SOW HIM Optum 2.pdf

Rosebud Service Unit Optum Medical Encoder Services Performance Work Statement

Performance Work Statement (PWS) Optum

Medical Encoder

C.1 Background

The mission of the Rosebud Service Unit is to raise the physical, mental, social and spiritual health of American Indians and Alaska Natives to the highest level. The Rosebud Service Unit (RSU) is located in the south-central part of South Dakota. The Rosebud Hospital is a thirty-five (35) bed hospital, Joint Commission (TJC) accredited acute care hospital associated with an Emergency Department and two (2) housing campus locations.

It is the intent of the Rosebud Service Unit to provide coding services lo our hospital encounters for the Rosebud Service Unit in Rosebud, South Dakota, 57570. Coding includes assigning ICD-10-CM, CPT, HCPCS and DRG codes for all of our patient encounters for the entire Rosebud Hospital this includes visits for these departments and locations: Outpatient, Inpatient, Home and Offsite. Based upon supporting documentation, the coders assign codes to all patient encounters to ensure that visits are coded to the highest specificity to aid in our statistical reporting and also to help generate 3rd party revenue.

C.2 General Requirements

C.2.1 Purpose of Contract

The purpose of this non-personal service contract is to provide a coding support system that .assists in accurate and efficient coding of medical diagnosis and procedures performed by our clinic staff. This medical encoder tool helps ensure that Rosebud Service Unit (RSU) coders are not only coding most accurately but also helping us to obtain proper reimbursement for health care services provided. The Opium encoder helps support the current Rosebud Service Unit (RSU) Coding staff as we have one vacant position which will be advertised soon.

C.2.2 Contract Type

This online tool contract type will be Firm-Fixed Price, Fixed Unit Price for (7) licenses.

C.2.3 Contract Performance Period

A. The contract will be for a term of one (1) year from award date.

8. The firm-fixed price shall be inclusive of all cost associated with the performance of a contract.

C.2.4 Contract Place of Performance

The Encoder is online based so each coder will access the medical encoder via username and password.

C.3.1 Scope

Opium will provide unlimited support and training for the staff at no additional cost beyond the quoted price.

These tools are all online and accessed via a username and password. There is no software to be installed. There is no integration as they are stand-alone. All maintenance and updates are done automatically by Optum twice a month.

RevenueCyclePro.com is a comprehensive, online problem-solving tool that compiles the critical reference data hospitals need to increase efficiency across the entire revenue cycle< RevenueCyclePro.com provides: Access to a complete library of medical code sets, UB-04 billing and coding tips, and reimbursement information to address problems that are core to hospital revenue cycle processes.

A simplified research process that boosts productivity, featuring a search engine that helps you quickly find codes you are looking for - using acronyms, abbreviations or medical terms, and exclusive code crosswalks and coding tips that provide quick links from clinical codes to CMS source documentation, billing and reimbursement information.

Provides historical data for the previous eight quarters, in addition to the current quarter, allowing the user to resolve older claim problems using the codes, as well as the billing and coverage rules, in effect at the time.

Tools to help you resolve your most prevalent coding and billing errors and prevent rejections by using the latest UB-04 data set and Medicare billing guidelines, as well as revenue codes linked to CPT®/HCPCS codes.

Complete, updated Part A and Part B LCD policies, medical necessity data and national coverage policies 9NCDs) with crosswalks to CPT®/HCPCS, ICD-10/ICD-9CM revenue codes and billing code types to help you manage the ABN process and reduce denials.

The RevenueCyclePro.com Facility Encoder Module Add-On brings together all of the information and tools that coders need into a single, streamlined solution. Combined with RevenueCyclePro.com, the Facility Encoder Module presents vital coding information to coders precisely when and where they need it. all within a single code summary screen. Our proven hospital encoder technology integrated with the industry's most comprehensive coding, reimbursement and regulatory reference content, in one seamless product, helps coders achieve accuracy and high productivity.

This stand-alone solution offers coders, concurrent coders, case managers, CDI specialists, consultants, and finance individuals a full, robust encoder tool for coding, abstracting, research and payment validation: Logic and book coding: Leverages Opium proven knowledge-based and logic-based encoding for diagnosis and procedure code assignment

Logic path history tracks user's logic selections, allows user to unselect single or multiple selections and print a report of logic selections.

Edits: Provider-specific inpatient and outpatient medical necessity, MCE, OGE and Opium proprietary claim edits for all acute care and critical access hospitals and ambulatory surgery centers Reimbursement: Dynamic, real-lime, hospital-specific MS-DRG and APC grouping and pricing for reimbursement information and payment validation MS-DRG modeling: Enables complete coding accuracy when documentation supports it.

Integrated with RevenueCyclePro.com: Each code is linked lo vital references such as AHA Coding Clinics, Code Specific Guidelines, proprietary Opium Specialty Articles and Clinical Documentation guidelines, Optum CD! content and more at your fingertips

"RCP Code Detail" link: current and historical comprehensive code detail, including crosswalks transmittals, IOMs detail page is based on the discharge date

Full access to RevenueCyclePro.com provides additional vital content such as MDC optimizing lips, complete Uniform Billing Editor e-book, inpatient and outpatient hospital compliance checker leveraged from Opium Claims Manager

EncoderPro.com Professional is an online, real-time code look-up application for outpatient coding that delivers a higher degree of code detail and reference information on CPT®, HCPCS Level II, and both ICD- 9-CM and ICD-10-CM and PCS codes as well as cross coding functionality (CPT® to ICD, ICD to CPT®, etc.). Monthly automatic code updates throughout the year will help practices that bill Medicare Part B and private payers reduce rejected claims due to improper coding. The Professional version includes CCI edits as well as Medicare and commercial payment and coding information.

Local coverage determinations (LCDs) and Medicare's Internet Only Manuals access. Check procedures for Medicare coverage instructions and medical necessity edits across all CMS MACs. Understand which ICD-10-CM/procedure combinations define medical necessity and what the documentation guidelines are for successful claim submission. Gain insight into procedures and services that carry little or discretionary coverage and how to report them.

Modifier crosswalk. Choose from a comprehensive array of modifiers for each procedure based on millions of claim scenarios to ensure correct modifier use when billing payers.

Cross-coder relationships. Provides valuable content from 12 coding and billing specialty reference books in one powerful solution. Includes code set cross coding (ICD to CPT®, CPT® to ICD, etc.), cross- reference procedures to radiology, path/lab, medicine codes, and more.

Medicare CCI edits. Understand coding relationships for bundled and mutually exclusive procedures and check your code combinations through a full year of CCI.

ICD-10-CM and PCS. Includes mapping content from ICD-9-CM volumes 1 and 3 codes to ICD10-CM and PCS codes (as well as backward mapping) using the GEM (General Equivalency Mappings) and Opium Map Select clinical mapping content. Also includes ICD- 10-CM and PCS searching and Opium tabular (ICD10-CM and PCS books) content.

COR Information

Andrea Garrigan, COR III andrea.garrigan@ihs.gov

CONTRACTOR AUTHORITY:

1. Authority

1.1. No person other than the Contracting Officer has authority to bind the Government with respect to this contract.

1.2. No action or omission of any government employee or representative other than the Contracting Officer shall increase or decrease the scope of this contract or shall otherwise modify the terms and conditions of this contract.

1.3. In no event shall any of the following be effective or binding on the Government or imputed to the Contracting Officer with respect to this contract:

1.3.1. An understanding or agreement between the Contractor and anyone other than the Contracting Officer.

1.3.2.A purported modification or change order issued by anyone other than the Contracting Officer.

1.3.3.A promise by anyone other than the Contracting Officer to provide additional funding or make payments; or

1.3.4. An order, direction, consent, or permission from anyone other than the Contracting Officer to:

1.3.4.1. Incur costs in excess of a specified estimated cost, allotment of funds, or other ceiling; or

1.3.4.2. Expend hours in excess of a specified level of effort.