PWS_Jun_2016.pdf

PERFORMANCE WORK STATEMENT

Medical Coding Audit and Training

1. GENERAL. This contract is in support of the San Antonio Military Medical Center (SAMMC), Patient Administration Division, Medical Records Branch, for medical coding auditing services and staff education and training. The contractor will identify the strengths and weaknesses of SAMMC coding practices and documentation to optimize billing and reimbursement practices while maintaining compliance with regulations. The contractor will identify and report opportunities for performance improvement, customize coder and physician education and training to improve coding accuracy.

2. QUALIFICATIONS. Auditing staff and training personnel will be American Health Information

Management Association (AHIMA) credentialed with at least 10 years of experience in the respective audit fields of inpatient and professional services coding. Contractor will provide a copy of credentials of all staff providing audit services for the purpose of this contract.

3. OPSEC INFORMATION.

3.1. Work under this contract is UNCLASSIFIED. The Contractor shall comply with all applicable

DoD security regulation and procedures during the performance of this contract. The Contractor shall not disclose and must safeguard procurement sensitive information, computer systems and data, Privacy Act data, and Government personnel work products obtained or generated in the performance of this contract. Contractor employees will be issued by the Government a Common Access Card

(CAC) which is required for access to Government computer databases and entrance to the installation. Additionally, all Contractor employees must be issued a special identification card issued by APPLICABLE PMO Badge and ID Office prior to reporting for duty. The Contractor shall be responsible for the control and safe keeping of all Government issued IDs and ensure all badges are returned to the COR upon termination of an employee or the contract end date. The Contractor shall ensure all contractor employees are aware that in the event either of the Government IDs are lost or stolen that they are to advise the PM or alternate immediately upon discovery. The Contractor shall ensure that the COR is notified the same day the employee reports an ID lost or stolen. The

Government shall conduct criminal background checks on all Contractor employees in accordance with the procedures set forth in Public Law 100-235, DoD Directive 5200.28, DoD Directive 5200.2-

R, DoDI 1402.5. and submit to the PM or the Alternate. The Contractor is responsible for ensuring all Contractor employees must complete the SF86, Authorization for Release of Information form and ensure all background check submittals are initiated in accordance with this PWS prior to employees providing services at APPLICABLE facilities. Background checks shall be based on fingerprints of individuals obtained by qualified Government law enforcement or security personnel, inquiry’s conducted through the Federal Bureau of Investigation (FBI) and the State Criminal History

Repository check, and a local Installation Record Check., if required. The procedures for completing the required background check are outlined in the Department of Defense Instruction (DoDI) 1402.5.

Government will not allow any employees to start work until clearance of criminal background check has been completed.

3.2. Investigation Requirements (if applicable). The contractor providing service under this contract is required to initiate and document the new employee’s Electronic-Questionnaires for Investigations

Processing (e-QIP) and coordinate, or validate through the BAMC Security Manager’s Office all background investigation requirements needed for employment at BAMC, or in BAMC organizations. Clearances will be validated using the Joint Personnel Adjudication System (JPAS) when a new employee begins in-processing after contract is awarded. The SF 85P Questionnaire for

Public Trust Positions is to be completed and printed and electronic copies (downloaded from internet program) are to be hand carried to the BAMC Security Manager prior to performance. The Contractor shall have proof of U.S. citizenship (certified copy of birth certificate or naturalization papers) or a valid U.S. Immigration Form 1-151 and Alien Registration Card ("Green Card"). As a minimum, the contractor providing service requiring operating government-furnished workstations that have access to Department of Defense e-mail and requiring unescorted entry to a restricted area/Controlled Areas, must successfully complete a National Agency Check (NAC). The contractor shall coordinate and schedule appointments with the BAMC Security Manager prior to performance. The BAMC security manager will initiate the Request for Personnel Security Action, review the security questionnaire and request a Local File Check from the Provost Marshall prior to scheduling an appointment with the

Security Specialists to submit the e-QIP for processing. This security questionnaire must be completed and processed by the BAMC Personnel Security Office prior to contract performance. The contractor is responsible for monitoring the coordination and completion of the scheduled appointment date and time with the Security Manager.

3.3. Freedom of Information Act Program (FOIA and Privacy Act). The contractor shall comply with

DOD Regulation 5400.7-R, DOD Freedom of Information Act Program requirements. The Freedom of Information Act sets policy and procedures for the disclosure of records to the public and for marking handling transmitting and safeguarding For Official Use Only materials.

3.4. Reporting Requirements. The contractor shall comply with DoD 5200.2-R, January 1987, Personnel Security Program and AR 380-67, 9 September 1988, Department of the Army Personnel

Security Program Regulation. Contractor shall report to the BAMC Security Manager any information or circumstances which may pose a threat to DOD or contractor personnel, resources, or

DOD information.

3.5. Removal of contract employee. The government reserves the right to require immediate temporary or permanent removal of any individual whose actions raise reasonable suspicion that patient care or services may be compromised in any way or that pose a threat of harm to other contractor/government personnel or self. The employee may be required to submit to drug/alcohol testing. The government reserves the right to require temporary or permanent removal of any individual who refuses testing. Notification of all removals will be made by the Contracting Officer

Representative (COR). Removal of any individual does not relieve the contractor of any performance requirement.

3.6. Physical Security. The contractor shall comply with all Force Protection Condition (FPCON) procedures, Random Antiterrorism Measures (RAMS) and local search/identification requirements.

The contractor shall be responsible for safeguarding all government equipment, information and property provided for contractor use at the end of each business day. The Contractor shall ensure all government facilities, equipment, and materials shall be secured at the close of each duty day.

3.7. Government Computer Access Requirements (if applicable). If this contract requires contractor personnel to have access to government computers, contractor personnel requiring access to government computers shall successfully complete, a National Agency Check (NAC), before obtaining access to the computer. These investigations shall be submitted by the government at no additional cost to the contractor. Common Access Cards (CACs) for Contractor Personnel are required which is hereby incorporated by reference if not otherwise included. The contractor shall comply with Homeland Security Policy Directive (HSPD)-12, Policy for Common Identification

Standard for Federal Employees and Contractors and Federal Information Processing Standard 201

3.8. Keys and Lock Combinations (if applicable). The contractor shall abide by all current BAMC key control and lock combination procedures The Contractor shall be responsible for any keys issued to the employee. The keys shall not be duplicated. The Contractor shall ensure that its employee’s not allow government-issued keys be used by personnel other than those currently authorized. No unauthorized personnel shall be allowed entry into the locked area. Keys shall not be used to open work areas for personnel other than personnel engaged in performance of their duties, unless authorized by the Government functional area chief. The employee shall use keys issued to them to secure/open areas only as directed by the COR and/or functional area chief. Lost keys and/or locks shall be reported to the issuing party and COR immediately upon recognition of the loss. The COR shall notify the PMO of the lost key. The employee shall be responsible for the replacement costs of any lost keys and any associated locks. Reimbursement shall be provided before the Government replaces lost keys or performs re-keying.

3.9. Key Control (if applicable). The contractor shall safeguard all keys issued by the government and ensure they are used only by authorized contractor personnel. The contractor shall not duplicate issued keys and shall report lost keys to the COR immediately. The contractor will be charged for lost keys, re-keying and lock replacement as required.

3.10. Antiterrorism (AT) / Operations Security (OPSEC) Requirements: For OPSEC to be effective, all Contractors must be aware of OPSEC and understand how OPSEC complements traditional security programs. All personnel must know how to apply and practice OPSEC in the performance of their daily tasks. OPSEC must become a mindset of all Contractor employees and be performed as second nature. To accomplish this level of OPSEC vigilance, OPSEC training programs must be action and job-oriented, enabling the workforce to put into practice the knowledge and tactics, techniques, and procedures (TTPs) they learned in training. Training should maximize the use of lessons learned to illustrate OPSEC objectives and requirements. In order to ensure accomplishment of training, the Government will include OPSEC training as a part of their organization’s annual training guidance. Contractor employees must complete Level I OPSEC and AT awareness training within 30 calendar days of reporting to duty in according to Army Regulation 530-1 and 525.13. AT

Level I awareness training is also available at https://atlevel1.dtic.mil/at.

3.11. iWATCH Training: The Government will brief all Contractor personnel on the local iWATCH program. This local developed training will be used to inform employees of the types of behavior to watch for and instruct employees to report suspicious activity to their COR. Contractor employees must complete iWATCH training within 30 calendar days of reporting to duty.

4. SECURITY AND CONFIDENTIALITY.

4.1. The contractor will be responsible for safeguarding all medical information provided for auditing purposes. The contractor shall not retain any copies, paper or electronic information once the work is completed. The contractor shall be aware that proven violation of confidentiality of patient information shall be a cause for termination of the contract.

4.2. The contractor shall not release patient medical information except for the purposes of this contract, without the expressed written authorization from the Contracting Officer Representative

(COR). The contractor shall be responsible for its employees in release of confidentiality and/or proprietary information. All contractor personnel shall observe the requirements imposed on sensitive data by law, Federal Regulation, and DoD/AR policies and procedures. Contract employees shall be responsible for maintaining patient confidentiality at all times. All individually identifiable health records shall be treated with the strictest confidentiality. All CDs provided to the contractor for the purpose of this contract will be returned to the SAMMC for disposal at the completion of work at no cost to the government. The contractor shall comply with the Privacy Act, 38, USC 5701, and 38 USC 7332.

5. Specific Tasks

5.1. There are approximately 2,100 inpatient discharges and over 6,000 Emergency Room (ER) visits every month with 3,000 providers currently practicing at this facility.

5.2. Period of performance for this contract will be 120 days from contract award and audit activities will begin no more than 30 days after receipt of contract award.

5.3. The contractor will conduct chart reviews for coding accuracy for purposes of gaining insight and appreciation for overall ICD-10 coding, billing and documentation accuracy. The review will consist of 1,000 inpatient records and 500 Emergency Room encounters. The records will consist of dates of service after October 1, 2015, from all inpatient and ER specialties treated at SAMMC (i.e.

trauma, newborn, all surgical specialties, internal medicine, rehab, burn, behavioral health, cardiology, nephrology, oncology, infectious disease, pediatrics, orthopedics, podiatry, family medicine, general surgery, ophthalmology, gastroenterology).

5.4. Each record is to be reviewed for assessment of clinical documentation completeness and effectiveness in relationship to patient clinical presentation, severity of illness, treatment and workup and hospital resource consumption as well as code assignment appropriateness and accuracy, utilizing official pertinent inpatient and outpatient coding guidelines as well as Coding Clinic guidelines and advisories. Opportunities for physician queries will also be provided.

5.5. The contractor will evaluate client selected records for the level of completeness of clinical documentation present, with particular focus on accuracy in capturing the correct principal diagnoses, complications and co-morbidities (MCC), secondary diagnoses, and medical necessity to support reported and procedures performed, conditions found in the medical records and the congruence between the documentation present in the chart and the codes and Diagnostic Related Group (DRG) assignments made by the SAMMC coding staff.

5.6. A comprehensive Executive Summary Report of findings and recommended action plan will be provided at the conclusion of the chart reviews based on audit results and analysis of data identified.

The Executive Summary Report will be briefed to SAMMC leadership in a face-to-face presentation.

The contractor will email the Executive Summary Report in a Microsoft Office Power Point format to the SAMMC Coding Managers at least 2 days prior to the face-to-face presentation. The contractor will coordinate the date, time and location of conference room with SAMMC Coding Managers.

SAMMC Coding Managers will reserve a conference room with audio/visual capabilities for the face-to-face presentation.

5.6.1. SAMMC Coding Managers will provide complete medical records to the contractor on password protected CDs. Auditing services will be conducted off site at the contractor’s place of business over a course of 4 consecutive weeks from receipt of records.

5.6.2. The contractor will provide a detailed report of findings within 15 business days after conclusion of the audit for each record reviewed. The findings will be organized by inpatient and

Emergency Department encounters, highlighting specific documentation and coding insufficiencies/discrepancies identified through record review. Rationale and reasoning for each identified finding will be incorporated into the report with citation of relevant coding or other guidelines as necessary and appropriate. The contractor will provide an action plan outlining and detailing a specific course of action to address each finding and concern that incorporates valid and reliable measures of success in improving each finding.

5.6.3. The contractor will calculate the overall coding accuracy for inpatient and ER and identify missed opportunities for clinical coding queries that may impact coding accuracies and reimbursement optimization.

5.6.4. The contractor will customize coder and physician education and training to improve coding accuracy based on the findings in the Executive Summary. Classroom training sessions will be coordinated with SAMMC Coding Managers and be conducted onsite over 5 consecutive business days. Training classrooms with audio/visual capabilities will be reserved in advance by

SAMMC Coding Managers. Dates and times will be scheduled within one week of submission and briefing of Executive Summary and findings. The scheduled training sessions will be within

4 – 6 weeks from date of briefing.

6. GOVERNMENT FURNISHED PROPERTY (GFP) AND SERVICES: Government furnished equipment or property will not be provided with the exception of the CDs containing medical records for the completion of coding audits. Audio/visual equipment will be available for use in SAMMC conference rooms for the face-to-face presentation and training sessions.

7. Travel: Travel to/from the Contractor’s location shall be in accordance with the Joint Travel

Regulation per diem rates and standard class airfare.

8.0 Sexual Harassment under the Sexual Assault Prevention and Response Program (SHARP)

a. Reporting requirements required by OTSG/MEDCOM Policy Memo 13-062, Policy for

Reporting Incidents of Sexual Assault and Sexual Harassment under the Sexual Assault Prevention and

Response Program (SHARP), dated 12 November 2013.

b. The contractor shall require all Contract Service Providers (CSP) with knowledge of an incident of sexual assault occurring on a Government facility, to include a Government leased facility, where the contractor is providing services under this contract, to report the incident to the contractor who shall immediately (within 24 hours) report the incident in writing to the government's COR. All incidents shall be reported whether they involve contractor personnel or Government personnel, or other individuals.

c. The contractor shall require all CSPs with knowledge of an incident of sexual harassment occurring on a Government facility, to include a Government leased facility, where the contractor is providing services under this contract, to report the incident to the contractor who shall immediately

(within 24 hours) report the incident in writing to the government's COR. All incidents shall be reported whether they involve contractor personnel or Government personnel, or other individuals.

d. The contractor shall ensure all service providers receive Sexual Harassment/Assault Response and Prevention (SHARP) training not later than 60 calendar days after contractor personnel begins performance under this contract. Training can be obtained either online or in person. Contractor personnel can attend SHARP training provided by MEDCOM on an every other month basis by contacting (210) 221-6118 for class date/time and availability. If the employee has an AKO account, they can access online the Team Bound Self Study course through Army Learning Management System

(ALMS) at http://www.atsc.army.mil/tadlp/delivery/alms.asp.

9. Local Clause 5008

Exclusion from Participation in Federal Health Care Programs (October 2015)

a. The Contractor shall not employ or contract with any individual or entity (hereinafter collectively referred to as “person”) to provide items or services that will be included in invoices submitted to the

Government under this contract if such person is listed on the Department of Health and Human Services

(HHS) Office of the Inspector General (OIG) List of Excluded Individuals and Entities (LEIE) or the

TRICARE Sanctioned Provider List. The Government is legally prohibited from paying for provision of items or services by such persons. The prohibition extends to services beyond direct patient care, such as services of persons in executive or leadership roles and administrative and management services, whether or not such services are billed separately. The LEIE may be found at http://oig.hhs.gov/fraud/exclusions.asp, and the TRICARE Sanctioned Provider list at http://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Quality-And-Safety-of-

Healthcare/Program-Integrity/Sanctioned-Providers. The LEIE and TRICARE Sanctioned Provider List are hereinafter collectively referred to as “the Lists.”

b. Prior to start of contract performance, the Contractor shall (a) query the Lists to determine whether the name of any person the Contractor employs or contracts with to provide services or items for which payment may be made under this contract appears on the Lists, and (b) certify to the Contracting Officer that the Contractor has queried the Lists and no such names appear on either of the Lists.

c. During performance of the contract, and prior to persons other than those whose names were queried in accordance with paragraph 2, above, (hereinafter “new persons”) providing services or items under the contract, the Contractor shall (1) query the Lists as in paragraph b, and (2) certify to the Contracting

Officer that the names of such new persons do not appear on either of the Lists.

d. The Contractor is advised that during performance of the contract, MTF personnel will perform a recurrent recheck of the names of contractor personnel working in the MTF against the Lists, as specified in OTSG/MEDCOM Policy Memo 15-037. The Government will notify the Contractor in the event any contractor personnel working in the MTF appear on either of the Lists.

e. Should any person providing items or services under the contract appear on either of the Lists at any time during contract performance, the Contractor shall (a) in cases where the Contractor identified the person, notify the Contracting Officer, and (b) promptly remove that person from the contract.

f. Violation of any aspect of the above paragraphs shall be considered a material breach of the contract and may result in termination of the contract.

g. The Contractor is further advised that, in accordance with Civil Monetary Penalties Law [CMP]

(codified at 42 USC § 1320a-7a):

1. There are steep civil monetary penalties associated with billing the Government for providing items or services by a person on either of the Lists, and with failing to return to the Government any overpayments received for provision of such items or services.

2. Billing under the contract for provision of items or services by a person on either List may also result in exclusion of the person that employs or contracts with such person.

http://www.atsc.army.mil/tadlp/delivery/alms.asp http://oig.hhs.gov/fraud/exclusions.asp http://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Quality-And-Safety-of-Healthcare/Program-Integrity/Sanctioned-Providers http://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Quality-And-Safety-of-Healthcare/Program-Integrity/Sanctioned-Providers

h. HHS OIG has issued a Special Advisory Bulletin on the Effect of Exclusion from Participation in

Federal Health Care Programs with additional information on the CMP. The Special Advisory Bulletin may be found at http://oig.hhs.gov/exclusions/files/sab-05092013.pdf.

(End of Clause)

10 Contractor Manpower Reporting (CMR)

The contractor shall report ALL contractor labor hours (including subcontractor labor hours) required for performance of services provided under this contract via a secure data collection site.

The contractor is required to completely fill in all required data fields using the following web address: http://www.ecmra.mil/

Reporting inputs will be for the labor executed during the period of performance during each Government fiscal year (FY), which runs October 1 through September 30. While inputs may be reported any time during the FY, all data shall be reported no later than October 31 of each calendar year, beginning with 2013. Contractors may direct questions to the help desk at help desk at: http://www.ecmra .mil/.

11. QUALITY ASSURANCE/SURVEILLANCE PLAN.

Acceptable Performance

Standard

PWS Para Performance

Objective

Performance Threshold Assessment Method

Perform timely record reviews (audits).

Para 5.6.1 95% compliant Completion of record reviews will be within

4 weeks from commencement of contract.

95%

Inspection of audit documentation at 4 weeks from commencement of contract.

Provide Executive

Summary with detailed findings action plan.

Para 5.6.2. 95% compliant Submission of Executive Summary will be completed within 15 business days after conclusion of the audit.

Documented submission date of Executive Summary and scheduling of face to face briefing.

Provide customized coder and physician training based on findings of record reviews.

Para 5.6.4. 95% compliant Detailed training based on the audit findings will be scheduled within one week of briefing Executive Summary and action plan findings and conducted within 4-6 weeks.

Document scheduling of training dates and commencement of training.

(End of PWS) http://oig.hhs.gov/exclusions/files/sab-05092013.pdf http://www.ecmra.mil/