Scope of Work.pdf

STATEMENT OF WORK

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Outpatient Medical Coding

Objective:

The purpose of this contract is for outpatient medical coding services at the Indian Health Service (IHS) Cass Lake Hospital in Cass Lake Minnesota, Cass County.

Background:

To ensure proper reimbursement as well as regulatory compliance, the Centers of Medicare/Medicaid Services (CMS) and other third party payers have initiated precise guidelines for all providers. These guidelines include documentation requirements that demonstrate medical necessity and correct coding that depend on data integrity. The Office of Inspector General (OIG) of the United States Department of Health and Human Services (DHHS) believes that all participants in the Medicare and Medicaid programs have an ethical and legal duty to ensure the integrity of their transactions with CMS, Federal and State rules and regulations. These services will permit service units to move towards strict adherence to CMS, Federal and State compliance guidelines and maintain consistency with the highest standards of business and professional ethics. Coding compliance is a key component of Medicare’s condition of participation in fostering and monitoring improved health care outcomes.

Indian Health Service (IHS) uses the official coding guidelines for clinical classification systems such as, but not limited to, current editions of International Classification of Disease-Clinical Modification (ICD-CM), Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS).

Scope:

The Cass Lake Service Unit (CLSU) will coordinate the work schedule with the contractor. CLSU will be responsible to ensure payment through a task order method.

The contractor will comply with the American Hospital Association (AHA) Official Coding Guidelines for ICD-10-CM and the Current Procedural Terminology (CPT) Guidelines, and any specific IHS coding and data entry policies and procedures. The timeframes for coding will be initial review of the visit within 4 days of the encounter and coding completion within 2 weeks of the visit.

The contractor will have access, with restrictions as defined by CLSU, to the following Resource and Patient Management System (RPMS) modules and other access as requested by the contractor and agreed upon by the Service Unit for revenue enhancement purposes.

a. Patient Registration System

b. Patient Care Component (PCC) / Electronic Health Record (EHR), and Pharmacy

c. Other as deemed necessary by CLSU

In order to meet CLSU needs in the revenue cycle and medical records management, contractor will be required to provide the following:

Contractor will work in partnership with CLSU Unit to assure continuity of support services, either through direct performance of necessary functions or in sharing responsibilities with service unit staff. Contractor will be expected to serve as an auxiliary resource to the service unit in support services. Contractor must be prepared to provide medical coding services.

Contractor and CLSU will participate in an introductory coding conference call and to be followed with a weekly conference call for the duration of the contract.

Outpatient Coding Scope of Work

1. Contractor Responsibilities:

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a. Shall code and make complete and accurate all assigned medical visits (ambulatory outpatient, laboratory, radiology and others) via the IHS RPMS EHR, and PCC packages. In accordance with IHS and National Reporting and Coding Guidelines.

b. Shall have access to the IHS RPMS EHR. system to view notes and critical information for correct visit information and coding of all evaluation & management (E/M), diagnoses, CPT, HCPCS, modifiers and apply medical significance matching of diagnoses to services.

c. Assignment of E/M, CPT, and HCPCS will be completed and modified/appended via the RPMS system.

d. The IHS RPMS Coding Queue (CQ) will be accessed for review, accuracy, and completion of all medical visits before a claim can be generated. When a visit cannot be completed in the coding queue, the vendor needs to access the RPMS PCC data entry to mark as an Incomplete (I) also adding deficiency specifying why the visit is complete.

e. Code outpatient visits – all assigned visits for contractor coding will be qualitatively analyzed by

CLSU medical record staff, before initial review and coding by the contractor. Visits requiring further documentation in order to be coded will be handled by the contractor in the following manner:

o Marked in the Coding Queue (CQ) with an “I” as Incomplete o Reason for deficiency entered into the CQ chart audit notes, o Notification sent to the appropriate provider/nurse.

o Contractor will review all “I” (incomplete) visits for coding-readiness on a weekly basis o Contractor will complete visits within 48 hours of visit documentation being completed and ready for coding.

e. A report of findings via the CQ will be documented and presented via phone and a written report as a tool of communication and education for all physician and ancillary staff.

f. Editing, appending, merging, moving data elements, and deleting duplicate entries will be part of the process with application of reporting requirements via the RPMS system.

g. Visit data from PCC/Pick Lists/EHR will be reviewed (CQ) for accuracy and completeness to the highest allowable level so the facility receives the appropriate level of reimbursement. National Coding Guidelines will be applied via PCC.

h. There shall be no additional charge for reports generated by the contractor.

i. Schedule weekly management meetings or as needed to discuss project needs.

j. Contractor personnel shall have prior experience in coding and billing outpatient visits, ambulatory procedures and have experience in medical records coding (ICD-10-CM and CPT-4), Certified Coders preferred, and the use of applicable computer technology to accomplish duties required.

k. Contractor, when working incomplete visits in EHR, will send provider “Notifications” for any record deficiencies (coding, documentation), utilizing the EHR Notifications with a cc: notification to Cass Lake Coding Compliance Coordinator.

l. Utilize the RPMS PCC EHR systems, including the CQ, in order to process all contracted medical documents as required.

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m. Must have knowledge of revenue enhancement cycle processes, private insurance carriers and Medicare reimbursement practices and requirements and be able to demonstrate knowledge. Must have knowledge of a compliance program and HIPAA requirements.

1. Government Responsibility:

a. The Government will provide proper in-service to the contractor so to become familiar with the Privacy Act and HIPAA requirements. All necessary documents pertinent to the Privacy Act, HIPAA Privacy rule and HIPAA Security Rule. Security clearances will be on file with the CLSU and other offices that require such documentation.

b. All work will be conducted off-site via VPN access to RPMS/EHR.

c. The Service Unit will provide proper in-service to the contractor to become familiar with the facility, Privacy Act, and other I.H.S. requirements.

d. The Government shall perform random audits no less than two (2) times per year on coding record keeping/security backup to ensure contract compliance. CLSU Coding Compliance Coordinator will perform the random audits