as mandated by HIPAA, provided by the authoritative sources ICD-10- CM/PCS = four organizations that make up the Cooperating Parties for the ICD-10- CM/PCS: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS (HCPCA = CMS and CPT =

AMA).

• These audits shall be performed separate from normal coding activities and shall conform to the individual task order requirements. These audits shall be based on compliance and address accuracy of coded data, health record documentation issues, process improvement and identify educational needs. Audit accuracy expectations are 95% and above and each audit will focus on one of the following:

Inpatient facility (DRG) coding, Outpatient facility coding, Inpatient professional services including surgery, and Outpatient services which would include ER, Urgent Care, clinic visits, and ambulatory surgery. Audits shall consist of reviewing the following:

o the first four listed diagnoses in the outpatient and inpatient setting – both facility and professional services o the first four listed procedures/services in the outpatient and inpatient setting – both facility and professional services

• Reports shall be prepared to allow for use by medical center staff in re-reviews, education, or to provide management updates. All reviews shall utilize electronic auditing of the computerized medical record system (CPRS), whenever possible.

Claims analysis and Non-VA records must be reviewed hardcopy. The reviews shall be conducted by remote data view. Should the information not be contained in CPRS or VistA, the medical center will overnight the documentation to the vendor.

• Contractor shall provide a detailed project plan for each review to include:

o Pre-audit prep call which outlines what will be needed by the auditors and/or HIM Chiefs o Specific timelines for completing review at each medical center o Timeframe for the facility reports and the consolidated network report o Number of reviewers for each medical center

Contractor shall develop a sample size that assures a 95% confidence level of accuracy for each of the auditing tasks indicated on the Task Order, including inpatient hospitalizations, outpatient visits, and non-VA records. At a minimum 10% of charts/encounters is to be reviewed to assure site confidence level. Contractor shall submit with the technical quotation for each task order a detailed description of how it 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, PTCA, pulmonary function, radiology, laboratory, etc.), primary care, mental health, medicine sub-specialty, surgery, observation, neurology, and non-VA records.

• Contractor shall review each facility’s HIMS policy and coding procedures prior to commencement of review.

• Contractor shall develop a collection tool for all reviews and shall submit with its technical quotation a sample of the tool that will be used.

• Contractor shall submit in its technical quotation the methodology for resolving coding questions by reviewers and ensuring inter-reviewer consistency and reliability.

• Contractor shall review findings with the HIMS Chief, Associate COR, management, and other designated medical center personnel to review proposed changes prior to final written report for mutually agreed upon changes within 7 business days following the review(s). The Contractor shall submit the final written report of all findings and recommendations detailing accuracy, financial impact and areas of concern within 15 business days of completion of audit.

• Weaknesses identified during the audit shall be used to provide education/training workshops using a ‘train the trainer’ format. This can be done either on site or remote. As such the Contractor shall develop a facility specific training plan to present to VISN/VAMC management officials, physicians/clinicians, sub-specialties if needed, and for health information management (coding) staff based on the findings of the review within 7 business days following the review(s).

• The Contractor shall conduct an exit interview/conference and education on all audit findings and recommendations with the Health Information Services Management and coding staff at the VA facility. If any ‘errors’ are found, the Contractor shall provide supporting documentation on why each is an error. This documentation should be developed with the expectation that the Contractor shall present the findings and the documentation to the VA staff as part of the training and education component of the audit.

Deliverable 3.1: Detailed project work plan in Microsoft Project or the VA approved project management software Primavera and briefing in Microsoft PowerPoint within ten (10) business days from date of award.

Deliverable 3.2: Sample of an External Audit Report format within ten (10) business days from date of award.

Deliverable 3.3: Review of audit findings/results, including a detailed list of the data (PHI) used, with the HIMS Chief, Associate COR, management, and other designated medical center personnel to review proposed changes within 7 business days following the audit.

Deliverable 3.4: Final written report of all findings and recommendations detailing accuracy (including documentation of all records reviewed), financial impact and areas of concern within 15 business days of completion of audit.

Deliverable 3.5: An exit interview/conference with management officials at the discretion of the VISN/VAMC to be coordinated with the COR for the facility.

Task Four – CDIS Services:

• The goal of the documentation program whether inpatient or outpatient is to improve documentation so that it is accurate, complete, and reflects the patient’s true severity of illness. This in turn demonstrates the quality of care that was provided to the patient, allows for seamless continuity of care between healthcare providers and facilities, reduces unnecessary testing and treatment delays, and facilitates accurate coding which supports optimal workload capture and appropriate allocation funding.

o SAIL o Medical Record Review o Workload Capture & Productivity Analysis o VERA Reconciliation

Task Five – Training and Education

• Provide Quarterly Training to VA Facility Coders o Up to four hours per quarter o Including one approved CEU through AAPC/AHIMA

10. Reporting Requirements: The Contractor shall provide the local COR 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 Contractor and VISN or VAMC shall mutually agree on the report format. The Contractor shall provide a sample of such report with its technical quotation. The Contractor shall also provide Quality Reports for Task 2.

Quarterly, the Contractor shall provide a summary report (Attachment B) to the National HIMS COR. This report covers only work referred to the vendor based on a contractual agreement through the CONTRACT. The Contractor may propose modifications to the reporting requirements to the National COR.

11. Quality Control and Performance Metrics: The HIMS Manager or appointed designee will validate the contractor’s work to confirm that contractual coding meets accuracy requirements. The contractor is responsible for its own work as outlined in this Quality Control section. Coding accuracy will be determined by the number of correct codes compared to total number of codes, correct DRG assignment, and correct review and data entry of identified data items. The contractor must maintain a 95% accuracy level. Failure to meet the required level of accuracy may result in termination of the contract and/or task order in addition to the penalties described. The designated points of contact for the facility and the contractor will discuss any questions regarding coding or expected work.

Work is considered completed when it is received back at the VA facility with data entry done via the encoder or the documentation is at the VA facility. When the Contractor cannot meet this deadline, they must inform the VA facility contact person on or before the 10th business day. Work completed after the expected turnaround time set by the facility shall be subject to a 10% reduction in the negotiated price for the batch sent.

The Contractor shall have in place the following Coding Quality Control/Performance Process whereby the Contractor shall:

a. Perform on-going quality assessments of not less than 5% of all coded data elements and provide weekly results to the VA facility to ensure that the 95% accuracy rate is met.

Data elements include ICD-10-CM/PCS codes, CPT-4 codes, DRGs, and data items abstracted and entered by the contract coder. Contractor shall track results by coder to assure appropriate follow-up. Failure to meet the 95 % accuracy rate will result in a 10% reduction in payments until the 95% accuracy rate is reestablished. Failure to report results within the specified period three times during a calendar year may result in termination of the contract.

b. If monitoring demonstrates that work has fallen below the quality standard, the contractor shall develop a corrective action plan and include it with the data.

c. Corrective action plan should include training and education to Coders/VA facility Coders as needed.

12. Schedule for Deliverables: The Contractor shall meet the Delivery Schedule for each deliverable specified on the approved project plan for the Task Order.

13. Changes to the Statement of Work: Any changes to this SOW shall be authorized and approved only through written correspondence from the CO. 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 CO shall be borne by the Contractor.

14. Travel: Travel is not anticipated for this SOW, except for in connection with audit services.

When requested, travel and per diem shall be reimbursed in accordance with VA/Federal Travel Regulations. Travel must be pre-approved by the local COR and priced separately in the price schedule. Local commuting expenses, e.g. reimbursement charged for mileage, travel times, meals, parking, etc. and other direct costs (cell phone, etc.) will not be charged to the government.

Off-site coders may be required to attend on-site coding meetings and/or training if required by the facility, or to resolve identified issues.

15. Government Responsibilities:

a. The government shall provide VA reference material as requested by Contractor

b. As applicable, the VAMC shall provide space, work tables/desks and chairs, actual records

(paper and/or electronic), PCs and limited access to VistA options when Contractor staff is onsite. Equipment and workspace for off-site coders is the responsibility of the contractor.

c. All applications will be accessed via Citrix, through VPN, for all remote coders. Note that currently Rescue VPN is not compatible with Windows VISTA Operating System. CAG (Citrix Access Gateway) is compatible with multiple operating systems

16. Contractor Experience Requirements:

a. The Contractor must provide experienced, competent, credentialed personnel to perform coding and/or auditing activities. These are defined as key personnel and are those persons whose credentials were submitted. The Contractor agrees that the key personnel shall not be removed, diverted, or replaced from work without approval of the CO and COR.

b. Any personnel the Contractor offers as substitutes shall have the ability and qualifications equal to or better than the key personnel replaced. Requests to substitute personnel shall be approved by the COR and the CO. All requests for approval of substitutions in personnel shall be submitted to the COR and the CO within 30 calendar days prior to making any change in key personnel. The request shall be written and the Contractor shall provide a detailed explanation of the circumstances necessitating the proposed substitution. The Contractor shall submit complete documentation of the qualifications for the proposed substitute and any other information requested by the COR needed to approve or disapprove the proposed substitution. The COR will evaluate such requests. The CO will notify the Contractor of approval or disapproval thereof in writing.

c. Required Knowledge and Skills of Contract Coders:

• Contract Coders shall possess the ability to:

o Read and interpret health record documentation to identify all diagnoses and procedures that affect the current outpatient encounter visit, ancillary, inpatient professional fees and surgical episodes. .

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

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

o Apply knowledge of procedural terminology to recognize when an unlisted procedure code must be used in CPT.

o Code in accordance with CCI Bundling Guidelines.

o Use the Healthcare Common Procedural Coding Systems (HCPCS), where appropriate.

o Exclude from coding information such as symptoms or signs characteristic of the diagnoses, findings from diagnostic studies or localized conditions that have no bearing on current management of the patient.

d. Required Contract Coder Education and Experience:

o Contract coders must have a minimum of two years experience in the area that they will be coding.

o Contract coders/validation staff must possess formal training in: anatomy and physiology, medical terminology, pathology and disease processes, pharmacology, health record format and content, reimbursement methodologies and conventions, rules and guidelines for current classification systems (ICD-10- CM, ICD-10-CM/PCS, HCPCS and CPT).

o Coders must be credentialed and have completed an accredited program for coding certification, an accredited health information management or health information technician. For the purpose of this contract, a certified coder is someone with one of the following active credentials. Other credentials shall not be accepted.

American Health Information Management Association (AHIMA) credentials as a Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), and Certified Coding Specialist –Physician(CCS-P), or

American Academy of Professional Coders (AAPC) as a Certified Professional Coder (CPC) or Certified Professional Coder – Hospital

(CPC-H),

o Supervisory Coders must have a minimum of three year experience in coding, including 2 years in VHA .

o Credentialed Coders must have a minimum of two years experience in coding.

e. Required Credentials to Conduct Audits:

o Reviewers must have at least three years of training experience as a consultant 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. A resume(s) of the actual reviewer(s) must be included in the proposal, along with two (2) current client references specific to each individual reviewer, as well as proof of credentials. References, as well as proof of credentials, must be included in the proposal.

17. Property Rights, Confidentiality and Non-disclosure: The Contractor agrees that:

a. The preliminary and final deliverables and all associated working papers, application source code, and other material deemed relevant by the VA which has been generated by the contractor in the performance of this task order are the exclusive property of the U.S. Government and shall be submitted to the Contracting Officer at the conclusion of the task order.

b. The Contracting Officer will be the sole authorized official to release verbally or in writing, any data, the draft deliverables, the final deliverables, or any other written or printed materials pertaining to this Blanket Purchase Agreement. No information shall be released by the contractor. Any request for information relating to this task order presented to the contractor shall be submitted in writing to the Contracting Officer for response.

c. Press releases, marketing material or any other printed or electronic documentation related to this project, shall not be publicized without the written approval of the Contracting Officer.

d. Additionally, the Contractor shall sign a National Business Associate Agreement

(Attachment 3) with the VA, in accordance with the HIPAA mandate after award.

e. All individually identifiable health records shall be treated with the strictest confidentiality.

Access to records shall be limited to essential personnel only. Records shall be secured when not in use. At the conclusion of the contract all copies of individually identifiable health records shall be destroyed or returned to VA. The contractor shall comply with the Privacy Act, 38 USC 5701, and 38 USC 7332 and HIPAA regulations.

18. Security and Privacy:

18.1 Information and Records

18.1.1 All information and records provided to Contractor by VA, in whatever medium, as well as all information and documents, including drafts, emails, back-up copies, hand-written notes and copies that contain such information and records gathered or created by Contractor (collectively referred to as “VA information”) in the performance of this contract, regardless of storage media, are the exclusive property of VA. Contractor does not retain any property interest in these materials and will not use them for any purpose other than performance of this contract.

18.1.2 Upon completion or termination of the contract, Contractor will either provide all copies of all VA information to VA or certify that it has destroyed all copies of all VA information as required by VA in a method specified by VA, at VA’s option. The Contractor will not retain any copies of VA information. Where immediate return or destruction of the information is not practicable, Contractor will return or destroy the information within 30 days of completion or termination of the contract. All provisions of this contract concerning the security and protection of the VA information that is the subject of this contract will continue to apply to the VA information for as long as the Contractor retains it, regardless of whether the contract has been completed or terminated.

18.1.3 Prior to termination or completion of this contract, Contractor will not destroy VA information received from VA or gathered or created by Contractor in the course of performing this contract without prior written approval by VA.

18.1.4 Contractor will receive, gather, store, backup, maintain, use, disclose and dispose of VA information only in accordance with the terms of this contract and applicable federal and VA information confidentiality and security laws, regulations and policies.

18.1.5 The Contractor shall not make copies of VA information except as necessary to perform this agreement or to preserve electronic information stored on Contractor electronic storage media for restoration in case any electronic equipment or data used by the Contractor needs to be restored to an operating state.

18.1.6 Contractor shall provide access to VA information only to employees, subcontractors, and affiliates only: (1) to the extent necessary to perform the services specified in this Contract, (2) to perform necessary maintenance functions for electronic storage or transmission media necessary for performance of this contract, and (3) only to individuals who first satisfy the same conditions, requirements and restrictions that comparable VA employees must meet in order to have access to the same VA information.

These restrictions include the same level of background investigations, where applicable.

18.1.7 Contractor will store, transport or transmit VA information only in an encrypted form, using an encryption application that meets the requirements of FIPS 140-2, and is approved for use by VA.

18.1.8 Except for uses and disclosures of VA information authorized by this contract for performance of the contract, the contractor may use and disclose VA information only in two other situations: (i) in response to an order of a court of competent jurisdiction, or (ii) with VA’s prior written authorization. The contractor will refer all requests for, demands for production of, or inquiries about, VA information to VA for response.

18.1.9 If VA information subject to the contract includes information protected by 38 USC 7332, or 5705, include the following after the last sentence of the paragraph immediately above: Contractor shall not release information protected by either 38 USC 5705 or 7332 in response to a court order, and shall immediately refer such court orders to VA for response.

18.1.10 Prior to any disclosure pursuant to a court order, the Contractor shall promptly notify VA of the court order upon its receipt by the Contractor, provide VA with a copy by fax or email, whichever is faster, and notify by telephone the VA individual designated in advance to receive such notices. If the Contractor cannot notify VA before being compelled to produce the information under court order, the Contractor will notify VA of the disclosure as soon as practical and provide a copy of the court order, including a copy of the court order, a description of the records provided pursuant to the court order, and to whom the Contractor provided the records under the court order. The notice will include the following information to the extent that the Contractor knows it, if it does not show on the face of the court order: the records disclosed pursuant to the order, to whom, where, when, and for what purpose, and any other information that the Contractor reasonably believes is relevant to the disclosure. If VA determines that it is appropriate to seek retrieval of information released pursuant to a court order before Contractor notified VA of the court order, Contractor will assist VA in attempting to retrieve the VA information involved.

18.1.11 The Contractor will inform VA, by the most expeditious method available to Contractor, of any incident of suspected or actual access to, or disclosure, disposition, alteration or destruction of, VA information not authorized under this Contract (“incident”) within one hour of learning of the incident. An incident includes the transmission, storage or access of VA information by Contractor or subcontractor employees in violation of applicable VA confidentiality and security requirements. To the extent known by the Contractor, the Contractor’s notice to VA will identify the information involved, the circumstances surrounding the incident (including to whom, how, when, and where the VA information was placed at risk or compromised), and any other information that the contractor considers relevant.

18.1.12 Contractor will simultaneously report the incident to the appropriate law enforcement entity(ies) of jurisdiction. The Contractor, its employees, and its subcontractors and their employees will cooperate with VA and any law enforcement authority responsible for the investigation and prosecution of any possible criminal law violation(s) associated with any incident. The Contractor also will cooperate with VA in any civil litigation to recover VA information, to obtain monetary or other compensation from a third party for damages arising from any incident, or to obtain injunctive relief against any third party arising from, or related to, the incident.

18.1.13 In addition to notifying the COR on this Contract, VA will provide the Contractor with the name, title, telephone number, fax number and email address of the VA official to whom the Contractor will provide all notices required by this Contract. This shall be indicated on the specific task orders.

18.1.14 VA has the right during normal business hours to inspect the Contractor’s facility, information technology systems and storage and transmission equipment, and software utilized to perform the contract to ensure that the Contractor is providing for the security of VA data and computer systems in accordance with the terms of this Contract.

18.1.15 Contractor will receive, gather, store, backup, maintain, use, disclose and dispose of VA information only in compliance with all applicable Federal Information Processing Standards (FIPS) and Special Publications (SPs) issued by the National Institute of Standards and Technology (NIST) concerning VA information that is the subject of this contract. If NIST issues or updates an applicable FIPS or SP after execution of this contract, the parties agree to negotiate in good faith to implement the FIPS or SP in this contract.

18.1.16 The Contractor will provide appropriate administrative, technical, and physical safeguards to ensure the confidentiality and security of the Owner’s data and to prevent unauthorized use or access to it. VA sensitive information must not be transmitted by remote access unless VA-approved protection mechanisms are used. All encryption modules used to protect VA data must be validated by NIST to meet the currently applicable version of Federal Information Processing Standards (FIPS) 140 (See http://csrc.nist.gov/groups/STM/cmvp/ for a complete list of validated cryptographic modules). Only approved encryption solutions using validated modules may be used when protecting data during transmission. Additional security controls are required to guard VA sensitive information stored on computers used outside VA facilities. All VA data must be stored in an encrypted partition on the hard drive and must be encrypted with FIPS 140 validated software. The application must be capable of key recovery and a copy of the encryption key(s) must be stored in multiple secure locations.