Statement of Work

Clinical Documentation Integrity (CDI) Training for Kansas City VAMC Clinical Documentation Integrity Specialists (CDIS), Coders, HIMS Staff, Physician, Providers, and Registered Nurse Advisors’ (RNA) Champions.

1. Background

The Kansas City VA Medical Center (VAMC), including associated Hospital and Community- Based Outpatient Clinics (CBOCs) located across Kansas and Missouri, requires a comprehensive Clinical Documentation Integrity (CDI) training program to support accurate, complete, and compliant clinical documentation. The Health Information Management Service (HIMS) Department seeks the procurement of CDI training curriculum designed to be delivered through both virtual and in-person instruction to Clinical Documentation Integrity Specialists (CDIS), Coders, HIMS Staff, Physician, Providers, and Registered Nurse Advisors’ (RNA) Champions.

This acquisition aligns with the Kansas City VAMC’s five-year strategic plan to enhance accuracy, acuity capture, and overall data integrity across all care settings. The contractor shall provide a structured, specialty-specific curriculum that includes professional education, consultation, and operational support. The training program must offer comprehensive online modules supplemented by instructor-led, face-to-face sessions, ensuring accessibility for staff with varying schedules and responsibilities.

2. Scope

Clinical Documentation Integrity (CDI) involves the concurrent or retrospective review of health records to identify documentation that is ambiguous, incomplete, conflicting, or clinically nonspecific. A successful CDI program requires specialized training that equips staff with the knowledge and skills necessary to perform these reviews accurately and in compliance with VHA and federal documentation standards.

The training program shall include full online access for a base period of one (1) year with four

(4) option years, enabling:

• Continuous access for Providers who must complete training around clinical schedules.

• Role-specific and self-paced training for Clinical Documentation Integrity Specialists (CDIS), Coders, HIMS Staff, Physician, Providers, and Registered Nurse Advisors’ (RNA) Champions.

• Availability of curriculum for new hires onboarding throughout the contract period.

Following completion of the CDI curriculum, participants including Clinical Documentation Integrity Specialists (CDIS), Coders, HIMS Staff, Physician, Providers, and Registered Nurse Advisors’ (RNA) Champions shall demonstrate an understanding of the core components listed in Statement of Work section 3.

3. Core Components of the Kansas City VA Medical Center CDI Curriculum

• Foundations of CDI

– Purpose and goals of CDI

– Roles and responsibilities across disciplines

– Overview of inpatient and outpatient documentation standards

• ICD-10-CM, ICD-10-PCS, HCPCS, and CPT Foundations

– ICD-10-CM Official Guidelines for Coding and Reporting

– ICD-10-PCS structure, root operations, and application

– CPT/HCPCS fundamentals with an outpatient focus

– Code selection logic aligned with CDI standards

• Clinical Concepts and Key Indicators

– Major body systems and associated clinical indicators

– Diagnostic criteria and common conditions requiring clarification

– Specialty-specific documentation concepts

• Query Compliance and Documentation Improvement

– CMS, VHA, and Joint Commission compliant query requirements

– Best practices for query structure and communication

– Provider education strategies

• DRG and Reimbursement Concepts

– MS-DRG structure and sequencing

– CC/MCC impact and acuity capture

– Relationship between documentation accuracy, VERA funding, and revenue

• Clinical Case Review Application

– Concurrent and retrospective review exercises

– Case-based gap analysis

• CDI Operations and Workflows

– Collaboration workflows between CDI and Coding

– Review prioritization and productivity standards

– Use of CDI tools and encoders

• Regulatory and Compliance Framework

– CMS Conditions of Participation

– Federal and VA-specific CDI guidance

– Ethical standards in documentation review

• Ongoing Learning and Assessment

– Knowledge checks, quizzes, and case assessments

– Annual refresher content

– Access to updated guidelines throughout the contract period

4. Specific Requirements

The contractor shall:

• Provide customized specialty training for all group sizes, including Clinical Documentation Integrity Specialists (CDIS), Coders, HIMS Staff, Physician, Providers, and Registered Nurse Advisors’ (RNA) Champions. Training must support small group, large group, and one-on-one delivery formats.

• Deliver structured training modules addressing documentation best practices, regulatory compliance, clinical validation, risk adjustment, SOI/ROM, ELOS, and specialty-specific documentation needs.

• Conduct an assessment of current CDI workflows and provide recommendations for process improvement.

• Develop or revise query templates in accordance with CMS, VHA, and national best-practice guidelines.

• Provide ongoing educational support, including refresher sessions, Q&A sessions, and updates on regulatory, coding, or guideline changes.

• Participate in collaborative meetings with Clinical Documentation Integrity Specialists (CDIS), Coders, HIMS Staff, Physician, Providers, and Registered Nurse Advisors’ (RNA) leadership, as requested by the COR.

• Ensure that all training materials, content, and delivery adhere to federal regulations, CMS/VA guidelines, and recognized industry standards (ACDIS, AHIMA).

• Provide all VA attendees with full access to the web-based curriculum, recordings, reference materials, and learning assessments.

• Provide opportunities for participants to earn MEUs, NEUs, and/or CEUs, as applicable.

• Supply written materials and reference guides needed for training, including—but not limited to—the following resources:

– CCDS and CCDS-O Exam Study Guides

– CDI Specialist Inpatient & Outpatient Training Guides

– Clinical Documentation Integrity Coding Guides (ICD-10-CM/PCS)

– Clinical Validation and Documentation Integrity references

– Coder’s Desk Reference (Diagnosis, PCS, CPT/HCPCS)

– DRG Desk Reference

– HCC Guide

– E/M Coding Advisors

– Interventional Radiology Guides

– ICD-10-CM/PCS Expert and Handbook editions

– JustCoding Pocket Guides

– Pocket Guides for Inpatient and Outpatient Coding Rules

– Risk Adjustment Coding resources

– Physician Advisor Guide to CDI

5. Deliverables

The contractor shall provide:

• Training schedule and curriculum outline.

• Customized virtual and in-person training sessions.

• Documentation improvement assessment report.

• Updated or newly developed query templates.

• Attendance records and post-training evaluations.

• Final summary report detailing training outcomes, recommendations, and next steps.

6. Performance Monitoring

The COR, along with KCVA HIMS leadership, Provider Champions, and Quality Management, will monitor contractor performance. The contractor shall:

• Provide ongoing follow-up training to reinforce Clinical Documentation Integrity Specialists (CDIS), Coders, HIMS Staff, Physician, Providers, and Registered Nurse Advisors’ (RNA) objectives.

• Support post-implementation evaluation and continuous improvement.

• Conduct an annual CDI process assessment.

Performance will be evaluated based on adherence to contract requirements, timeliness, curriculum quality, training effectiveness, and staff satisfaction.

7. Place of Performance

Kansas City VA Medical Center.

8. Government Furnished Information (GFI)

The VA will provide contractor access to applicable policies, systems, and documentation standards necessary to deliver training and conduct assessments.

9. Period of Performance

Base Period: One (1) year from date of award.

Option Periods: Four (4) one-year option periods.