Section J Attachment 5 - Sample TOPR for Service Type II.doc

DEPARTMENT OF THE AIR FORCE

HQ AIR FORCE DISTRICT OF WASHINGTON

SAMPLE TOPR FOR SOW DEVELOPMENT ONLY 15 Dec 10

MEMORANDUM FOR MSS CONTRACTORS

FROM: Enterprise Strategic Sourcing Group

Wright-Patterson AFB, OH 45433-7401

SUBJECT: SAMPLE Task Order Proposal Request, Centralized, Medical Coding & Auditing Services, Service Type II

1. The Government hereby requests an official task order proposal for a Service Type II requirement at multiple Air Force Medical Treatment Facilities (MTFs) for Medical Coding & Auditing Services on the Air Force Medical Commodity Council (AFMSCC) Medical Support Services (MSS) contract. The government requires the period of performance for this requirement (estimated) to be 1 Oct 2011 – 30 September 2012 with four (4) one-year option periods. If the Government awards the task order (s) to your company, the Government will assign a unique task order number. Additionally, we will also provide specific details about invoicing through Wide Area Workflow (WAWF) to the appropriate payment office.

2. The Statement of Objectives (SOO) for Medical Coding & Auditing Services as well as an addendum are attached to this Task Order Proposal Request (Attachments 1 and 2). An earlier performance start date is not authorized. All contract terms and conditions apply along with requirements in attachments and addendums.

a. The SOO outlines the overall objectives, the unique military parameters for the business as well as the applicable guidelines for AFMS operations.

b. The SOO Addendum provides background information, workload, locations, invoicing methodology, and transition period requirements.

c. The AFMS Centralized MTF Coding Manual (Attachment 3) standardizes policy, personnel qualifications, business rules and operational framework and service requirements.

3. The following pertinent information should be considered:

· Hours of Operation/Federal Holidays. The contractor shall provide services at each of the MTFs Monday through Friday from 0900-1500, excluding Federal holidays.

· This has been an existing requirement for the last 5+ years; therefore, incumbents may be available. The requesting office will provide the MTF point of contact information upon release of this proposal request and formal receipt of acknowledgement from each company.

4. The contractor’s task order proposal must include technical and price sections. The evaluation will utilize the Past Performance Price Tradeoff criteria per Section H.3 of the main contract. The Government reserves the right to award all some or none of these requirements. The Government also reserves the right to award 1-4 task orders to meet this requirement according to the groupings by Major Command designation for having AFMS requirement:

Proposed Grouping – by MAJCOM

ACC (

AETC

AFDW & AFMC & USAFA & GSC

AFSPC & AMC & PACAF

a. Pricing will be a single, unit rate for completed, coded encounter regardless of encounter type or location. Since Medical Coding and Auditing Services was pre-established as a Service Type II in the main MSS contract, not-to-exceed unit rate and escalation rate may apply in accordance with Section H.3 of the main contract.

b. The technical proposal shall include only the Statement of Work (SOW). Do not merely restate specifics provided in the SOO and the addendum. It is imperative that your staffing model, business approach and daily operational plans clearly demonstrate your method to hire qualified personnel, prepare for service responsibility, participate in the transition of services and then maintain acceptable performance thresholds throughout the life of this task order. At a minimum, the SOW must include the following sections. The offeror may add sections if needed to demonstrate their proposed plan. The SOW is limited to 20 pages. Personnel resumes are not authorized.

Section 1: Scope

Description of Services (includes workload, locations, timeliness and completion standards)

Section 2: Organizational Structure (all team members including subcontractors; how you will integrate with the MTF, Air Staff Program Management Office)

Section 3: Business Approach (plan, strategy and staffing model as well as transition plans) Section 4: General Information

Personnel (labor categories, qualifications, numbers at locations, staffing flexibility, availability, contractor management)

Work schedules Section 5: Contingency Plan

Contractor must provide provisions for maintaining productivity at all locations or complete backlog workload as a result of systems failures (i.e. AHLTA/CHCS downtime) or other unforeseen contingencies (staff loss, replacement personnel delays, etc.). Contractor must provide details on how they will handle a significant increase or decrease in workload.

Section 6: Contractor Responsibilities (program management, human resource management, and quality control plan)

Section 7: Service Summary

Performance Measures (thresholds, goals and standards)

Quality Assurance (internal controls for self inspection—how, when and why?)

Section 8: Contractor Deliverables and Furnished Materials

Best Practices

Monthly Reporting Requirements/Invoice Back Up (example of report)

Software Used for Reporting

c. The contractor is not required to provide a past performance section. The Government will obtain the offerors’ performance record for all service summary items for this contract from the AFMSCC monthly performance report (dashboard) for the past performance evaluation factor in the task order evaluation process.

5. The government reserves the right to award without discussions. If the government decides to award with discussions, the Government will notify you as soon as possible.

6. Proposals are due in electronic format by 1300hrs (EST) on 5 January 2011. If you have any questions, please contact Missy Government, Contract Specialist, AFMC/PKY at 937-555-1212 or missy.government@af.mil.

//signed//

Contracting Officer 5 Attachments

1. Statement of Objectives

2. SOO Addendum

3. AFMS Centralized Coding Operations Manual

4. Workload by Location

5. AFMOA Audit Results Report, Oct 08 – Feb 09 cc: AFMSA/SG5M

AFMOA/SGHC

MEDICAL CODING AND AUDITING SERVICES

STATEMENT OF OBJECTIVES

1. PROGRAM GOAL: To supply all necessary equipment and labor required to perform outpatient and inpatient medical coding and auditing services for military medical treatment facilities and conduct training for clinical staff on coding guidelines, procedures and coding accuracy to improve medical coding knowledge and capabilities of members on proper coding.

2. CONTRACT OBJECTIVES: Utilize the best commercial practices in conjunction with military directives and parameters to conduct efficient coding and auditing services for the Air Force Medical Service.

3. BACKGROUND:

a. These services are currently accomplished by military, DoD civilians or contractors within MTFs.

b. The volume and demand for services varies by facility. The contractor is required to submit a price per coded medical encounter. The number of outpatient records to be coded per year will be specified on each task order proposal request.

5. MILITARY PARAMETERS: AFMS policies, business rules, productivity thresholds, timeliness and accuracy standards, and reporting requirements as well as minimum personnel qualifications for coding operations are outlined in the AFMS Centralized MTF Coding Manual.

5. OBJECTIVES:

a. Using a fully qualified professional coding personnel staffing model, complete required workload, conduct mandatory training for MTF personnel to improve knowledge, skill and capabilities of clinical staff, and manage overall coding services.

b. Based on available medical documentation, code or review and correct daily medical encounters using current guidelines.

c. Meet or exceed timeliness and accurate standards.

d. Maintain productivity to support and comply with AFMS metrics for coding services.

e. Provide a price per coded medical encounter

f. Establish internal controls to ensure quality coding, auditing, documentation assessments, and reporting of data quality statistics.

Addendum to Standard Statement of Objectives (SOO)

1. BACKGROUND: These services are in support of 58 AFMS locations. For more than 5 years, services have been contracted.

2. WORKLOAD. Per the MASS contract and the standard Statement of Objective (SOO), the volume and demand for services varies by facility and depends greatly upon each MTF’s capabilities, staffing and beneficiary population. However, actual workload has been diligently tracked and projections for each facility have been calculated for the offerors. Historical workload (coded records) is available in the Workload & Pricing file (Attachment 5) of the Task Order Proposal Request memorandum.

Some MTFs are expected to be merged in the BRAC process with Army facilities in multi-market locations such as San Antonio, National Capital Region, McCord and Pope AFB. Therefore, that workload is subject to change significantly in the future, but at this time it is impossible to affirm a projected date and impact on workload estimate. Changes to services, operational locations or workload should be anticipated. The awarded contractor will be notified 60 days prior to required implementation date for changes to be effective.

3. Service Clarification

· The AFMS Centralized Coding Operations Manual, June 2009 (Attachment 4 of the memorandum) outlines the roles and responsibilities, service requirements, business rules and operating procedures. Additionally, it provides policy, guidance, performance measures and metrics for compliance with Air Force standards. MSS contractors shall use this guide and its directives (thresholds, acceptable quality levels or standard operating procedures) as they develop their Statement of Work (SOW) and complete proposal for this requirement.

· The Contractor will be responsible for the full operations and management of the coding operations (as outlined for each MTF) thereby allowing the Government to only provide the oversight required to ensure the contractor is performing satisfactorily as outlined in the SOO, SOW and IAW with MSS contract. The Government will not be supplementing staff for contractor-designated workload. The Government will not dictate the number of personnel; however, services are expected to be available and manned appropriately at least Monday-Friday, 0900-1500 daily and the workload is to be completed within the Air Force standard timelines. This may include down days and/or non-federal holidays.

· Invoicing - Coded records in complete status in AHLTA/CHCS and CCE are considered complete records and therefore, billable to the Government. For example, incomplete records, errors, or non-transmitted encounters, training sessions or notifications to providers do not count as a coded record. Records audited as part of the AFMOA Audit will also be a separate billable record to the Government. All direct and indirect costs should be built into the associated Unit Rates. The contractor shall be paid per the estimated records. Since monthly workload varies at times significantly due to seasonal flu and cold patterns, surges in returning military, deployments, etc., invoiced dollars will be of equal amounts. It will be calculated by the offeror’s unit rate times the projected units to be purchased divided by 12 to determine the standard monthly invoice amount (per contract H.3). The contractor shall reconcile the workload quarterly to ensure the billed units match actual units; thus allow for any necessary adjustments to the invoice 4 times per year.

· One invoice for all participating MTFs is required. However, the contractor-developed external documentation is required to accompany the invoice with a breakdown by MTF, type of coded record (billables, ER, APV, IBWA, etc.) with overall total coded record numbers, unit rate and total billed dollar value.

· Because of the number of MTFs on this task order, the backup documentation for the invoice will be required to be sent to the QAP or Government designee 10 days prior to submission of the invoice. This will ensure adequate time for validation and any company revisions to be completed; thereby ensuring timely invoice payment.

4. TRANSITION PERIOD

The contractor must be ready to assume medical coding operations on 1 October 2012 in order to avoid a break in service. The Contractor is responsible for ensuring staff complete all requirements for obtaining access to the various MTFs including by not limited to Network, CHCS & AHLTA Accounts) as defined in the MASS contract (14 days prior to start of performance). Security provisions (CAC cards) and network accounts must be active for all staff prior to 1 October. Security appointments/packages will be provided IAW the MSS contract, Section C, Paragraph 2.4.10.

5. GOVERNMENT QAPs. Each MTF will identify a primary and alternate Government QAP who shall be the primary means of communication and coordination between the Contractor’s on-site staff and the MTF as well as the contractor management staff and AFMOA Coding Program Office.

AFMS Centralized MTF Coding Manual

Version 1.1

INDEX

CHAPTER

PAGE

1. Introduction

2. Centralized Policy

3. Benefits of Centralizing

4. Definitions

5. Standard Personnel Qualifications

6. Roles and Responsibilities Standardized Business Rules

7. Standard Business Rules

8. Coding Operational Framework

9. Key Requirements

10. References

1. Introduction

Medical coding practices and procedures impact nearly every operation in a medical treatment facility. From operational activities to optimize military medicine to the military accounting system, medical coding must accurately account for the services rendered to beneficiaries in order to manage patient care, record workload, define and track population health to forecast demand, and to measure the cost of care.

The AFMOA is responsible for ensuring complete, timely, and accurate coding of medical encounters at all medical treatment facilities. Utilizing specialized Government computer systems, coding operations are completed by either a provider or a professional coder and then validated by a certified professional coder. Other certified professional coders independently audit a significant sample to ensure integrity in the review processes.

This manual is written in order to create a reference to foster an environment where medical coding personnel--contractor, civilian and military, commit to a common vision and values that empower decentralized teams to efficiently achieve complete and accurate medical coding activities in accordance with directives, regulations, and guidance. Establishment of the common vision and values for the AFMS provides the framework for expected stakeholder behavior and program outcomes while creating win-win solutions with our contracted partners. Great benefits are expected from collaborative approaches to the workload, productivity, as well as the obstacles encountered regularly at the medical treatment facilities.

VISION – AFMS encounters are coded within DoD time standards and are 100% accurate according to published coding guidelines

To state it simply, the medical coding operations are six building blocks. The directives and guidelines for the activity guide each codable encounter. Those guidelines are strengthened by training and continued force development that the AFMS requires. Policy and resources will support those expectations and be executed through centralized operations and lastly, validated by auditing process.

Figure 1 – Coding Operations

2. Centralized Policy

In the past, the AFMS has decentrally-funded all MTFs for coding services. Decentralized coding and auditing contracts have yielded differing services, contract terms and conditions, as well as outcomes. A central contracting source for both MTF medical coding operations as well as an AFMOA Auditing Cell has been determined the best way to proceed. MTFs in the 50 United States and its territories are required to use the AFMS Commodity Council, Medical Administrative Support Services contract (Spiral 2) to procure services with the exception of 6 MTFs that were previously designated 8(a) company contracts (Cannon, FE Warren, Hurlburt Field, Patrick, Robins and Tinker). The standard Statement of Objective along with the requirements in this manual for personnel qualifications, workload, contractor deliverables, and monitoring and surveillance will help the program office enforce their centralized policies, guidelines and expectations. This will standardize operations by reducing the coding variations in the AFMS.

Effective 1 October 2009, AFMOA will take control and oversight of existing coding contracts. For Phase I, 36 sites will be consolidated under the base year of the task order. They include: ACC (15), AETC (12), Bolling, Dover, Grand Forks, Little Rock, McChord, McConnell, Travis, USAFA, and Wright-Patterson. Phase II will consolidate another 22 sites effective 1 October 2010 if the base year is deemed successful. Phase III will create a similar contract vehicle for OCONUS locations effective 1 October 2010.

The major focus of the work will be directed toward provider training requirements versus an increasing number of encounter reviews. Therefore, a statistically significant sample will be used to identify deficiencies in the provider understanding, coding knowledge, as well as template set up, training resources and tools to assist providers to accurately code.

Funding for Phase I will still be in the individual MTF baselines. Therefore, each MTF phased over to the centralized task order will still be required to pay for the services that they receive according to “fair share” methodology and the units times the contracted unit rate. New money has not been received for this requirement. In the subsequent years, the dollars are expected to be pulled to the FOA level away from the MTFs.

Malmstrom

Grand Forks

Holloman

Table 1 – Centralization Schedule – MTF by Phase

3. Benefits of Centralizing

Although each facility may have a unique mission and population, the AFMS expects medical coding personnel follow the AFMS and DoD guidelines and the new program business rules outlined in this manual. Adopting standardized business rules, procedures, monitoring and surveillance, as well as contractor expectations, will ensure procured services and medical coding strategies which will allow each MTF to operate effectively and efficiently while providing validity to centralized audit programs.

4. Definitions

1. Coding is defined as reviewing medical documentation and assigning accurate codes (i.e., E&M, ICD, CPT, HCPCS, etc.). The coded information is reported through multiple Government reporting systems.

2. Auditing is defined as reviewing medical documentation and validating the codes entered into the systems are accurate.

3. AFMOA Audit is defined as reviewing medical documentation and validating codes (through an automated tool) to record MTF coding accuracy using the AFMOA audit tool or other independent audit method. Findings from the audit are used to measure coding accuracy on the data quality statements and the Surgeon General’s metrics.

4. A “complete, coded record” is defined as an encounter with supporting documentation, that was coded according to rules as defined by AFMS, DoD, and current coding classification systems. Other coding related fields are to be included (modifiers, units of service, etc.). These records will be annotated in the Government computer systems and flagged as “transmitted completed” or “complete.” Encounters on “hold” are not considered complete.

5. Absent sick records are defined as a record of inpatient treatment services are provided to Active Duty personnel in a civilian (or VA) hospital. These services are the result of an accident or emergent illness that precluded the AD member from obtaining services in a military medical treatment facility. All or portions of their hospital care may be provided in a civilian facility. Not all MTFs are currently capturing this workload.

6. Medical Administrative Support Services. A 5-year, $96.4M Multiple Award Task Order, Indefinite Delivery/ Indefinite Quantity, non-personal services contract for administrative support personnel managed by the AFMS Commodity Council.

7. AHLTA (Armed Forces Health Longitudinal Technology Application). An electronic medical record documentation system designed for the MHS.

8. SADR. A record of outpatient treatment data generated by the MTF during an encounter and includes demographics, diagnostic codes, primary care manger, treating provider, clinical service and other data field.

9. CAPER. (Comprehensive Ambulatory /Professional Encounter Record). An electronic data record used to report outpatient ambulatory and inpatient professional encounter biometric information.

10. CARS/CATS. (Coding Audit Review System/Coding Audit Tool System). The AFMOA audit tool provides the AFMS with a detailed, more efficient method for data collection in reporting coding accuracy.

11. Under-Coded Encounters. This error occurs when the provider/coder failed to assign codes for services provided and supported by documentation.

12. Over-Coded Encounters. This error occurs when provider/coder enter medical codes for services not provided or supported by documentation.

13. External Resource Sharing Agreement encounters (ERSA). Military health care personnel, active duty and civilian, may provide covered medical services to active duty and TRICARE beneficiaries in a network facility. Coding requirements would include capturing of the professional services provided by the Government employee. The workload shows the MTFs with valid ERSAs in place.

14. Billable encounter (a.k.a., OHI billable). Encounters for patients with Other Health Insurance that will be a claim in the Third Party Collections Program.

15. Remote Services. The Government defines “remote” as services for an MTF not being accomplished within that MTF.

5. Standard Personnel Qualifications

Outpatient Medical Coder:

· Recognized Certifications include:

· Registered Health Information Technician (RHIT)

· Registered Health Information Administrator (RHIA)

· Certified Professional Coder (CPC)

· Certified Coding Specialist (CCS)

· Certified Coding Specialist – Physician (CCS-P)

· Any of the above certifications are acceptable for outpatient medical coders as long as candidate has a minimum of three year experience in the outpatient setting (physician’s office or ambulatory surgery centers) within the last five years.

· Current certification must be granted by an accrediting institution recognized by the American Health Information Management Association (AHIMA) and/or American Academy of Professional Coders (AAPC).

· Experience in the business office (billing, accounts receivable) is not a qualifying factor.

Outpatient Coding Auditor, Leading Coding Supervisor or Trainer:

· Recognized Certifications include:

· Registered Health Information Technician (RHIT)

· Registered Health Information Administrator (RHIA)

· Certified Professional Coder (CPC)

· Certified Coding Specialist (CCS)

· Certified Coding Specialist – Physician (CCS-P)

· A minimum of 5 years medical coding/auditing experience within the last eight years is required.

· Current certification must be granted by an accrediting institution recognized by the American Health Information Management Association (AHIMA) and/or American Academy of Professional Coders (AAPC).

Inpatient Coder:

1. Registered Health Information Technician (RHIT)

2. Registered Health Information Administrator (RHIA)

3. Certified Coder Specialist (CCS)

4. Certified Professional Coder-Hospital (CPC-H) is acceptable for inpatient professional services and Ambulatory Procedure Visits coding.

5. Current certification must be granted by an accrediting institution recognized by the American Health Information Management Association (AHIMA) and/or American Academy of Professional Coders (AAPC).

6. A minimum of three years inpatient coding experience within the last five years is required.

Inpatient Coding Auditor:

7. Registered Health Information Technician (RHIT)

8. Registered Health Information Administrator (RHIA)

9. Certified Coder Specialist (CCS)

10. Certified Professional Coder-Hospital (CPC-H) are acceptable with 5 years inpatient medical coding auditing experience.

11. Current certification must be granted by an accrediting institution recognized by the American Health Information Management Association (AHIMA) and/or American Academy of Professional Coders (AAPC).

12. A minimum of five years inpatient coding experience within the last eight years is required.

MTF Quality Assurance Personnel (QAP) Designee:

13. Must be a Government employee

14. Prefer a certified coding professional

15. Experienced with coding operations at the MTF

16. Accountable, responsible, and has the authority over the coding services in the MTF

6. Roles and Responsibilities

1. Provider: Providers are responsible for accurately documenting the events that transpired during the patient’s encounter. Documentation may be either in a paper or electronic format.

2. Coder: Coders are responsible for ensuring appropriate numeric codes are applied to accurately describe the encounter for both diagnoses and procedures. This may be completed by either applying alphanumeric codes on a paper record or through validating provider selected codes in the electronic record. Provides feedback and training to providers to improve accuracy rates.

3. Auditor: The auditor is responsible for ensuring the selected codes are accurate in Government computer systems and fully represent the provider’s documentation. Individuals validate the coding done either by the coder or the provider (via AHLTA). Provides feedback and training to provider/coder to improve their coding abilities.

4. AFMOA Coding Program Office: Provides comprehensive contract management and oversight for the task order/contracts. Delegates responsibilities to MTF QAPs. Collects and records surveillance inputs and certifies the invoice for payment. Approves corrective action plans. Provides guidance and acts as final authority regarding official AFMS coding and auditing rules. Provides official and standardized training material and as approving authority for any and all training information provided by the coding trainers.

5. AFMS Commodity Council & AFDW Contracting Officer or Representative: Maintains the task order/contract file documentation, conducts QAP training, completed task order and contract modifications, exercises options and is solely the official communicating office with the contractor and the AFMOA program manager. Collects monthly surveillance inputs from QAP and completes Contractor Performance Assessment Reporting System (CPARS) annual reports.

6. Quality Assurance Personnel (QAP): Conducts contract monitoring and surveillance activities at the MTF. Assists AFMOA program manager with certifying receipt of acceptable services through the automated surveillance system. Reports problems, issues and concerns to AFMOA Program Office and Commodity Council POCs.

7. Contractor Management Staff: Assume responsibility for coding services at the MTFs and complete the required workload in timely and accurate manner. Responsible for the management and reporting of the entire “business operations” to the MTF and coordinates with the AFMOA program office.

7. Standard Business Rules

Business rules are the fundamental, underlying constraints, and policies of a business. They define the core of the enterprise. They need to be standardized in order to support complex operations across business units.

1. The Military Health System (MHS) requires MTF commanders to be responsible and accountable for ensuring providers document all patient treatment in the medical record and are held responsible for the accuracy and completion of that data and the coding they complete.

2. Coding, auditing, management, or training workload currently accomplished by Federal employees (GS), will remain their workload and will NOT be accomplished by contractor personnel. The following will not be included as contractor workload.

Table 2 – Federal Employee locations and responsibilities

3. The Annual UBO/UBU Conference is a 3-4 day conference and workshop. It is highly recommended that each MTF have representation at the conference (MTF or contractor lead, supervisor, program manager, trainer and/or site auditor would benefit from attendance).

4. Each MTF may utilize DoD civilian employees or contracted professional coders to enter coding information and/or to validate provider-coded encounters as long as there is a clear distinction between Government and contractor workload. At no time will Government personnel be integrated into the contractor’s area of responsibility by supplementing services procured on contract.

5. Coding reference books (i.e., ICD, CPT, HCPCS, Coding Clinic, CPT Assistant, Merck Manuals, etc.) required for completion of duties is the employer’s responsibility. Therefore, the Government is only required to provide reference books and materials for Government employees. The MTF is responsible for purchasing the needed reference books. The contractor will provide their own materials.

6. All professional coding personnel shall receive AHLTA training conducted by the Government. Having this knowledge will ensure that coding staff can assist providers with maintaining and updating templates or ICD/CPT favorite lists; thus, integrating them into the front end of the coding process. The QAP should facilitate interactions with the AHLTA trainer at the MTF to work jointly on development of training so that professional coding staff are aware of how the providers are being instructed to complete the electronic medical record. This will ensure consistent training that does not negatively impact coding activities.

7. Medical coding professionals shall not audit records they have personally coded. However, the contracted service shall be required to perform peer reviews for accuracy compliance for their internal, corporate processes. These controls are documented in the contractors’ Quality Control Plan and are not billable separately as a unit.

8. A bi-annual review of forms, superbills, pick lists, and templates should be completed to ensure validity and appropriateness, or as table updates occur or by guidance from AFMOA Coding Program Office.

9. Coding personnel in the MTF will meet the minimum qualifications as outlined in the Standard Personnel Qualifications. Contractor personnel brought into the MTF to conduct coding, review and training services must hold the proper certification at the time of placement. No waiver can be granted and no acceptance of a promise of future certification authorized.

10. The AFMS Coding Program Office (AFMOA/SGHC) is the final authority regarding coding guidance. All coders and auditors must abide by the coding rules established by the Coding Program Office.

11. The Air Force will follow the 1997 Documentation Guidelines for Evaluation and Management (E&M) Services. For questions on coding issues, an AF Coding Help Desk is available via e-mail or phone: phsohelpdesk@brooks.af.mil 1-800-298-0230. The AFMOA Coding Program Office also provides coding guidance via specialty handbooks, coding newsletters, and teleconferences. The AFMS will utilize the following:

· The MHS Coding Guidance: Professional Services and Specialty Coding Guidelines will be used at all times. This document provides MHS-specific guidance for coding ambulatory and professional service encounters.

· The MHS Guidelines for Inpatient Coding will be used at all times for inpatient records. This document provides MHS specific guidance for inpatient institutional records.

The MHS guidelines are derived from the following source documents, and take precedence over them:

International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) or current coding classification system;

Current Procedural Terminology (CPT), 4th Edition;

Centers for Medicare and Medicaid Services (CMS) Documentation Guidelines for Evaluation and Management (E&M) Services;

Healthcare Common Procedure Coding System (HCPCS);

The American Hospital Association (AHA) Coding Clinic;

The American Medical Association (AMA) CPT Assistant;

The Coding Clinic for HCPCS.

These documents are not intended to be an all-inclusive reference for MHS and AFMS coding guidance. In absence of specific AFMS and MHS coding guidance, refer to the appropriate industry standard coding conventions.

12. The following outpatient workload will be accomplished at every facility:

· 100% of OHI billable encounters will be coded or validated by a professional coder within 3 business days of encounter or receipt of the record on the CCE worklist. The coder will provide second-level review of encounters for billing to ensure compliance with legal and procedural policies and to ensure optimal reimbursement while adhering to regulations prohibiting unbundling and other questionable practices.

· 100% of Emergency Department documented encounters will either be coded or validated by a professional coder within 3 business days of encounter or receipt of the record on the CCE worklist.

· 100% of Ambulatory Procedure Visits will be coded or validated by a professional coder within 15 days of encounter or receipt of the record on the CCE worklist.

· An additional 10% of outpatient encounters not meeting the criterion above (OHI billables, Emergency Department, or Ambulatory Procedure Visits) will be required to identify errors that will guide immediate provider feedback and future training needs. The required percentages are based on total projected encounters by MTF. The records selected will include 5% of encounters for Flight Medicine and the remainder will be driven by CCE edits and historical accuracy rates for the MTF, Clinic and Provider (see below for specific criteria). The additional workload will be determined by this methodology unless AFMOA Coding Program Office directs a special focused audit. MTF QAPs will get a 30-day notice with specific instructions on how to determine the 10% additional encounter reviews if necessary.

a. No nurse or technician visits that are not properly co-signed (original and/or electronic) will be included in this workload.

b. In addition to business practice requirements, the information obtained from completing the above identified outpatient workload will be compiled and utilized to identify and execute training needed to improve coding accuracy and compliance.

c. Annual workload projections are available. However, total monthly encounters reviewed are expected to be fairly equivalent based upon available encounters, random sampling within the selection process described below. The below order of record selection should be followed until the proper number of encounters (10% of outpatient encounters that are not OHI billables, Emergency Department of APV) has been validated by a professional coder:

MTFs with CCE

i. The first criterion is to ensure the additional encounters include 5% of encounters from Flight Medicine. For example, if Flight Medicine sees 200 patients in the month under review, a minimum of 10 records will be included in the workload.

ii. The second criteria will be all encounters that did not pass the CCE edits.

iii. Any remaining capacity to reach additional encounters will include records for clinics who are below the 95% accuracy rate in the last three AFMOA Audit Reports: 1) Starting with clinics below the threshold in all of the three categories (E&M, CPT/HCPCS and ICD) for three consecutive months; 2) If the percentage of record allows, the second criteria will focus on clinics below the threshold in E&M and/or ICD, but meet threshold for CPT/HCPCS for three consecutive months, then 3) clinics below threshold for CPT/HCPCS. A random sample of all providers in the clinic as well as every clinic meeting the above criteria will be included in the review. Documentation on the identification process, the random sampling method, and results must be maintained for billing or monitoring records. This will be available for the QAP review.

ii. If workload is still needed, the next criteria for identifying the other encounters to be validated by a professional coder shall be the providers who had notifications from the coders regarding errors for that month (as outlined as notifying the provider – See paragraph 10 and 11 below).

iii. If records are still needed, return to the process in ii. above, but include clinics who are at the lowest percentile below the targeted 95% accuracy.

MTFs without CCE

i. The first criteria for review are 5% of encounters from Flight Medicine, if applicable.

ii. For facilities that do NOT have CCE, reviews will focus specifically on clinics below the 95% accuracy rate in the last three AFMOA Audit Reports: 1) Starting with clinics that were below threshold in all of the three categories (E&M, CPT/HCPCS and ICD) for three consecutive months. 2) If the percentage of record allows, the second criteria will focus on clinics that were below threshold in E&M and/or ICD, but meet threshold for CPT/HCPCS for three consecutive months, then 3) clinics below threshold for CPT/HCPCS. A random sample of all providers in the clinic as well as every clinic meeting the above criteria will be included in the review. Documentation on the identification process, the random sampling method and results must be maintained for billing or monitoring records.

ii. If workload is still needed, the next criteria for identifying the other encounters to be validated by a professional coder shall be the providers who had notifications from the coders regarding errors for that month (as outlined in Paragraph 10 & 11 below).

iii. If records are still needed, return to the process in ii. above, but include clinics who are at the lowest percentile below the targeted 95% accuracy.

OUTPATIENT WORKLOAD EXPECTATIONS

Figure 2 – Workload Expectation

13. Coding personnel will NOT change provider documentation in AHLTA to include information in the Assessment/Plan and Disposition sections. The coding professional is responsible for changes to the codes for the encounters they code or validate. Upon review, if changes are needed, the coding professional may edit the codes as required to make them accurate based on the available documentation for that encounter. Then, notification must be made to the provider to provide immediate feedback and training to the provider. This should be accomplished at least weekly and give enough detail so the provider can ascertain the encounter, the error and the reason for the coding advice and direction. If the provider reviews the previous encounter and just reopens it versus amending/appending, the corrections will remain in the computer system. These notifications should be maintained and be summarized as a monthly deliverable to the QAP so that details regarding the contractors’ training efforts are communicated up the AFMS chain of command, but also as back up documentation to the invoice.

14. Every effort should be made to have the provider make required documentation changes within AHLTA when required to correct coding. However, at times accurate medical documentation may be at odds with coding guidance. In these instances AHLTA or other medical documentation will not be changed simply to support billing or coding rules. However, coding personnel shall be permitted to make any necessary changes to codes within the coding systems (ADM and CCE). These changes will only occur after notification to the provider and the SGH has been made.

15. When a previously coded AHLTA note is amended or appended the new information will overwrite any previous ADM/CHCS/CCE information. If this occurs after a change has been made within the coding system, the previously corrected codes may be overwritten. Code changes such as this may not be identified until an audit is performed. If found, code changes should be made in ADM at no cost to the government.

16. Coding accuracy shall be at least 95% for three individual metrics: E&M, CPT and ICD. An overall aggregate for the MTF individual clinics (MEPRS codes) and provider-level details are available. The AFMOA Audit Tool and its results are used to assess the MTF coding accuracy rates. For all clinics, if accuracy rates are below acceptable quality levels for 2 consecutive months for Government personnel provided services, the AFMOA Coding Program Office, in conjunction with the MTF, will outline a Get Well Plan. If accuracy rates are below acceptable quality levels for 2 consecutive months for contractor personnel, the AFMOA Coding Program Office IAW the AFMS Commodity Council will issue a Letter of Concern for the contractor to develop a corrective action plan for Government approval. If corrective actions are not successful after 60 days, a Cure Notice will be issued to the contractor, which could result in termination of services.

17. For computer downtime preventing the use of AHLTA, the coders are expected to continue by using paper records for coding, and review.

18. For computer downtime preventing the use of CCE, coders are expected to review encounter documentation, validate codes, and directly enter in ADM.

19. For computer downtime preventing the use of CHCS, coders are expected to review and code from paper records and then enter information into system when it returns online.

20. Professional coder staff shall provide training and feedback to providers in order to improve provider knowledge and coding accuracy. This shall begin with initial training within 30 days of a new provider’s arrival at the MTF. Thereafter, it can be “provider requested” or “accuracy driven” training sessions. A provider requested training session shall be scheduled as soon as possible, but no later than 7 calendar days from the request and conducted as soon as possible, but no later than 21 calendar days from the request. Focused training is identified by the coding validation process, internal audits, AFMOA results or external reviews. Recurring monthly training (i.e., lunch session, clinic staff meetings) is encouraged; quarterly training is required. Further training may be advisable as dictated by results of the monthly AFMOA audit and errors identified by the on-site coders when performing their workload requirements. Training documentation must be maintained and reported monthly. The supporting documentation should include the training topics, the materials, list of attendees, and a critique from the providers/coders that were trained. For MTFs below the 95% accuracy threshold, training will be increased based upon a contractor correction action plan and/or AFMOA approved internal training plans. Training materials developed by the contractor must be approved by QAP and/or AFMOA Coding Program Office and maintained in the Quality Control Plan.

21. The following inpatient (institutional and/or professional) workload will be accomplished at every facility:

a. 100% of dispositions will be coded within 15 days from discharge in order to be completed by the provider within 30 days of discharge. Some of these dispositions may include absent sick records.

b. 100% of rounds (IBWA) visits by the attending provider will be coded within 30 days post inpatient discharge. However, coding of IBWA encounters is expected to occur daily.

c. MHS Guidelines for Inpatient Coding will be used as the official guidance. In absence of specific MHS coding guidance, refer to the appropriate industry standard coding conventions.

22. External Resourcing Sharing Agreement (ERSA) workload may be in place at some MTFs. Coders will capture the inpatient professional services performed by providers at the civilian facilities according to the most current policy and guidelines available.

23. Contractor personnel shall retrieve documentation (paper or electronically) when required for completion of any centralized and AFMOA directed auditing activities; forward (secure electronic transmission) to AFMOA or designated office for independent review, auditing activities. AFMOA Coding Program Office will determine if contractor will perform the tasks.

24. The AFMOA Audit only includes outpatient and APV encounters at present. This audit is a separate Government requirement and is not associated with the performance of contractors under the MASS or other existing contracts. However, in addition, because the AFMS places great emphasis upon the quality of coder training, the segment of records coded or validated by the contractor staff, will be used monthly to measure accuracy compliance to the 95% performance threshold for all three metrics – E&M, CPT and ICD.

· AFMOA monthly audit responsibilities will be accomplished by Government (GS) personnel if available in the facility. The following locations have qualified Government personnel that must complete the AFMOA audit effective immediately: Barksdale AFB, Eglin AFB, USAF Academy and Wright-Patterson AFB.

· If no qualified GS personnel are available, the AFMOA audit will be completed by the contractor. The individual(s) must possess the minimum qualifications outlined above for a coding auditor. An independent audit cell procured separately is anticipated to begin centralized auditing on or about March 2010. Until that time, contractor personnel may be used to complete the AFMOA Audit requirements. The AFMOA Coding Program Office will assign the audit responsibilities and will provide a 60 day notice to the contractor to discontinue AFMOA Audit completion activities.

AFMOA audit results/reports will be provided monthly to the AFMOA Coding Program Office and to each MTF

a. Errors identified during the AFMOA Audit will be corrected at no additional charge for any coding errors originally applied by contractor staff.

b. Identify aggregate coding errors and recommend focused clinic-specific training in order to improve documentation, support appropriate code application, and correct future provider coding accuracy rates.

c. Providers must be notified of any recommended coding changes per DoD Guidelines

25. Productivity standards established by the contractor must meet the Air Force’s threshold:

a. Outpatient visits must be coded or reviewed within 3 business days from the date of receipt or date of visit whichever is lesser.

b. Ambulatory Procedure Visits must be completed within 15 calendar days from the date of the encounter.

c. Inpatient records must be complete within 15 calendars days from disposition and signed by the provider and in close status within 30 days.

d. Maintain a 95% coding accuracy rate for each metric - E&M, CPT and ICD as determined by Government audit results.

26. CCE System Administration is an MTF responsibility. Managing user accounts is the CCE administrator’s role. User accounts must be approved by the QAP for contractor coding staff.

27. AHLTA, ADM or CCE Transmission Errors (sometimes called ‘write back errors”) should be monitored/ by the contractor staff and corrected if they are caused by a coder entry or a provider template error. If they are caused by lack of data integrity, co-signatures, or system interfaces, correction of the errors in the computer system is a Government responsibility. Write-back errors identified by the contractor will be communicated to the MTF QAP.

28. The Government defines “remote” as services for an MTF not being accomplished within that MTF. CCE and Essentris do not have inter-MTF access capabilities. Due to that limitation and because the new program has a strong emphasis on provider training, remote coding services are not possible.. In very rare circumstance (due to situations beyond anyone’s control), completion of the AFMOA audit may be accomplished via remote access; however, prior approval by the AFMOA Coding Program Office is required. . A request with justification in writing from the MTF Commander and QAP (if applicable) must be submitted to the AFMOA Coding Program Office for review and approval of remote services. Necessary permissions and data safeguards must be in place and subsequently approved through the proper systems/communications personnel to the AFMOA Coding Program Office. An acceptable internal training plan and schedule must be instituted and include training objectives (initial, monthly, and routine) for providers at the remote location where no on-site professional coders exist.

29. The MTF Coding Compliance Plan is mandated by DoDD 6040.42. It’s purpose is to develop internal controls to ensure compliance with coding guidelines and to identify problem coding areas and documentation practices. The plan includes improvements in medical record documentation and the education and training of providers and coding staff. Due to the centralized nature of the program effective 1 October 2009, one overall compliance plan will be created and provided to each MTF for HSI inspections or internal use. The AFMOA Coding Program Office will maintain and revise the plan as needed. If the services in your MTF are contractor-provided, a Quality Control Plan (QCP), IAW with the MASS contract is required 10 days after assuming services at the MTF. Therefore, specific processes, contingency plans, training schedules, meeting assignments and areas of responsibility will be outlined in detail in the QCP. Per the MASS contract, Section J, Attachment 5, Performance Plan, Paragraph 7, the QCP is the contractor’s responsibility; however, it must be accepted by the QAP at each MTF.