Attachment_1_-_PWS.pdf

Performance Work Statement

MEDICAL CODING

AT

UNITED STATES AIR FORCES IN EUROPE (USAFE)

MILITARY TREATMENT FACILITIES

RFQ NO. FA5641-17-R-0004

HQ USAFE/SG

AFMOA/SGAR

December 1, 2017

Table of Contents

1. Introduction

1.1 Mission

1.2 Background

1.3 Scope

2. General Requirements

2.1 Non‐Personal Services

2.2 Business Relations

2.3 Contract Administration and Management

2.4 Subcontract Management

2.5 Contractor Personnel, Disciplines, and Specialties

2.6 Location and Hours of Work

2.7 Federal Holidays

2.8 Closures

2.9 Personal Appearance and Conduct

2.10 Travel/ Temporary Duty (TDY)

3. Description of Duites, Qualification/Experience and Education for Medical Coder III, Medical

Coder II, Medical Coder I, and Lead

3.1 Medical Coder III

3.2 Medical Coder II

3.3 Medical Coder I

3.4 Medical Coder Lead

4. General Contractor Requirements

4.1. Requirements of all Coders

5. Security and Safety Requirements

5.1 Security, Background Checks, and Safeguarding Material

5.2 Health Requirements

5.3 Transition

5.4 Reference Material

6. Government Furnished Materials/ Services for Contractors working with MTFs

6.1 Support Services

6.2 Applicable Directives

7. Service Delivery Summary

8 Deliverables

8.1 Monthly Program Status Report

8.2 Listing of Personnel

8.3 Outpatient Coding Report

8.4 Inpatient Coding Report

8.5 Monthly Report of Training Support

8.6 Issues Log

8.7 Employee Training Contrl Plan

8.8 MTF Quality Control Plans

9. Appendices

Appendix A

Appendix B

Appendix C

Appendix D

Appendix E

Appendix F

Appendix G

Appendix H

1. Introduction The HQ USAFE/SG and The Air Force Medical Service Medical Coding Program Office (AFMS MCPO), AFMOA/SGAR requires medical coding support for complete, timely, and accurate medical coding.

Services shall be in compliance with the Military Health Services Coding Guidelines and be conducted on site at:

Aviano Air Base (AB), Italy

Ramstein AB, Germany

Spangdahlem AB, Germany

Royal Air Force (RAF) Lakenheath, United Kingdom (UK)

Medical coding personnel at these sites will also provide remote coding of billable encounters at all other USAFE Medical Treatment Facilities (MTFs) as needed.

1.1 Mission

The Air Force Medical Service (AFMS) Mission is to enable medically fit forces, provide expeditionary medics, and improve the health of all we serve to meet our Nation's needs. "Trusted Care Anywhere" is the mantra of the Air Force Medical Service. Our priorities align with Air Force priorities to ensure mission success. We embrace our heritage of innovation and relentlessly pursue advances to enhance safety, effectiveness, and efficiency of care we deliver to beneficiaries and support we provide to

Combatant Commanders. The medical Contractor shall help the AFMS provide reliable access to safe, quality care, for all that the AFMS serves, promote positive patient experiences and outcomes, focus on the appropriate utilization of People and Resources with timely, complete, and accurate medical coding and training.

1.2 Background

The Military Health System, including the Air Force Medical Service, like the civilian healthcare industry, utilizes medical coding for a variety of purposes. While medical coding can provide a detailed clinical picture of a patient population, it can also be useful in overseeing population health, anticipating demand, assessing quality outcomes and standards of care, managing business activities, and receiving reimbursements for services.

1.3 Scope

The Contractor shall provide non‐personal services and perform assistance in improving its medical coding support and overall resource management processes and performance, including optimizing the

Prospective Payment System reimbursement, acceleration of reimbursement, cost savings initiatives and implementation of comprehensive, commercial best practices based systems. As a result, the

AFMS MCPO requires coding services to be provided in support of these initiatives. The Contractor shall provide supplemental staffing for coding personnel to perform outpatient record coding, inpatient record coding, ambulatory procedure coding, and related medical record functions covering a wide range of medical specialties for the specific Medical Treatment Facility (MTF). This will include 100% of

Billable encounters, Emergency Department encounters, Ambulatory Procedure Visit encounters, Inpatient Professional Services encounters, Inpatient Facility encounters, and, at a minimum, 10% of all other direct care (non‐billable) outpatient encounters. The minimum 10% direct care outpatient records coding task will primarily be a review of the electronic medical record completed by the provider, involving the coder editing diagnosis or procedure codes entered by the provider as necessary. Coding personnel in this contract will aid the AFMS Coding Trainers in providing education and feedback to all professional, clinical, and ancillary support staff. Related medical records functions including, but not limited to, pulling, copying, scanning and filing of outpatient records, inpatient records and ambulatory procedure records may be required.

2. General Requirements This section describes the general requirements for this effort. The following sub‐sections provide details of various considerations on this effort.

2.1 Non‐Personal Services

The Government shall neither supervise contractor employees nor control the method by which the

Contractor performs the required tasks. Under no circumstances shall the Government assign tasks to, or prepare work schedules for, individual contractor employees. It shall be the responsibility of the

Contractor to manage its employees and to guard against any actions that are of the nature of personal services, or give the perception of personal services. If the Contractor believes that any actions constitute, or are perceived to constitute personal services, it shall be the Contractor's responsibility to notify the Procuring Contracting Officer (PCO) immediately.

2.2 Business Relations

The Contractor shall successfully integrate and coordinate all activity needed to execute the requirement. The Contractor shall manage the timeliness, completeness, and quality of problem identification. The Contractor shall provide corrective action plans, proposal submittals, timely identification of issues, and effective management of subcontractors (if applicable). The Contractor shall seek to ensure customer satisfaction and professional and ethical behavior of all contractor personnel.

2.3 Contract Administration and Management

The following subsections specify requirements for contract, management, and personnel administration.

2.3.1 Contract Management

The Contractor shall establish clear organizational lines of authority and responsibility to ensure effective management of the resources assigned to the requirement. The Contractor must maintain continuity between the support operations at Aviano, Ramstein, Spangdahlem, and RAF Lakenheath

MTFs and the Contractor's corporate offices.

2.3.2 Contract Administration

2.3.2.1 The Contractor shall establish processes and assign appropriate resources to effectively administer the requirement. The Contractor shall respond to Government requests for contractual actions in a timely fashion. The Contractor shall have a single point of contact between the Government and Contractor personnel assigned to support contracts or task orders. The Contractor shall assign work effort and maintaining proper and accurate time keeping records of personnel assigned to work on the requirement. The Contractor shall provide full coverage for each specific MTF for the required hours of performance. The Contractor shall provide 100% staffing NLT 30 days after the contract start date.

2.3.2.2 The Contractor may use non‐compete provisions in its employment agreements to prevent the loss of personnel by the Contractor during the period of performance of this contract. However, the

Contractor shall not use non‐compete provisions in its employment agreements that would prevent its contract personnel from being employed by or from accepting offers of employment from the new

Contractor of the follow‐on contract or offers of employment from the Government. It would hinder the Government’s ability to accomplish the mission of providing medical care to its beneficiaries.

2.3.3 Materials

The Contractor shall be responsible for providing current year basic coding books, as defined by the

AFMS MCPO, for the contract employees at no cost to the Government for use in the MTF. The

Contractor shall be financially responsible for the replacement of any lost coding books and reference material. This requirement is not intended to support the Government or military employees. It is for contract employees only.

2.3.4 Personnel Administration

The Contractor shall provide the following management and support as required:

2.3.4.1 Provide services during designated Government non‐work days or other periods where

Government offices are closed due to weather or security conditions.

2.3.4.2 Maintains the currency of their employees by providing initial and refresher training as required to meet the PWS requirements.

2.3.4.3 The Contractor shall provide a list of all personnel (with social security numbers) and all supporting personnel documentation showing initiation of a background investigation, compliance with the Health Insurance Portability Accountability Act, and compliance with health and immunization requirements for working in a MTF. The documents should be provided to the COR 15 calendar days prior to the contract start date and within 15 calendar days of the hire of new and replacement personnel.

2.3.4.4 The Contractor shall have sufficient qualified personnel available so that all services are provided in the event a contract personnel scheduled to work becomes ill, resigns, is terminated, or is otherwise unavailable to work. The proposed substitutes shall have at least the minimum qualifications required for the position and shall be replaced without break in services. The Contractor shall notify to

COR for contract personnel scheduled to work in advance.

2.3.4.5 The Contractor will provide qualified replacements NLT 30 calendar days from the date of a position vacancy due to resignation or termination, or substitute for a temporary vacancy created by illness or emergency lasting greater than 80 hours, 95% of the time.

2.3.4.6 Notification to the COR shall be accomplished NLT five (5) calendar days from the date of a position vacancy due to resignation or termination, or substitute for a temporary vacancy when a position cannot be filled with a qualified replacement or substitute.

2.3.4.7 Scheduled absences of contract personnel shall be coordinated with the COR at least 30 calendar days in advance. Depending on how the hours are specified will determine whether or not the

Contractor supplies a substitute, but all absences with over 80 consecutive hours (normally 2 weeks) will require a substitute

2.4 Subcontract Management

The Contractor shall be responsible for any subcontract management necessary to integrate work performed on this requirement and shall be responsible and accountable for subcontractor performance on this requirement. The prime contractor will manage work distribution to ensure there are no

Organizational Conflict of Interest (OCI) considerations. Contractors may add subcontractors to their team after notification to the Procuring Contracting Officer (PCO) or Contracting Officer Representative

(COR). Cross teaming may or may not be permitted.

2.5 Contractor Personnel, Disciplines, and Specialties

The Contractor shall accomplish the assigned work by employing and utilizing qualified personnel with appropriate combinations of education, training, and experience as specified within this PWS. The

Contractor shall match personnel skills to the work or task with a minimum of under/over employment of resources. The Contractor shall ensure the labor categories as defined in the Labor Categories document (see attachment), labor rates, and man‐hours utilized in the performance of each Task Order

(PWS line item) issued hereunder will be the minimum necessary to accomplish the task [consider application based on contract type and whether or not pre‐established rates exist]. The Contractor shall provide the necessary resources and infrastructure to manage, perform, and administer the contract.

developed by contractor management and has been approved by the AFMS MCPO prior to use in recruiting, administered by contractor management IAW AFMS MCPO instructions, with a score of 80% or higher. The coding test must include a sufficient number of questions and scenarios to test the candidate’s knowledge of anatomy and physiology; medical terminology; disease processes;

pharmacology; assignment of ICD‐10‐CM diagnosis codes; assignment and leveling of E&M codes in the

Inpatient, Emergency Department, and Outpatient environments; assignment of CPT codes for the professional component of inpatient and ambulatory surgical procedures, diagnostic procedures, and therapeutic procedures; assignment of ICD‐10‐PCS codes for the facility component of procedures

(specific to Medical Coder III testing only); use of modifiers; and assignment of HCPCS codes.

2.5.2 Continuing Education Requirements

All medical coders are required to maintain required continuing education hours and any other competencies in order to maintain current and proper national coding certification(s) requirements for this position at no expense to the Government. The Contractor will be required to provide proof of current certification in good standing of all coding personnel to the Government on an annual basis and upon Government request.

2.5.3 Additional Coding Certifications

Recognizing the ongoing evolution of types and complexity of coding in civilian industry, the

Government, through the AFMS MCPO, retains the right to require new and/or additional coding certifications for the positions described in this contract.

2.5.4 Equivalency Determinations

All contractor requests for equivalency determinations in regards to required education, experience, or coding certifications will be forwarded to the AFMS MCPO for final decision.

2.5.5 English Language Requirement

The contract personnel shall be able to read, write and speak English well enough to communicate effectively with patients, staff, and other personnel. If English is not the primary language of a candidate, the candidate should be able to pass the Test of English as a Foreign Language, which will be administered by the Contractor.

2.6 Location and Hours of Work

2.6.1. Staffing

The Government estimate for the work to be performed in this PWS is included below:

MTF Medical Coder III

Medical

Coder II

Medical

Coder I TOTAL

Aviano 1 0 1 2

Ramstein 0 0 1 1

Spangdahlem 0 0 1 1

RAF Lakenheath 1 1 1 3

TOTAL: 2 1 4 7

2.6.2 Accomplishment of the results contained in this PWS requires work at Aviano, Ramstein, Spangdahlem, and RAF Lakenheath MTFs and at various contractor, subcontractor, and Government facilities. Normal workdays are Monday through Friday except US Federal Holidays; however each facility may have their own policy. Workers typically work eight (8) hours per day, 40 hours per week.

Flextime workers start not earlier than 0600 and not later than 0900. Core hours of work are from 0900 to 1500 daily. All employees are expected to be available during core hours. The Contractor shall follow local base reporting procedures during weather or security closures. The Contractor may propose operational hours in their strategy to create efficiencies, meet high demand, meet customer needs and improve customer satisfaction, but specific MTF approval and arrangements would be required. On occasion that the military designate a weekday as a family day thus resulting in the closure of some clinics or departments, negating the need for contractor services on such days as applicable for each specific MTF; such closures will be coordinated with the COR. On‐site and remote locations may change due to mission requirements and/or extenuating circumstances.

2.7 Federal Holidays

The following is a list of legal federal holidays and services are not required:

New Year’s Day, January 1st

Martin Luther King's Birthday, 3rd Monday in January

President’s Day, 3rd Monday in February

Memorial Day, Last Monday in May

Independence Day, July 4th

Labor Day, 1st Monday in September

Columbus Day, 2nd Monday in October

Veteran's Day, November 11th

Thanksgiving Day, 4th Thursday in November

Christmas Day, December 25th

NOTE: Any of the above holidays falling on a Saturday will be observed on the preceding Friday;

holidays falling on a Sunday will be observed on the following Monday. The Government may add additional family days in conjunction with these holidays which may result in MTF closures.

2.8 Closures

During anticipated closure of the MTF due to Command declared training holidays, family days, administrative leave granted to the entire staff, or other closures, the Contractor staff assigned to the

MTF will not be required to perform.

2.9 Personal Appearance and Conduct

2.9.1 Appearance

The contract personnel shall present a clean and neat well‐groomed appearance at all times. The contract personnel are required to wear an MTF identification badge (name tag) visible on the front of their outer clothing.

2.9.2. Conduct

2.9.2.1. Contract personnel shall not introduce new procedures or services without prior approval of the COR or designated Government representative. In disagreements or deviations from established guidelines or new protocols, the COR or appointed representative shall be the deciding authority.

2.9.2.2. Contract personnel shall abide by Federal and local MTF regulations (as applicable) and requirements concerning the nature of limited privileged communication between patients and the contract personnel as may be necessary for security and personnel reliability programs; by federal and local MTF regulations concerning the confidentiality of patient records, as embodied in federal statutes including the Privacy Act of 1974 and the Health Insurance Portability & Accountability Act of 1996. All regulations referenced are available for review from the COR or appointed representative at the MTF.

All medical records and reports shall remain the property of the Government.

2.9.2.3. Abide by MTF bylaws (as applicable), The Joint Commission, Accreditation Association for

Ambulatory Health Care (AAAHC), Department of Defense (DoD) and Medical Department regulations with regard to Compliance, Patient Safety, Performance Improvement and Risk Management directives, including, but not limited to, in‐service training, maintenance of records, performance evaluation, and release of medical information.

2.9.2.4. Contract personnel working within a MTF shall make use of all appropriate equipment;

supplies and services made available by the Government. No equipment shall be disposed of without prior consent from COR or appointed representative. All computer disks and working materials shall remain the property of the government.

2.9.2.5. Contacts MTF POC for arrival after the start of normal work hours (late arrival).

2.10 Travel/ Temporary Duty (TDY)

2.10.1 The Government does not currently expect coders under this contract to be required to travel. In the event travel is required, the Government will direct all travel.

3.1. Medical Coder III

3.1.1 Duties for Medical Coder III

3.1.1.1. Verifies or assigns codes for the diagnosis, evaluation and management, admissions, surgeries, procedures, materials, medications, supplies, or any other codes required for the completeness and accuracy of professional and institutional (facility) components of Inpatient, External

Resource Sharing Agreement (ERSA), Ambulatory Procedure Visit (APV), Observation, Emergency

Department (ED), and Outpatient encounters in the medical record.

3.1.1.2. Verifies the component parts of medical record to ensure completeness and accuracy of diagnosis, operations, and special diagnostic or therapeutic procedures that must conform to industry standards, including the Center for Medicare and Medicaid Services (CMS) guidelines, and MHS Coding

Guidelines.

3.1.1.3. Codes the principal diagnosis, co‐morbidities, complications, therapeutic and diagnostic procedures, supplies, materials, injections, and drugs using knowledge of accepted coding practices, guidelines and conventions; medical terminology; anatomy and physiology; disease processes;

treatment modalities; diagnostic tests; pharmacology; therapeutic procedures; the International

Classification of Diseases, 10th Edition, Clinical Modification and Procedure Coding System (ICD‐10‐

CM/PCS); Current Procedural Terminology (CPT); Healthcare Common Procedure Coding System

(HCPCS); and any other coding classification systems required by the DoD.

3.1.1.4. Inputs codes into applicable MHS coding systems, including, but not limited to: CCE, CHCS

(ADM), Essentris, MHS Genesis, and AHLTA. The Medical Severity ‐ Diagnostic Related Group (MS‐DRG) is automatically assigned by the grouper software) for inpatient stays, but understanding of MS‐DRG concepts is required to ensure correct assignment.

3.1.1.5. Reviews medical documentation and assign codes for inpatient institutional (facility) and professional services admissions and encounters to identify inconsistencies or discrepancies that may cause inaccurate coding, medico‐legal re‐percussions or impacts quality patient care. Identifies any problems with legibility, abbreviations, etc., and brings to the provider’s attention. Examines records for proper sequence of documents, presence of authorized signatures, and sufficient data is documented that supports diagnosis, treatment administered, and results obtained. This work includes attending provider, consultant, surgical, and ancillary services. Medical Coder III coders support the Third Party

Collection office (as needed) to ensure they have the documentation to submit a claim for reimbursement.

3.1.1.6. In contingency situations, Medical Coder III coders may be directed by the AFMS MCPO to provide remote coding support to other AFMS MTFs via MHS computer systems.

3.1.1.7. Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding. Monitors ever‐changing regulatory and policy requirements affecting coded information for the full spectrum of services provided.

3.1.1.8. Develops and submits a written (electronic or hard copy) query IAW AFMS guidelines to the provider to request clarification of provider documentation that is conflicting, ambiguous, or incomplete in regards to any significant reportable condition or procedure.

3.1.1.9. Works with providers to resolve documentation issues to support coding compliance.

3.1.1.10. Assigns applicable codes to encounters based upon provider responses to queries and reports queries and responses IAW AFMS guidance.

3.1.1.11. Acts as a source of reference to medical staff having questions, issues, or concerns related to coding. Responds to provider questions and provides examples of appropriate coding and documentation reference(s) to provide clarity and understanding. Based on contacts from the medical staff identifies training opportunities and works with coding training personnel to focus on consistency and clarity of coding advice provided.

3.1.1.12. Assists AFMS Medical Coding Trainers with providing initial coding training to providers by providing guidance to professional and technical staff in documentation requirements for coding as needed.

3.1.1.13. Supports AFMS coding compliance by researching and interpreting existing guidance, and seeking clarification from the supervisor, coding trainers, or Service coding representatives.

3.1.1.14. Performs focused audits of specific MTFs, medical specialties, clinics, coders, or providers when directed and IAW AFMS audit procedures.

3.1.1.15. Performs administrative related tasks associated with medical records final reviews/audits and contacting various departments, services, or medical staff to obtain data needed to complete the records.

3.1.1.16. Maintains confidentiality and privacy of medical, personal, and sensitive information in compliance with the Health Insurance Portability and Accountability Act.

3.1.1.17. Complies with AFMS coding compliance requirements regarding training and reporting of potential violations.

3.1.1.18. System Edit Error Corrections

The entry and transmittal of patient and coding data through different Government computer systems will sometimes be flagged for errors (known as “write‐back errors”). Write‐back errors are corrected by the MTF staff or coders and tracked through corrective action. Write‐back errors generated by a patient administration error (for example, incorrect or missing demographic information) is corrected by the

MTF Patient Administration section. The Medical Coder III may be used to correct all write‐back errors caused by coding errors.

3.1.1.19. Provides assistance as necessary to the MTF Data Quality and Group Practice Managers in compiling, analyzing, and reporting MTF coding data for performance purposes as directed.

3.1.1.20. Maintains a delinquency report of missing records in order to facilitate completion of work within the required Air Force thresholds.

3.1.1.21. Provides medical record support when required to locate, sort, copy, scan, collate, and perform other medical record functions necessary to gather documentation for the Air Force Data

Quality (AF DQ) or Defense Health Agency (DHA) coding audits.

3.1.2. Qualification/Experience Medical Coder III.

3.1.2.1. Five (5) years of medical coding experience utilizing knowledge of the International

Classification of Diseases, Clinical Modification (ICD‐CM), and Procedural Coding System (PCS);

Healthcare Common Procedure Coding System (HCPCS); Current Procedural Terminology (CPT);

Prospective Payment System (PPS) and Diagnostic Related Groupings (DRGs); Ambulatory Payment

Classifications (APCs); Resource‐Based Relative Value Scale (RBRVS); industry nomenclature; medical and procedural terminology; anatomy and physiology; pharmacology; disease processes; medical specialties; medical diagnostic and therapeutic procedures; and ancillary services (includes, but is not limited to, Laboratory, Occupational Therapy, Physical Therapy, and Radiology) in two (2) or more medical, surgical and ancillary specialties within the past 10 years. One (1) year of performance in the specialty is required to be qualifying. Multiple specialties encompass different medical specialties (i.e.

Family Practice, Pediatrics, Gastroenterology, OB/GYN, etc.) that utilize ICD, E&M, CPT, and HCPCS codes.

The five (5) years of required coding experience also requires candidates to have utilized medical computer software programs, such as electronic health records, to abstract, analyze, and/or evaluate clinical documentation and enter/edit diagnosis and procedure codes; adapt to changes in processes, procedures, and systems using analytical or problem solving skills; read, review or listen to questions regarding coding and clinical documentation issues or problems; make decisions and judgments regarding coding data, documentation, application of guidelines, rules, or standards; and respond clearly, effectively, and tactfully to questions regarding coding and clinical documentation issues or problems.

The five (5) years of required coding experience may not include work experience limited to making codes conform to specific payer requirements for the business office (insurance billing, accounts receivable), or limited to ancillary specialties that usually do NOT use Evaluation and Management

(E&M) codes.

3.1.3. Education

A minimum of one of the following is required:

An associate’s degree in Health Information Management; or

A university certificate in medical coding; or

At least 30 semester hours’ university/college credit that includes relevant coursework such as anatomy/physiology, medical terminology, health information management, and/or pharmacology.

Successful completion of an AAPC or AHIMA coding certification preparation course for professional services or facility coding that includes medical terminology, anatomy and physiology, health information management concepts, and pharmacology.

Education in section must be from an accredited educational institution recognized by the American

Health Information Management Association (AHIMA) and/or American Academy of Professional Coders

(AAPC).

3.1.4. Coding Certifications. Medical Coder III coders are required to possess one of the following professional services coding certifications AND one of the following institutional (facility) certifications:

Professional Services Coding: Registered Health Information Technician (RHIT); Certified

Professional Medical Auditor (CPMA); Certified Professional Coder (CPC); Certified Outpatient

Coder (COC), Certified Coding Specialist – Physician (CCS‐P).

Institutional (Facility) Coding: Registered Health Information Administrator (RHIA); Certified

Inpatient Coder (CIC), Certified Coding Specialist (CCS).

3.2. Medical Coder II

3.2.1. Duties for Medical Coder II

3.2.1.1. Verifies or assigns codes for the diagnosis, evaluation and management, admissions, completeness and accuracy of professional and institutional (facility) components of External Resource

Sharing Agreement (ERSA), Ambulatory Procedure Visit (APV), Observation, Emergency Department

(ED), and Outpatient encounters in the medical record.

3.2.1.2 Verifies the component parts of medical record to ensure completeness and accuracy of diagnosis, operations, and special diagnostic or therapeutic procedures that must conform to industry standards, including the Centers for Medicare and Medicaid Services (CMS guidelines, and MHS Coding

3.2.1.3. Codes the principal diagnosis, co‐morbidities, complications, therapeutic and diagnostic guidelines and conventions; medical terminology; anatomy and physiology; disease processes;

treatment modalities; diagnostic tests; pharmacology; therapeutic procedures; the International

Classification of Diseases, 10th Edition, Clinical Modification and Procedure Coding System (ICD‐10‐

CM/PCS); Current Procedural Terminology (CPT); Healthcare Common Procedure Coding System

(HCPCS); and any other coding classification systems required by the DoD.

3.2.1.4. Inputs codes into applicable MHS coding systems, including, but not limited to: CCE, CHCS

3.2.1.5. Reviews medical documentation and assign codes for inpatient institutional (facility) and professional services admissions and encounters to identify inconsistencies or discrepancies that may cause inaccurate coding, medico‐legal re‐percussions or impacts quality patient care. Identifies any problems with legibility, abbreviations, etc., and brings to the provider’s attention. Examines records for proper sequence of documents, presence of authorized signatures, and sufficient data is documented that supports diagnosis, treatment administered, and results obtained. This work includes attending provider, consultant, surgical, and ancillary services. Medical Coder II coders support the Third Party

3.2.1.6. In contingency situations, Medical Coder II coders may be directed by the AFMS MCPO to

3.2.1.7. Adheres to accepted coding practices, guidelines and conventions when choosing the most

3.2.1.8. Develops and submits a written (electronic or hard copy) query IAW AFMS guidelines to the provider to request clarification of provider documentation that is conflicting, ambiguous, or incomplete

3.2.1.9. Works with providers to resolve documentation issues to support coding compliance.

3.2.1.10. Assigns applicable codes to encounters based upon provider responses to queries and

3.2.1.11. Acts as a source of reference to medical staff having questions, issues, or concerns related documentation reference(s) to provide clarity and understanding. Based on contacts from the medical staff identifies training opportunities and works with coding training personnel to focus on consistency

3.2.1.12. Assists Medical Coding Trainers with providing initial coding training to providers by

3.2.1.13. Supports AFMS coding compliance by researching and interpreting existing guidance, and

3.2.1.14. Performs focused audits of specific MTFs, medical specialties, clinics, coders, or providers

3.2.1.15. Performs administrative related tasks associated with medical records final reviews/audits

3.2.1.16. Maintains confidentiality and privacy of medical, personal, and sensitive information in

3.2.1.17. Complies with AFMS coding compliance requirements regarding training and reporting of

3.2.1.18. System Edit Error Corrections

The entry and transmittal of patient and coding data through different Government computer systems will sometimes be flagged for errors (known as “write‐back errors”). Write‐back errors are corrected by the MTF staff or coders and tracked through corrective action. Write‐back errors generated by a patient administration error (for example, incorrect or missing demographic information) is corrected by the

MTF Patient Administration section. The medical coder may be used to correct all write‐back errors caused by coding errors.

3.2.1.19. Provides assistance as necessary to the MTF Data Quality and Group Practice Managers in

3.2.1.20. Maintains a delinquency report of missing records in order to facilitate completion of work within the required Air Force thresholds.

3.2.1.21. Provides medical record support when required to locate, sort, copy, scan, collate, and

Quality (AF DQ) or Defense Health Agency (DHA) coding audits.

3.2.2. Qualification/Experience Medical Coder II

3.2.2.1 Five (5) years of medical coding experience utilizing knowledge of the International

Classification of Diseases, Clinical Modification (ICD‐CM); Healthcare Common Procedure Coding System

(HCPCS); Current Procedural Terminology (CPT); Prospective Payment System (PPS); Ambulatory

Payment Classifications (APCs); Resource‐Based Relative Value Scale (RBRVS); industry nomenclature;

medical and procedural terminology; anatomy and physiology; pharmacology; disease processes;

medical specialties; medical diagnostic and therapeutic procedures; and ancillary services (includes, but is not limited to, Laboratory, Occupational Therapy, Physical Therapy, and Radiology) in two (2) or more medical or surgical specialties within the past 10 years; OR 3 years’ APV coding experience within the last 6 years in a military coding environment. A minimum of one (1) year of performance in the specialty is required to be qualifying. Multiple specialties encompass different medical specialties (i.e. Family

Practice, Pediatrics, Gastroenterology, OB/GYN, etc.) that utilize ICD, E&M, CPT, and HCPCS codes.

The five (5) years of required coding experience also requires candidates to have utilized medical computer software programs, such as electronic health records, to abstract, analyze, and/or evaluate clinical documentation and enter/edit diagnosis and procedure codes; adapt to changes in processes, procedures, and systems using analytical or problem solving skills; read, review or listen to questions regarding coding and clinical documentation issues or problems; make decisions and judgments regarding coding data, documentation, application of guidelines, rules, or standards; and respond clearly, effectively, and tactfully to questions regarding coding and clinical documentation issues or problems.

The five (5) years of required coding experience may not include work experience limited to making codes conform to specific payer requirements for the business office (insurance billing, accounts receivable), or limited to ancillary specialties that usually do NOT use Evaluation and Management

(E&M) codes.

3.2.3. Education

A minimum of one of the following is required:

An associate’s degree in Health Information Management; or

A university certificate in medical coding; or

At least 30 semester hours’ university/college credit that includes relevant coursework such as anatomy/physiology, medical terminology, health information management, and/or pharmacology.

Successful completion of an AAPC or AHIMA coding certification preparation course for professional services or facility coding that includes medical terminology, anatomy and physiology, health information management concepts, and pharmacology.

Education in section must be from an accredited educational institution recognized by the American

Health Information Management Association (AHIMA) and/or American Academy of Professional Coders

(AAPC).

3.2.4. Coding Certifications. Medical Coder II coders are required to possess one of the following professional services coding certifications:

Professional Services Coding: Registered Health Information Technician (RHIT); Registered

Health Information Administrator (RHIA); Certified Professional Medical Auditor (CPMA);

Certified Professional Coder (CPC); Certified Outpatient Coder (COC), Certified Coding Specialist

– Physician (CCS‐P).

3.3. Medical Coder I

3.3.1 Duties for Medical Coder I

3.3.1.1 Verifies or assigns codes for the diagnosis, evaluation and management, admissions, completeness and accuracy of professional and institutional (facility) components of Outpatient encounters in the medical record.

3.3.1.2. Verifies the component parts of medical record to ensure completeness and accuracy of diagnosis, operations, and special diagnostic or therapeutic procedures that must conform to industry standards, including the Centers for Medicare and Medicaid Services (CMS) guidelines, and MHS Coding

3.3.1.3. Codes the principal diagnosis, co‐morbidities, complications, therapeutic and diagnostic guidelines and conventions; medical terminology; anatomy and physiology; disease processes;

treatment modalities; diagnostic tests; pharmacology; therapeutic procedures; the International

Classification of Diseases, 10th Edition, Clinical Modification (ICD‐10‐CM); Current Procedural

Terminology (CPT); Healthcare Common Procedure Coding System (HCPCS); and any other coding classification systems required by the DoD.

3.3.1.4. Inputs codes into applicable MHS coding systems, including, but not limited to: CCE, CHCS

3.3.1.5. Reviews medical documentation and assign codes for inpatient institutional (facility) and professional services admissions and encounters to identify inconsistencies or discrepancies that may cause inaccurate coding, medico‐legal re‐percussions or impacts quality patient care. Identifies any problems with legibility, abbreviations, etc., and brings to the provider’s attention. Examines records for proper sequence of documents, presence of authorized signatures, and sufficient data is documented that supports diagnosis, treatment administered, and results obtained. This work includes attending provider, consultant, surgical, and ancillary services. Medical Coder I coders support the Third Party

3.3.1.6. In contingency situations, Medical Coder I coders may be directed by the AFMS MCPO to

3.3.1.7. Adheres to accepted coding practices, guidelines and conventions when choosing the most

3.3.1.8. Develops and submits a written (electronic or hard copy) query IAW AFMS guidelines to the provider to request clarification of provider documentation that is conflicting, ambiguous, or incomplete

3.3.1.9. Works with providers to resolve documentation issues to support coding compliance.

3.3.1.10. Assigns applicable codes to encounters based upon provider responses to queries and

3.3.1.11. Acts as a source of reference to medical staff having questions, issues, or concerns related documentation reference(s) to provide clarity and understanding. Based on contacts from the medical staff identifies training opportunities and works with coding training personnel to focus on consistency

3.3.1.12. Assists Medical Coding Trainers with providing initial coding training to providers by

3.3.1.13. Supports AFMS coding compliance by researching and interpreting existing guidance, and

3.3.1.14. Performs focused audits of specific MTFs, medical specialties, clinics, coders, or providers

3.3.1.15. Performs administrative related tasks associated with medical records final reviews/audits

3.3.1.16. Maintains confidentiality and privacy of medical, personal, and sensitive information in

3.3.1.17. Complies with AFMS coding compliance requirements regarding training and reporting of

3.3.1.18. System Edit Error Corrections. The entry and transmittal of patient and coding data through different Government computer systems will sometimes be flagged for errors (known as “write‐ back errors”). Write‐back errors are corrected by the MTF staff or coders and tracked through corrective action. Write‐back errors generated by a patient administration error (for example, incorrect or missing demographic information) is corrected by the MTF Patient Administration section. The medical coder may be used to correct all write‐back errors caused by coding errors.

3.3.1.19. Provides assistance as necessary to the MTF Data Quality and Group Practice Managers in

3.3.1.20. Maintains a delinquency report of missing records in order to facilitate completion of work within the required Air Force thresholds.

3.3.1.21. Provides medical record support when required to locate, sort, copy, scan, collate, and

Quality (AF DQ) or Defense Health Agency (DHA) coding audits.

3.3.2. Qualification/Experience Medical Coder I

3.3.2.1. Four (4) years of medical coding experience utilizing knowledge of the International

Classification of Diseases, Clinical Modification (ICD‐CM); Healthcare Common Procedure Coding System

(HCPCS); Current Procedural Terminology (CPT); Prospective Payment System (PPS); Ambulatory

Payment Classifications (APCs); Resource‐Based Relative Value Scale (RBRVS); industry nomenclature;

medical and procedural terminology; anatomy and physiology; pharmacology; disease processes;

medical specialties; medical diagnostic and therapeutic procedures; and ancillary services (includes, but is not limited to, Laboratory, Occupational Therapy, Physical Therapy, and Radiology) in two (2) or more medical or surgical specialties within the past eight (8) years; OR three (3) years’ outpatient coding experience within the last 6 years in a military coding environment. A minimum of one (1) year of performance in the specialty is required to be qualifying. Multiple specialties encompass different medical specialties (i.e. Family Practice, Pediatrics, Gastroenterology, OB/GYN, etc.) that utilize ICD, E&M, CPT, and HCPCS codes.

The five (5) years of required coding experience also requires candidates to have utilized medical computer software programs, such as electronic health records, to abstract, analyze, and/or evaluate clinical documentation and enter/edit diagnosis and procedure codes; adapt to changes in processes, procedures, and systems using analytical or problem solving skills; read, review or listen to questions regarding coding and clinical documentation issues or problems; make decisions and judgments regarding coding data, documentation, application of guidelines, rules, or standards; and respond clearly, effectively, and tactfully to questions regarding coding and clinical documentation issues or problems.

The five (5) years of required coding experience may not include work experience limited to making codes conform to specific payer requirements for the business office (insurance billing, accounts receivable), or limited to ancillary specialties that usually do NOT use Evaluation and Management

(E&M) codes.

3.3.3. Education

A minimum of one of the following is required:

An associate’s degree in Health Information Management; or

A university certificate in medical coding; or

At least 30 semester hours’ university/college credit that includes relevant coursework such as anatomy/physiology, medical terminology, health information management, and/or pharmacology.

Successful completion of an AAPC or AHIMA coding certification preparation course for professional services or facility coding that includes medical terminology, anatomy and physiology, health information management concepts, and pharmacology.

Education in section must be from an accredited educational institution recognized by the American

Health Information Management Association (AHIMA) and/or American Academy of Professional Coders

(AAPC).

3.3.4. Coding Certifications. Medical Coder I coders are required to possess one of the following professional services coding certifications:

Professional Services Coding: Registered Health Information Technician (RHIT); Registered

Health Information Administrator (RHIA); Certified Professional Medical Auditor (CPMA);

Certified Professional Coder (CPC); Certified Outpatient Coder (COC), Certified Coding Specialist

– Physician (CCS‐P)

3.4. Lead Coder

3.4.1 Duties for Lead Coder

3.4.1.1. Acts as liaison between contractor management staff and the Government.

3.4.1.2. Coordinates efforts and work of other coders in this contract to ensure that work described in the scope of this PWS is met at all locations in an effective and timely manner.

3.4.1.3. Performs the same duties as Medical Coder III; lead coders will be one of the required

Medical Coder IIIs required by the contract, not an additional requirement.

3.4.2. Qualification/Experience Lead Coder

3.4.2.1 Same as for Medical Coder III, but with two years of supervisory experience preferred.

3.4.3. Education of Lead Coder:

3.4.3.1. Same as for Medical Coder III.

4. General Contractor Requirements This section describes the special requirements for this effort. The following sub‐sections provide details of various considerations on this effort:

4.1. Requirement of All Coders

4.1.1. Any worksheets with personally identifiable information shall be disposed of according to MTF guidelines. The Contractor shall comply with the Privacy Act, the Health Insurance Portability

Accountability Act, 38 USC 5701 and 38 USC 7332 IAW FAR Clauses 52.244‐1 Privacy Act Notification and

52.2242.

4.1.2. Reviews inpatient and outpatient encounters IAW all AFMS and DoD instructions and guidance;

such as AFI 41‐210; Military Health Systems (MHS) Coding Guidelines, or others as defined by the AFMS through the AFMS MCPO, and DoD.

4.1.3. Adheres to all policies outlined, as well as any changes provided by the AFMS through the AFMS

MCPO, or DoD that may occur during the term of this contract. Command and MTF staff will provide changes to policy to all contracting personnel upon implementation.

4.1.4. Audits for MTF specific needs IAW the current version of the AFMS Medical Coding Manual when directed; such as new provider audits, clinical areas of concern regarding coding and problematic coding noted by particular clinical staff.

4.1.5. Validates the diagnosis, evaluation and management, procedure, and all other codes required to process the encounter as complete and support the billing office.

4.1.6. Performs independent audits determining the need for training of its employees, IAW the provisions of the current version of the AFMS Medical Coding Manual. The Contractor will develop a formal training plan to address 1) new employee orientation, 2) recurring employee training as a result of coding audit findings, and 3) annual contractor staff training on coding changes. A formal training plan will be submitted to the government within 30 calendar days of hire. Formal training plans will be reviewed semi‐annually. All training must be documented and maintained in a file plan.

4.1.7. Ensures all professional staff members are aware of their personal coding errors so corrections can be made; and shall be completed at the time the errors are noted.

4.1.8. Collaborates with AFMS Medical Coding Trainers to ensure all professional staff members receive standardized guidance regarding coding on monthly basis and that professional staff receive a new provider orientation.

4.1.9. Collaborates with AFMS Medical Coding Compliance Specialists in regards to performance and reporting of focused coding audits or reviews of professional or clinical staff.

4.1.10. Collaborates with AFMS Medical Coding Trainers to ensure that professional staff receive a new provider orientation.

4.1.11. Attends quality meetings/ brief staff, provide metric data of coding activities, and provide other coding‐specific support within the MTF.

4.1.12. Attends training, briefings, clinical Staff Assistance Visits, and other meetings that may require coding expertise as determined by the MTF Coding Manager.

4.1.13. Assists within an area outside of the clinical setting with prior coordination and approval with the COR; such as the billing department, command section, or other sections requiring the assistance and expertise of a coding specialist.

4.1.14. AFMOA DQ Audits

4.1.14.1. AFMOA Audit Documentation Retrieval

Retrieves, copies, and forwards encounter documentation monthly for the AFMOA audit as necessary.

Detailed pull lists will be available for download no later than 15th of the month. Transmission of requested records will be completed within 10 calendar days after receipt of the pull list.

4.1.14.2. Retrieves documentation for the dates of service to be reviewed from AHLTA and Essentris

(Inpatient, APV, Obstetrics, and Emergency Room). Copies documentation (non‐AHLTA encounters

(Emergency Room, Obstetrics, etc.), APV, and inpatient records) shall be forwarded (thru secure electronic media transmission or registered/certified mail (if records are sent by mail)) to AFMOA or designated office for independent review, auditing activities. Records are to be treated as protected health information, e.g. appropriate containers for mailing and return receipt for mailed documents.

4.1.14.3. Submits Inpatient/APV records to include all documentation relative to the…