Attachment 1 - RFI Questions.docx

RFI – Information Sought: Code Sets

The U.S. Department of Veterans Affairs (VA) is conducting market research to identify vendors capable of developing, maintaining, and regularly delivering comprehensive billing code sets that align with VA’s Community Care Referral Guidelines (CCRGs). CCRGs specify the clinically authorized scope of services for community care referrals, but they do not include the specific CPT, HCPCS, ICD‑10, DRG, APC, or related billing codes required for accurate claims adjudication.

VA seeks industry partners with the expertise, tools, and coding resources necessary to translate CCRG clinical guidance into validated, up‑to‑date code sets and provide recurring deliverables for VA review and approval. Vendors must also be capable of incorporating new codes, retiring obsolete codes, applying pricing and bundling rules, and ensuring continued alignment with national standards and VA payment policy.

The information collected through this RFI will support acquisition planning and help VA determine the cost, feasibility, technical approaches, and industry capabilities associated with procuring contractor‑developed code sets for use across the Next Generation community care environment.

VA is seeking vendor support to create comprehensive billing code sets that align with the clinical categories described in the CCRGs. Using the Cardiology example attached (Attachment A), vendors would be responsible for developing code sets that accurately map all applicable billing codes under each allowable service category, such as:

• Code Set 00002: All procedure codes for cardiac‑related imaging tests

• Code Set 00003: All cardiac‑related laboratory procedures

• Code Set 00004: All cardiac‑related diagnostic studies

• Code Set 00005: All cardiac‑related device interrogations These standardized code sets will be used by VA to support accurate claims adjudication, ensure policy compliance, and maintain consistency across community care referrals.

RFI - Information Sought:

A - GENERAL INFORMATION

A1. Organization Name and the year in which the company was established/founded (please list any previous names used).

A2. Company ownership (public, private, joint venture).

A3. Company socio-economic designation, if applicable?

A4. Identify any contract vehicles held that support this work.

A5. Please identify all Special Item Numbers (SIN), Pools or business arrangements that are applicable to this requirement.

A6. Please identify the NAICS code deemed most appropriate for this requirement.

B – CAPABILITY AND EXPERIENCE INFORMATION

B1. Describe past experience (specify prime or sub and number of years of experience) and current capability to develop and maintain healthcare billing code sets (CPT, HCPCS, ICD‑10, DRG, APC).

B2. What coding tools, databases, or industry resources does your organization use to maintain current and accurate code sets?

B3. Provide examples of similar work performed for federal agencies or large healthcare systems.

B4. How much lead time will be needed from a notification of award to delivery of services?

C – CODE SET DEVELOPMENT APPROACH

C1. Describe your methodology for mapping clinical guidance (such as CCRGs) to specific billable codes.

C2. How does your organization ensure all appropriate codes are included and that mismatches or exclusions are minimized?

C3. What is your approach for incorporating new, revised, or retired codes into routine updates?

C4. How would your organization set limits for codes to avoid overutilization?

D – DELIVERABLES AND UPDATE CADENCE

D1. What update cadence do you recommend (monthly, quarterly, or other)?

D2. What standard formats do you provide for code set deliverables, and can these be customized for VA’s needs?

D3. Describe your process for ensuring each deliverable is complete, accurate, and ready for VA validation.

E – QUALITY ASSURANCE AND VALIDATION

E1. What quality assurance methods do you use to validate code accuracy and completeness?

E2. How do you ensure alignment with reimbursement rules, bundling logic, and nonreimbursable codes?

E3. What mechanisms exist to track and resolve discrepancies or errors identified by VA?

F – SCALABILITY AND VOLUME MANAGEMENT

F1. How does your organization manage code set development across numerous specialties and high-volume code families?

F2. What capacity do you have to support expansion as VA adds or updates CCRGs?

F3. Describe your ability to deliver accelerated updates, if required.

G – TOOL, TECHNICAL INTEGRATION AND INTEROPERABILITY

G1. What platforms support your code creation, maintenance, and version control processes?

G2. What delivery mechanisms do you support (API, SFTP, structured files, etc.)?

G3. How do you support integration with claims adjudication systems?

H – STAFFING AND EXPERTISE

H1. Describe the qualifications and certifications of the coding staff who would support this effort.

H2. What level of staffing (FTEs) do you anticipate assigning to a project of VA’s scale?

H3. How do you ensure continuity of operations and redundancy for ongoing updates?

I – CONTRACTOR – VA INTERACTION MODEL

I1. What information or guidance would you require from VA to create accurate code sets?

I2. How does your organization typically coordinate with federal oversight teams?

I3. What division of responsibilities between VA and the contractor do you recommend for optimal performance?

J – RISKS, CHALLENGES AND RECOMMENDATIONS

J1. What risks should VA anticipate in outsourcing code set development?

J2. What mitigation strategies do you recommend?

J3. Based on your experience, what workflow or update cadence best supports federal claims accuracy and compliance?

K – COST AND PRICING STRUCTURE

K1. Provide estimated costs for developing and maintaining code sets mapped to VA’s CCRGs.

K2. Describe your pricing model (fixed annual cost, per update cost, per specialty pricing, tiered structure, etc.).

K3. What cost drivers (e.g., number of specialties, update frequency, level of customization) would affect pricing?