D.1 PBV Contract referenced Attachments and SOPs.docx

PBV Contract Attachments (as of September 1, 2023) This list is subject to changes and updates.

1.4. HUD-VASH Directive 1162.05(1)

3.3. , 3.10, 4.9.7., 5.1, 16.2 Stages of Case Management, and minimum visit requirements (SOP) and HUD-VASH Case Management SOP.

3.5. HUD-VASH Documentation SOP.

3.9. VASH Discharge SOP

3.10., 5.4., 7.3, 7.4 HUD-VASH Stages of Case Management and Minimum Visit Requirements SOP

3.19. HUD-VASH Documentation Standard Operating Procedure (SOP),

3.19.1. VHA Directive 1082 Patient Care Data Capture and VHA Directive 1161 Productivity and Staffing in Clinical Encounters For Mental Health Providers

3.23. HUD-VASH Huddle SOP

4.2. Homeless Operations Management and Evaluation System (HOMES)

4.3. Sample Resource Handout.

4.9.3. Pre-inspection checklist.

5.2.10.1. Mental Health Treatment Plan and Mental Health Treatment Plan Goals

5.2.10.4. Sample Psychosocial Assessment.

5.2.10.6. CERS Procedure for Medical and Psychiatric Emergency Response in the Community and CERS Management and Escalation of Health Status Concerns

5.2.10.7. CERS Management and Escalation of Health Status Concerns and CERS Incident-Death Reporting Manual

6.7. HUD-VASH Case Transfer SOP.

7.2.3.3. Provide care within their scope of practice and as outlined in HUD-VASH Team Roles.

7.2.3.4. Primary Care Engagement SOP

7.2.3. VA Peer Specialist Approved Certification Process October 1-2019

8.3. VHA Handbook 6500

10.1.3. VHA Directive 1192 Seasonal Influenza Prevention Program for VHA Health Care Personnel

11.1. HUD-VASH Competency folder SOP

13.7. VHA Directive 1605.01 Privacy and Release of Information

14.3. CERS Peer Review Procedure SOP

HUD-VASH Stages of Case Management And Minimum Visit Requirements SOP.pdf image4.emf

HUD-VASH Documentation SOP.pdf image5.emf

HUD-VASH Discharge SOP.pdf

HUD-VASH Stages of Case Management And Minimum Visit Requirements SOP.pdf

HUD-VASH Documentation SOP.pdf image6.emf

1082_D_2023-03-09.pdf

T-1

Department of Veterans Affairs VHA DIRECTIVE 1082 Veterans Health Administration Transmittal Sheet Washington, DC 20420 March 9, 2023

PATIENT CARE DATA CAPTURE AND CLOSEOUT

1. REASON FOR ISSUE: This Veterans Health Administration (VHA) directive states requirements and responsibilities for a standardized method to capture all clinical interactions as patient abstracts and establishes timelines required for closeout.

2. SUMMARY OF MAJOR CHANGES: This directive:

a. Combines requirements for data capture and closeout into a single directive.

b. Removes reference to the National Patient Care Database, which is no longer in use.

c. Replaces software-specific terms (e.g., Veterans Information Systems and Technology Architecture, Computerized Patient Record System) with the general term “electronic health record” to accommodate future technology system changes.

d. Updates terminology from “encounter” to “abstract” to better describe the focus of this directive and ensure consistent and clear uses and definitions are applied.

3. RELATED ISSUES: VHA Directive 1907.01, VHA Health Information Management and Health Records, dated April 5, 2021.

4. RESPONSIBLE OFFICE: The Office of Health Information Governance (105HIG) is responsible for the content of this directive. Questions may be addressed to 971-212- 0055 or VHAHIGHIMVAStaff@va.gov.

5. RESCISSIONS: VHA Directive 1082, Patient Care Data Capture, dated March 24, 2015, and VHA Directive 1233, Closeout of Veterans Health Administration Corporate Patient Data Files Including Quarterly Patient Census, dated June 14, 2017, are rescinded.

6. RECERTIFICATION: This VHA directive is scheduled for recertification on or before the last working day of March 2028. This VHA directive will continue to serve as national VHA policy until it is recertified or rescinded.

mailto:VHAHIGHIMVAStaff@va.gov

March 9, 2023 VHA DIRECTIVE 1082

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BY DIRECTION OF THE OFFICE OF

THE UNDER SECRETARY FOR HEALTH:

/s/ Steven Lieberman, MD, MBA Deputy Under Secretary for Health

NOTE: All references herein to Department of Veterans Affairs (VA) and VHA documents incorporate by reference subsequent VA and VHA documents on the same or similar subject matter.

DISTRIBUTION: Emailed to the VHA Publications Distribution List on March 9, 2023.

i

CONTENTS

1. PURPOSE

2. BACKGROUND

3. DEFINITIONS

4. POLICY

5. RESPONSIBILITIES

6. PATIENT CARE DATA CAPTURE AND CLOSEOUT REQUIREMENTS

7. TRAINING

8. RECORDS MANAGEMENT

9. REFERENCES

1. PURPOSE

This Veterans Health Administration (VHA) directive states policy requiring the capture of all clinical interactions as patient abstracts (representing outpatient professional services, inpatient stays, inpatient visits in outpatient clinics, inpatient mental health services, rehabilitation treatment program services, inpatient clinical pharmacy services, surgical services and other professional services in support of revenue operations) and defines the closeout requirements for entering the abstracted data into VHA corporate data files. AUTHORITY: 38 U.S.C. §§ 7301(b), 7311(a).

2. BACKGROUND

a. Department of Veterans Affairs (VA) medical facilities are required to electronically report abstracted data representing the provision of care in VHA, including inpatient and outpatient VA medical facility and professional services, for inclusion in corporate data files used by VHA leadership and others for reporting, resource allocation, research and revenue.

b. This directive provides requirements and definitions to standardize methods for capture of clinical interactions by VA health care providers.

c. VHA is required to utilize data definitions for clinical and administrative data promulgated by internationally and nationally recognized standard-setting organizations and statutes (e.g., Health Insurance Portability and Accountability Act of 1996 (HIPAA)).

3. DEFINITIONS

a. Abstract. An abstract is a record in the electronic health record (EHR) that contains the coded data elements and additional administrative data used to represent the clinical interaction. NOTE: Abstracts may refer to Veterans Information Systems and Technology Architecture (VistA) Patient Care Encounters (PCEs) in the outpatient setting, formerly referred to as “encounters”, VistA Patient Treatment Files (PTFs) in the inpatient setting or Cerner Encounters which include both inpatient and outpatient care settings.

b. Clinical Interaction. A clinical interaction is an encounter between a patient and clinical professional resulting in surgical services, inpatient visits in outpatient clinics, inpatient mental health services, inpatient clinical pharmacy services, outpatient professional services, inpatient stays, rehabilitation treatment program services or other professional services. A clinical interaction also includes a clinical professional’s request for opinions or recommendations for treatment plans from another clinical professional.

c. Closeout. Closeout is the process of recording, completing and submitting an abstract representing a clinical interaction to the Austin Information Technology Center and receiving acceptance within the VHA corporate data file without error.

d. Electronic Health Record. EHR is the digital collection of patient health information resulting from clinical patient care, medical testing and other care-related activities. Authorized VA health care providers may access EHR to facilitate and document medical care. EHR comprises existing and forthcoming VA software including Computerized Patient Record System (CPRS), VistA and Cerner platforms. NOTE: The purpose of this definition is to adopt a short, general term (EHR) to use in VHA national policy in place of software-specific terms while VA transitions platforms.

e. Health Professions Trainee. A Health Professions Trainee (HPT) is an individual appointed under 38 U.S.C. §§ 7405 or 7406 who is participating in clinical or research training under supervision to satisfy program or degree requirements. HPT is a general term to describe undergraduate, graduate and post-graduate students, interns, residents, chief residents, fellows, VA advanced fellows and pre- and post-doctoral fellows who spend all or part of their training experiences at VA medical facilities. Some HPTs may be in non-clinical training fields but train in patient areas or use VA patient records or data in their training.

f. Non-Count. Non-count is a designation associated with an abstract based on the clinic location representing work performed that does not meet the definition of a reportable clinical interaction or all the requirements in paragraph 6.

g. Occasion of Service. An occasion of service is a specified, identifiable instance of activity provided in conjunction with an overall service which is not an independent clinical interaction and does not require independent clinical judgment in the overall diagnosis, evaluation and treatment of the patient’s condition(s). Occasions of service are the result of a clinical interaction. Examples include clinical laboratory tests, radiological studies, physical medicine interventions, medication administration and vital sign monitoring.

h. VHA Corporate Data Files. VHA corporate data files are copies of VA medical facility-reported abstracts that have completed closeout within 7 calendar days of the last treatment date. VHA corporate data files are utilized for national reporting, funding allocation determinations, health care planning, cost accounting and performance monitoring.

4. POLICY

It is VHA policy that VA medical facilities capture, report and document complete abstracts, including representation of clinical care by coded data governed by HIPAA, for inclusion in VHA corporate data files within 7 calendar days of the last treatment date for all clinical interactions that occur at VA medical facilities or are paid for by VA, in accordance with standard HIPAA data recording and reporting requirements. For patients admitted but not yet discharged at the time of the quarterly census, it is VHA policy that a quarterly census abstract must be captured, reported and completed within 7 calendar days of the end of the quarter representing the care provided during the quarter. Occasion of service activities must not be recorded as separate abstracts.

5. RESPONSIBILITIES

a. Under Secretary for Health. The Under Secretary for Health is responsible for ensuring overall VHA compliance with this directive.

b. Deputy Under Secretary for Health. The Deputy Under Secretary for Health is responsible for supporting the VHA Health Information Management (HIM) Program Office with implementation and oversight of this directive.

c. Assistant Under Secretary for Health for Operations. The Assistant Under Secretary for Health for Operations is responsible for:

(1) Communicating the contents of this directive to each of the Veterans Integrated Services Networks (VISNs).

(2) Assisting VISN Directors to resolve implementation and compliance challenges in all VA medical facilities within that VISN.

(3) Providing oversight of VISNs to ensure compliance with this directive and its effectiveness.

d. Executive Director, VHA Health Information Governance Program Office.

The Executive Director, VHA Health Information Governance Program Office is responsible for providing oversight of the VHA HIM Program Office to ensure compliance with this directive.

e. Director, VHA Health Information Management Program Office. The Director, VHA HIM Program Office is responsible for:

(1) Providing oversight for the VISN and VA medical facility compliance with this directive and ensuring corrective action is taken when non-compliance is identified through coordination with other offices and stakeholders, as appropriate.

(2) Providing clarifying guidance for VISNs and VA medical facility staff, including VA medical facility Chiefs of HIM (CHIMs), regarding all data capture and closeout processes.

(3) Providing VHA-specific HIM ad hoc training, tools and resources.

(4) Coordinating with other VHA program offices and departments to communicate and provide guidance on the data capture requirements and closeout process.

f. Veterans Integrated Services Network Director. The VISN Director is responsible for:

(1) Ensuring that all VA medical facilities within the VISN comply with this directive and informing leadership when barriers to compliance are identified.

(2) Ensuring all clinical interactions represented as abstracts for an outpatient visit or inpatient stay within the VISN are recorded, complete and have supporting documentation within 7 calendar days of the last treatment date.

(3) Ensuring EHR systems are current and up to date in accordance with nationally distributed software, software patches and content as made available by VA’s Office of Information Technology.

(4) Ensuring the VA medical facility Director holds staff accountable for completion of the required documentation in the patient’s health record to support any abstract data recorded within 7 calendar days of the last treatment date.

g. VA Medical Facility Director. The VA medical facility Director is responsible for:

(1) Ensuring clinical staff document clinical information in the EHR in conformance with legal health records as outlined in VHA Directive 1907.01, VHA Health Information Management and Health Records, dated April 5, 2021, including defining the provider of service, identification of patient, date and time of service, place of service, modality in which the service is provided, patient diagnoses or reason for the visit, services provided to the patient and treatment related to special authorities for medical care, time spent providing the care and disposition of the patient (see paragraph 6.c.(9)).

(2) Ensuring the provider of the services, in outpatient clinical settings and inpatient professional services, completes the abstract within 7 calendar days of the last treatment date. Any documentation to support the reported abstract, in the form of a progress note or equivalent in the EHR, must also be completed within 7 calendar days of the visit date.

(3) Ensuring psychiatrists, psychologists, licensed clinical social workers, pharmacists and Advanced Practice Providers (e.g., Certified Nurse Practitioner (CNP), Clinical Nurse Specialist (CNS), Certified Nurse Midwife (CNM), Certified Registered Nurse Anesthetist (CRNA) and Physician Assistant (PA)) document in the patient’s health record and complete the abstract of the clinical interaction on all mental health professional services provided in an inpatient or residential rehabilitation setting. NOTE:

For minimum clinical data requirements for data entry, see paragraph 6.c.(9).

(4) Ensuring a process is in place for review, acceptance and maintenance of any VISN or VA medical facility-created electronic encounter form templates or other documentation templates prior to implementation.

(5) Ensuring a process is in place to implement regular updates for any VHA HIM Program Office-provided national electronic encounter form templates provided on a quarterly basis.

(6) Ensuring a process is in place to monitor accuracy, completion and acceptance of all data abstracts and supporting documentation within 7 days of the last treatment date for inclusion in VHA corporate data files. This includes reviewing abstract completion status reports from the VA medical facility CHIM or designee.

(7) Ensuring a process is in place for auditing and providing education to VA clinicians (at least annually) to ensure abstracts are at or above the accepted minimum standard of 95% accuracy based on documentation in the patient’s health record.

(a) Education must be targeted based on the result of the audit with a plan of action for any individual falling below acceptable thresholds until the acceptable level of accuracy is achieved.

(b) Audit results and any corrective action must be reported to the VA medical facility Integrity and Compliance Committee as a plan to improve abstracted data accuracy until it reaches acceptable standards consistently. Clinicians identified for review and audit are limited to Doctors of Medicine (MDs), Doctors of Osteopathic Medicine (DOs), PAs and CNPs CNMs and CNSs. Additional staff may be included at the VA medical facility’s discretion and should be outlined in VA medical facility standard operating procedures for additional disciplines and services.

(8) Ensuring a process is in place to monitor and track that all abstracts representing clinical care provided are completed within the timeframes outlined and contain supporting documentation in the patient’s health record.

(9) Ensuring that all authorized community care that is provided is paid for by VA (e.g., acute inpatient and nursing home care provided to patients in the community) and is represented in VHA corporate data files, either by completion of an abstract or use of community provider claims. NOTE: Community care claims may be processed and paid up to 180 days from the discharge date.

(10) Ensuring a process is in place so all clinic locations are created and maintained with appropriate Decision Support System (DSS) identifier(s) as outlined by the VHA Managerial Cost Accounting Office (formerly the DSS Program Office).

h. VA Medical Facility Chief, Health Information Management. The VA medical facility CHIM is responsible for:

(1) Ensuring a quarterly census abstract is performed and completed for all bed occupants for which VA is responsible, except Contract Nursing Homes and State Veterans Homes.

(2) Ensuring VA medical facility HIM coding staff complete the coding and validate data capture for all inpatient admissions and surgical cases in the appropriate application.

(3) Ensuring a process is in place for auditing and providing education to VA health care providers and HIM coders in order to ensure that abstract coding is at or above the accepted minimum standard of 95% accuracy based on documentation in the patient’s health record.

(4) Ensuring that trained and competent coding staff perform content validation of the codes included on the encounter form templates used for code picklists using the

Automated Information Collection System.

(5) Ensuring HIPAA code sets, including International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS), for any locally created encounter form templates conform to the definitions and conventions included in the appropriate coding publications mandated by HIPAA and VHA coding guidelines. If VHA HIM nationally provided encounter form templates require installation and association with appropriate clinics, content updates are provided by VHA HIM Program Office.

(6) Monitoring and reporting status of abstract and health record documentation completion timeliness to the staff identified by the VA medical facility who is responsible for ensuring compliance, accountability and developing an action plan when necessary, including the VA medical facility Director.

(a) Education must be targeted based on the result of the audit with a plan of action for any individual falling below acceptable thresholds until the acceptable level of accuracy is achieved.

(b) Audit results and any corrective action must be reported to the VA medical facility Integrity and Compliance Committee as a plan to improve coding accuracy until it reaches minimum accuracy standard.

(7) Ensuring VA medical facility HIM professionals edit and update abstracts in the outpatient setting based on review and validation of documentation to ensure accuracy for all cases billed to third-party payers in accordance with the HIM and Consolidated Patient Accounting Center service-level agreement.

i. VA Health Care Provider. VA health care providers are responsible for:

(1) Documenting care in the EHR (e.g., using a progress note) in accordance with VHA Directive 1907.01 as evidence to support the abstract. NOTE: HPTs must follow documentation requirements outlined in VHA Directive 1400.01, Supervision of Physician, Dental, Optometry, Chiropractic, and Podiatry Residents, dated November 7, 2019; VHA Handbook 1400.04, Supervision of Associated Health Trainees, dated March 19, 2015; and VHA Directive 1400.09(1), Education of Physicians and Dentists, dated September 9, 2016, based on the VA health care provider who is independently responsible for care, assessment, delivery, abstract completion and documentation in the patient’s legal health record.

(2) Completing the abstract for outpatient care, inpatient mental health and rehabilitation professional services within 7 calendar days of the last treatment date and ensuring it accurately reflects the minimum required clinical data elements (see paragraph 6.c.(9)), including but not limited to code assignment for diagnosis and services provided. NOTE: Documentation to support the reported abstract in the form of a progress note or equivalent in the EHR must also be present and completed within 7 days of the visit date.

6. PATIENT CARE DATA CAPTURE AND CLOSEOUT REQUIREMENTS

a. The abstract contains the coded data elements and additional administrative data used to represent a clinical interaction. VHA Coding Guidelines are followed to record the coded data to support the continuity of patient care, resource allocation, performance measurement, quality management, provider productivity, research and third-party payer collections and reporting accuracy. NOTE: For more information about VHA Coding Guidelines, see https://dvagov.sharepoint.com/sites/vhahealth-information-management/Coding%20Resources/VHA%20Coding%20Guidelines. This is an internal VA website that is not available to the public.

b. Accuracy of all coding must be maintained at or above the identified acceptable level of 95% accuracy by both clinical staff and coders. NOTE: For additional information, see VHA HIM Clinical Coding Program Guide at https://dvagov.sharepoint.com/sites/vhahealth-information-management/Coding%20Resources/VHA%20Coding%20Guidelines. This is an internal VA website that is not available to the public.

c. The provider is responsible for documenting the clinical interaction, including review, evaluation, assessment and plan, in a progress note or other applicable document type (e.g., diagnosis or care delivery) and additionally must record in the abstract the diagnosis or reason for visit with highest degree of specificity known represented by ICD-10-CM code for the visit and CPT/HCPCS for service(s) provided as well as location, DSS identifiers (e.g., stop code(s)) and indication of treatment related to service connected or special authority conditions when applicable. Abstracts represent care in all settings (e.g., outpatient or inpatient).

(1) Interactions can include face-to-face, video, telephone or secure messaging interactions if the definition of the abstract is met. In order for audio-only telephone services to be reportable, there must be interaction between the patient and provider with the required elements of telephone codes, evaluation and management or medicine section of CPT, performed and documented as applicable, including time spent, assessment, chief complaint or reason for visit, history and medical decision making. Telephone services not meeting this definition must be recorded as historical or associated with non-count location for tracking only.

(2) Contact can occur through secure messaging related to a visit within the last 7 days but cannot be captured as workload as it is considered part of the actual face-to-face visit.

(3) Services incidental to and supporting the clinical interaction between the patient and the primary provider are considered part of the service provided by the primary provider and do not constitute separate reportable service or abstracts separately (e.g., taking vital signs, documenting chief complaint, giving injections, pulse oximetry, administering medications, review of patient’s health record, phone calls of test results).

(4) A telehealth contact between a provider and a patient is considered a clinical https://dvagov.sharepoint.com/sites/vhahealth-information-management/Coding%20Resources/VHA%20Coding%20Guidelines https://dvagov.sharepoint.com/sites/vhahealth-information-management/Coding%20Resources/VHA%20Coding%20Guidelines https://dvagov.sharepoint.com/sites/vhahealth-information-management/Coding%20Resources/VHA%20Coding%20Guidelines https://dvagov.sharepoint.com/sites/vhahealth-information-management/Coding%20Resources/VHA%20Coding%20Guidelines interaction when synchronous video technology or store and forward asynchronous technology is utilized as the modality to provide care. Additional information on telehealth services requirements is outlined by the VHA Managerial Cost Accounting Office at http://vaww.dss.med.va.gov/programdocs/pd_oident.asp and the Office of Connected Care Telehealth Program at VHA Telehealth Intranet site at https://dvagov.sharepoint.com/sites/VHA-Telehealth/docs/Forms/AllItems.aspx. NOTE:

These are internal VA websites that are not available to the public.

(5) All services recorded via an abstract must meet the definition of a clinical interaction and contain the supporting evaluation and medical decision making provided. The specific level of service must be recorded by applying American Medical Association guidelines for CPT/HCPCS code assigned. Additionally, the supporting documentation, in the form of a patient progress note or equivalent, must be present in the patient’s health record as evidence of services provided and include these elements along with the modality and time spent performing the service.

(6) The actual services provided to the patient by the provider must be fully and clearly documented and coded using CPT/HCPCS code assignment as the nationally accepted code sets, such as current edition CPT/HCPCS codes.

(7) For purposes of patient care data capture, mental health services include inpatient and residential rehabilitation professional services performed by a psychiatrist with the credentials of MD or DO; a psychologist with the credentials of Doctor of Philosophy (PhD) or Doctor of Psychology (PsyD); licensed clinical social workers; or licensed advanced practice nurses, and PAs with the credentials of CNP, CNS, CNM, CRNA or PA.

(8) All services must be associated with a location and accurate DSS identifiers (e.g., stop codes), to ensure accurate reporting of work performed and resource consumption.

(9) Minimum Clinical Data Elements. In addition to the current administrative data elements (e.g., eligibility, period of service and service-related condition information, patient address, next-of-kin), the minimum required clinical data elements for capture in the patient abstract are as follows:

(a) Patient. The person receiving health care services, including the full legal name, date of birth, Social Security Number (SSN) or pseudo-SSN (or other personal identifier) and eligibility.

(b) Diagnosis. Reason for visit, diagnosis or conditions that necessitated the clinical interaction, affected the treatment or were assessed or treated during the clinical interaction, including treatment plan assessed and continued.

1. The following are required to be reported as ICD-10-CM codes: purpose of the abstract noted by the provider as the problem, reason for visit or diagnoses which necessitated the clinical interaction.

http://vaww.dss.med.va.gov/programdocs/pd_oident.asp https://dvagov.sharepoint.com/sites/VHA-Telehealth/docs/Forms/AllItems.aspx

2. When more than one problem or diagnosis meets the definition of a reportable condition, the provider must determine which one is the primary reason the patient sought treatment. All additional diagnoses or conditions that affected the treatment of the patient, were assessed, were treated or where treatment was planned during the clinical interaction should be included as additional secondary codes.

(c) Classification Questions. The provider determination of whether or not a treatment was related to any adjudicated service-connected condition or treatment of special authority conditions related to exposure (e.g., Agent Orange, Ionizing Radiation, Military Sexual Trauma, combat Veterans or environmental contaminants) must be based on all conditions treated during the clinical interaction and the abstract must be designated as service-connected or designated as being related to the special authority.

(d) Date and Time of Service. Time is a single entry indicating the time that the clinical interaction was initiated. For all scheduled appointments, the date is the date services are provided. When unscheduled appointments are entered, the abstract date is the date and time the patient presented for interaction.

(e) Place of Service. Information about the location where the service was provided.

This includes the three-digit VA medical facility or station identifier, with any applicable suffixes (STA6A), as well as the DSS identifier(s). The place of service must include the five-character medical center national VHA division value. The division value must reflect the location where care was provided.

(f) Primary Provider. A Licensed Independent Practitioner (LIP) or a Licensed Practitioner (LP) providing the service on behalf of the LIP, who is the attending or rendering provider. An HPT must never be listed as the primary provider in an abstracts.

When the patient is seen by multiple providers during the same clinical interaction, both independent and non-independent, the provider with highest degree of licensure should be listed as primary. For example, if a nurse and physician both see the patient, the physician should be listed as primary. If the patient is being seen by a PA and a physician within the same clinic visit, the physician would be the primary provider with the PA listed as a secondary provider. If the patient is being seen by a CNP and a physician within the same clinic visit, the primary provider would be the physician.

However, if the patient is being seen by a CNP or PA and is treated only by the CNP or PA, the individual who is CNP/PA should be listed as the primary provider designated on the abstract.

d. All abstracts representing inpatient and outpatient care must be complete and error free within 7 calendar days of the treatment date (e.g., date of discharge, quarterly census date, visit date of service) for inclusion in VHA corporate data files. Census abstracts must be complete and error free within 7 calendar days of the end of the quarter. NOTE: Example of date calculation: if a patient’s Discharge Date is January 31, 2016, then the abstract must be closed and accepted no later than February 7, 2016.

Date of discharge to date of abstract accepted equals 7 calendar days.

e. Abstracts containing any erroneous or inaccurate data based on the health record documentation available at the time of coding must be corrected when it is discovered.

There is no time limit on correction of abstract based on documentation available at the time of recording. Changes other than data corrections as mentioned will not be permitted in accordance with ethical coding practices. There are multiple uses for data other than workload and it is important to have the data be as accurate as possible.

f. All coded data represented in patient abstracts may not be billable to third-party payers. Thus, there will be specific circumstances where the abstract, including codes assigned and code sequence, does not match one to one with the bill created for submission to third-party payers based on business rules for payment that require submission in a specific format to support adjudication.

g. Each VA medical facility must be set up with appropriate DSS identifiers. Utilized both locally and nationally, these identifiers describe DSS clinical work units. The VHA Managerial Cost Accounting Office maintains and nationally distributes the list of DSS identifiers which are updated annually. VHA Financial Program Policy Documents and information about the VHA Managerial Cost Accounting Office can be found at http://vaww.mcao.va.gov/programdocs/pd_oident.asp. NOTE: This is an internal VA website and is not available to the public.

(1) A primary DSS identifier must be assigned to clinic locations in outpatient, residential rehabilitation and inpatient clinic settings. The primary DSS identifier must depict the primary clinical workgroup responsible for the type of service provided during the clinical interaction.

(2) The secondary DSS identifier serves as a modifier to further define the primary workgroup or type of service provided. The DSS identifier(s) for a patient setting must meet the definitions outlined by the VHA Managerial Cost Accounting Office.

h. A VA medical facility including all identified divisions and Community-Based Outpatient Clinics (CBOCs) is considered to be the business entity furnishing health care at the organizational level. Sub-organizational level entities for which data must be retrievable include parent and community site, specific clinic (regardless of whether the site has more than one type of station suffix, e.g., a CBOC), treatment team and individual provider.

7. TRAINING

The following training is recommended annually and for all new clinical users who are involved with or responsible for abstract completion: Talent Management System (TMS) course VA 131001971, Data Capture and Closeout.

8. RECORDS MANAGEMENT

All records regardless of format (e.g., paper, electronic, electronic systems) created by this directive must be managed as required by the National Archives and Records Administration (NARA) approved records schedules found in VHA Records Control Schedule 10-1. Questions regarding any aspect of records management should be http://vaww.mcao.va.gov/programdocs/pd_oident.asp addressed to the appropriate Records Officer.

9. REFERENCES

a. 38 U.S.C. §§ 7301(b), 7311(a), 7405, 7406.

b. VHA Directive 1400.01, Supervision of Physician, Dental, Optometry, Chiropractic, and Podiatry Residents, dated November 7, 2019.

c. VHA Directive 1400.09(1), Education of Physicians and Dentists, dated September 9, 2016.

d. VHA Directive 1907.01, VHA Health Information Management and Health Records, dated April 5, 2021.

e. VHA Handbook 1400.04, Supervision of Associated Health Trainees, dated March 19, 2015.

f. VHA Coding Guidelines: https://dvagov.sharepoint.com/sites/vhahealth-information-management/Coding%20Resources/VHA%20Coding%20Guidelines.

NOTE: This is an internal VA website that is not available to the public.

g. VHA HIM Clinical Coding Program Guide:

https://dvagov.sharepoint.com/sites/vhahealth-information-management/Coding%20Resources/VHA%20Coding%20Guidelines. NOTE: This is an internal VA website that is not available to the public.

h. VHA Managerial Cost Accounting Office:

http://vaww.mcao.va.gov/programdocs/pd_oident.asp and http://vaww.dss.med.va.gov/programdocs/pd_oident.asp. NOTE: These are internal VA websites that are not available to the public.

i. VHA Office of Connected Care Telehealth Program:

https://dvagov.sharepoint.com/sites/VHA-Telehealth/docs/Forms/AllItems.aspx. NOTE:

This is an internal VA website that is not available to the public.

file:///C:/Users/VACOBE~1/AppData/Local/Temp/MicrosoftEdgeDownloads/2b419a1d-de6f-49e3-9d0c-34607a1ba2ef/1400_01_D_20191107.pdf file:///C:/Users/VACOBE~1/AppData/Local/Temp/MicrosoftEdgeDownloads/2b419a1d-de6f-49e3-9d0c-34607a1ba2ef/1400_01_D_20191107.pdf file:///C:/Users/VACOBE~1/AppData/Local/Temp/MicrosoftEdgeDownloads/fab3e34b-8f5e-4d71-8940-c79012004e54/1400_09(1)_D_2016-09-09.pdf file:///C:/Users/VACOBE~1/AppData/Local/Temp/MicrosoftEdgeDownloads/60d1ec57-c4f4-46c2-bf72-cb184dd433f0/1400_04_HB_2015-03-19.pdf https://dvagov.sharepoint.com/sites/vhahealth-information-management/Coding%20Resources/VHA%20Coding%20Guidelines https://dvagov.sharepoint.com/sites/vhahealth-information-management/Coding%20Resources/VHA%20Coding%20Guidelines https://dvagov.sharepoint.com/sites/vhahealth-information-management/Coding%20Resources/VHA%20Coding%20Guidelines https://dvagov.sharepoint.com/sites/vhahealth-information-management/Coding%20Resources/VHA%20Coding%20Guidelines http://vaww.mcao.va.gov/programdocs/pd_oident.asp http://vaww.dss.med.va.gov/programdocs/pd_oident.asp https://dvagov.sharepoint.com/sites/VHA-Telehealth/docs/Forms/AllItems.aspx image7.emf

1161_D_2020-04-28.pdf

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Department of Veterans Affairs Veterans Health Administration Washington, DC 20420

VHA DIRECTIVE 1161

Transmittal Sheet

April 28, 2020

PRODUCTIVITY AND STAFFING IN CLINICAL ENCOUNTERS FOR MENTAL

HEALTH PROVIDERS

1. REASON FOR ISSUE: This Veterans Health Administration (VHA) directive provides policy on individual mental health provider productivity based on clinical encounters for all psychiatrists, psychologists, mental health social workers, clinical pharmacy specialists, nurse practitioners (NP), clinical nurse specialists (CNS), physician assistants (PA), and other licensed independent providers who work in mental health programs and settings. NOTE: Nurse practitioners and clinical nurse specialists are both under the umbrella of Advanced Practice Registered Nurses (APRN).

2. SUMMARY OF MAJOR CHANGES: This VHA directive has been revised as follows:

a. Updates productivity calculation and annual review to be consistent with Office of Productivity, Efficiency, and Staffing (OPES). Aligns work relative value units (wRVUs) utilized for mental health productivity measurement with values utilized by OPES.

b. Eliminates Office of Mental Health Operations (OMHO) Appendices B (Imputed Work Relative Value Unit) and C (Calculation and Tracking of Individual Provider Productivity) from the original Directive 1161.

c. Expands requirement for individualized productivity targets to providers at all mental health locations, including inpatient, residential, and compensated work therapy settings.

d. Expands individualized productivity targets to include utilization of Current Procedural Terminology (CPT) coding frequency and encounters in situations where CPT codes have zero wRVUs.

e. Updates expectation of bookable time designation as a percent of total clinical labor mapping.

f. Clarifies use of OPES and Office of Mental Health and Suicide Prevention (OMHSP) productivity dashboards.

g. Updates staffing guidance to include consideration of OMHSP outpatient staffing ratio and population adequacy.

h. Removes providers assigned to Homeless Programs from mental health productivity expectations.

3. RELATED ISSUES: VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics, dated September 11, 2008.

April 28, 2020 VHA DIRECTIVE 1161

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4. RESPONSIBLE OFFICE: The Office of the Deputy Under Secretary for Health for Operations and Management for Clinical Operations, Office of Mental Health and Suicide Prevention (10NC5) is responsible for the contents of this directive. Questions may be directed to the Executive Director of the Office of Mental Health and Suicide Prevention at 202-461-4142.

5. RESCISSIONS: VHA Directive 1161, Productivity and Staffing in Clinical Encounters for Mental Health Providers, dated June 7, 2013, 10N Memorandum, Mental Health Productivity Targets, dated March 11, 2015; 10N Memorandum, Mental Health Productivity Targets, dated March 29, 2016; and 10N Memorandum, Mental Health Productivity Targets, dated May 24, 2016, are rescinded.

6. RECERTIFICATION: This VHA directive is scheduled for recertification on or before the last working day of April 2025. This VHA directive will continue to service as national policy until it is recertified or rescinded.

BY DIRECTION OF THE OFFICE OF

THE UNDER SECRETARY FOR HEALTH:

/s/ Renee Oshinski Deputy Under Secretary for Heath for Management and Operations

NOTE: All references herein to VA and VHA documents incorporate by reference subsequent VA and VHA documents on the same or similar subject matter.

DISTRIBUTION: Emailed to the VHA Publications Distribution List on April 28, 2020.

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CONTENTS

PRODUCTIVITY AND STAFFING IN CLINICAL ENCOUNTERSFOR MENTAL

1. PURPOSE

2. BACKGROUND

3. DEFINITIONS

4. POLICY

5. RESPONSIBILITIES

6. TRAINING

7. RECORDS MANAGEMENT

8. REFERENCES

APPENDIX A

RECOMMENDATIONS FOR MENTAL HEALTH PROVIDER PRODUCTIVITY

STANDARDS AND MONITORING ..............................................................................A-1

PRODUCTIVITY AND STAFFING IN CLINICAL ENCOUNTERS FOR MENTAL

1. PURPOSE

This Veterans Health Administration (VHA) directive provides policy on individual mental health provider productivity based on clinical encounters and attained work relative value units (wRVUs) for all psychiatrists, psychologists, nurse practitioners, clinical nurse specialists, physician assistants (PAs), social workers, clinical pharmacy specialists, and other licensed independent providers who work in mental health programs and settings. NOTE: Productivity expectations for psychiatrists, psychologists, social workers, counselors, and other staff of VA’s Readjustment Counseling Service, or who are assigned to non-mental health settings, such as medical social workers or to Homeless Programs, are excluded from this directive.

Productivity expectations for these providers are defined by the respective Program Office. AUTHORITY: Title 38 United States Code (U.S.C.) 1706 and 8110.

2. BACKGROUND

a. In 2016, mental health productivity targets were updated with regard to work relative value units (wRVU) productivity. This update included an acceptable range of specialty productivity (plus or minus one standard deviation from the discipline mean) using tools from the Office of Productivity, Efficiency, and Staffing (OPES) or Mental Health Onboard Clinical (MHOC) data. This directive reiterates these requirements and the process for OPES annual review (which, in 2016 was calculated using the mean, but is now calculated using the median to be consistent with OPES methodology).

b. The Government Accountability Office, in its report “The VHA, Better Data and Evaluation Could Help Improve Physician Staffing, Recruitment, and Retention Strategies,” GAO 18-124 (October 2017), required OPES to provide guidance on how to interpret and reconcile two productivity data sets (OPES and MHOC). This policy update continues to align MHOC and OPES processes for productivity calculation.

3. DEFINITIONS

The following definitions are for the purposes of this directive.

a. Acceptable Specialty Group Practice Range of Productivity. Acceptable group practice range of productivity is the productivity within the interquartile range (25th to 75th percentile). This range is considered an acceptable range of productivity, taking care not to compromise quality and patient access standards. NOTE: The definition distinguishes specialty group practice from individual practice. Specialty Group Practice productivity below the minimum productivity threshold is considered a practice requiring a remediation plan.

b. Bookable Clinic Hours. Bookable clinic hours are the number of hours allotted in each provider’s clinic schedule for direct patient care. Bookable clinic hours include face-to-face and virtual patient care time (e.g., telephone visits and tele-health). The time counted in the calculation must be unrestricted (i.e., no special permission scheduling or blocking of time).

c. Direct Patient Care Time. Direct patient care time is defined as the time to prepare, provide for, and follow-up on the clinical care needs of patients. Direct patient care time, or clinical time, is time not occupied by administrative (labor mapped) duties, teaching, or research. NOTE: Current labor mapping information is available at this Web site: (http://vaww.dss.med.va.gov/programdocs/pd_ProAud.asp). This is an internal VA Web site that is not available to the public.

d. Full-Time Equivalent Clinical. Full Time Equivalent Clinical (FTE(c)) is the portion of a full-time equivalent employee (removing leave) which is devoted to clinical, direct patient care as assigned by Managerial Cost Accounting (MCA) labor mapping.

e. Individualized Productivity Target. The Individualized Productivity Target is a productivity target specifically calculated for a provider based upon their assigned work and CPT coding expectations. The individualized productivity target is distinct from the Specialty Group Practice target (median), as the latter is the performance of all specialists, defined by Person Class, in that group. Given the complex nature of clinical work in mental health, the individualized target should be set by an appropriate professional, ideally from the same discipline, using current labor mapping, with concurrence from (or with delegated authority from) the VA medical facility Director, through the appropriate clinical service chief.

f. Level I Healthcare Common Procedure Coding System or Current Procedural Terminology. The American Medical Association (AMA) has defined a numerical code for each service and procedure. Level I Healthcare Common Procedure Coding System (HCPCS), also known as CPT codes are five-digit numeric codes updated annually by the AMA which each relate to a specific service or procedure. NOTE: In VHA, CPT codes are assigned to an encounter based on the clinical service or procedure performed at the time of the encounter.

g. Level II Healthcare Common Procedure Coding System or Current Procedural Terminology. Level II Healthcare Common Procedure Coding System (HCPCS) is another category of codes, updated annually by the AMA, that may be used in mental health settings for services not covered in the CPT codes. NOTE: In VHA, these codes are assigned to an encounter based on the clinical service or procedure performed at the time of the encounter.

h. Mental Health Providers. Mental health providers are defined as all Psychiatrists, Psychologists, Licensed Marriage and Family Therapists (LMFTS), Licensed Professional Mental Health Counselors (LPMHCs), Clinical Pharmacy Specialists (CPS), Licensed Master Social Workers (LMSW) and Advanced Practice Providers (APP) such as: NPs, CNSs, PAs, assigned to mental health programs (see Mental Health Onboard Clinical (MHOC) Education Materials Web Site.

https://vaww.portal2.va.gov/sites/PERC/PEC_Portal/SiteAssets/MHOC%20Staffing%20 and%20Productivity%20Method%20FULL.pdf. NOTE: For the purposes of this http://vaww.dss.med.va.gov/programdocs/pd_ProAud.asp https://vaww.portal2.va.gov/sites/PERC/PEC_Portal/SiteAssets/MHOC%20Staffing%20and%20Productivity%20Method%20FULL.pdf https://vaww.portal2.va.gov/sites/PERC/PEC_Portal/SiteAssets/MHOC%20Staffing%20and%20Productivity%20Method%20FULL.pdf directive, mental health providers at VA’s Readjustment Counseling Service (Vet Centers) are not included in this definition. Mental health providers at Vet Centers are not included in the productivity expectations of this directive.

i. Other Professional and Clinical Support Staff. Clinical support staff are defined as registered nurses (RNs), licensed practical nurses (LPNs), health care technicians and aides, peer support specialists, addiction therapists, rehabilitation counselors, vocational rehabilitation specialists, and other therapists assigned to the mental health service line. Clinical support staff are included in mental health clinical staffing ratios if they generate encounters in mental health stop codes.

j. Person Class File. The taxonomy for licensed health care providers who bill for health-related services rendered, and is inclusive for all those who appear on the Centers for Medicare and Medicaid (CMS) Provider Specialty listing. It reflects training, licensure, and scope of practice for that individual. Person Class associations are part of the minimum data set reported to the National Patient Care Database, which is VHA’s principal national repository of patient care data.

k. Relative Value Unit. The Centers for Medicare & Medicaid Services (CMS) relative value unit (RVU) is a measure of the complexity and time required to perform a professional service. The number of RVUs associated with each CPT code is determined by CMS and published in the Medicare physician fee schedule. The total RVU consists of three components: provider work (wRVU), practice expense and malpractice RVU. For productivity measurement, only the wRVU is utilized. wRVUs used for MH productivity are designated by OPES, and include CMS values, INGENIX Gap Codes, and OPES-derived imputed values. NOTE: Work component as defined in 42 U.S.C. 1395 is the portion of the resources used in furnishing the service that reflects physician time and intensity in furnishing the service. Such portion shall (i) include activities before and after direct patient contact, and (ii) be defined, with respect to surgical procedures, to reflect a global definition including pre-operative and post-operative physicians’ services. The RVU used in this directive and by CMS differ from time-based RVUs, defined locally by Managerial Cost Accounting Office (MCAO), which are used to compute VA cost for a rendered service. wRVU tables are available on the Veterans Integrated Service Network (VISN) Support Services Center (VSSC) Web site:

https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fWorkload Fee%2fEncounters%2fClinicStopsCPT&rs:command=render. This is an internal VA Web site that is not available to the public.

l. Specialty Group Practice. A specialty group practice is defined as the providers in a VA medical facility and its clinics who are providing mental health services. Mental health is an example of a specialty. All of the mental health specialty providers of a given VA medical facility and its associated clinics are considered a group practice for the purposes of this directive. NOTE: In some VA medical facilities, mental health providers may be assigned to multiple organizational departments or services but are considered to be in the same practice if providing mental health services.