Sample SoW.docx

Sample of Services Required Health Record Coding Services

SAN FRANCISCO VA HEALTHCARE SYSTEM

HEALTH INFORMATION MANAGEMENT

4150 Clements Street San Francisco, CA 94121

1.0 Background:

The Veterans Health Administration (VHA) currently captures and stores information including diagnoses, treatment, and healthcare providers for all inpatient and outpatient care using the VHA Coding Guidelines and industry standard International Classification of Diseases Clinical Modification, 10th Edition, Current Procedural Terminology, and Healthcare Common Procedure Coding System provided to patients treated at a Veterans Health Administration healthcare facility, and for patients treated at other healthcare facilities at Veterans Affairs expense.

Inpatient information is abstracted and entered in the national encoder product and electronic health record (EHR). The electronic abstract provides a record of inpatient activity, diagnoses, procedures, and surgeries performed from the time of admission to the time of discharge from inpatient care. Coding and abstracting are completed for inpatients treated at any level of a Veterans Affairs facility (hospital, nursing home, domiciliary, observation), and for Veterans receiving care at non-Veterans Affairs facilities at Veterans Affairs expense.

Outpatient information is abstracted and entered in the national encoder product and electronic health record (EHR). Data elements captured include but are not limited to the date and time of service, identification of the healthcare provider, diagnoses, procedures and applicable modifiers for all care provided including ancillary services and procedures. Surgical case coding includes the entry of coded procedures and diagnoses for all surgery cases into the national encoder product and EHR.

A national encoder product is required for all coding and is available at each Veterans Health Administration medical facility. The encoder provides all the tools needed to review, analyze, audit, and code inpatient and outpatient episodes of care. The Veterans Health Administration clinical coding program requires use of the national Veterans Affairs encoder product which includes reports. The encoder product is utilized to manage workflow and expedite the coding process, e.g. as a communication tool, a compliance tool, and to ensure all assigned services are coded within mandated timeframes, etc. Reports are produced and reviewed daily to ensure all assigned cases are coded within established timelines. The encoder software provides coders with current electronic references and support tools. The encoder product is updated and/or modified as needed to meet the data collection needs of the Veterans Affairs.