amendment to extend due date

Added: Mar 08, 2017 2:38 pm The scope of this work is to obtain clinical documentation improvement services. The contractor shall provide a full range of support services related to clinical documentation improvement, provide industry standards recommendations to optimize the VAMHCS clinical documentation process, and support the implementation of recommendations.

Services performed shall be of a non-personal nature. VA organizations will not provide supervision of contractor personnel. Contractor personnel shall at no time allow an employer-employee relationship to develop with VA organizations or their staff and VA organizations will refrain from any activities that create the appearance of such a relationship. Contractors shall not perform inherently governmental functions including: decision-making, supervision of government employees, supervision of contractors on other contracts and activities that create the appearance of performing such functions.

Documentation in the health record is used to evaluate the adequacy and appropriateness of patient care, provide clinical data for research and education, support reimbursement, medical necessity, quality of care measures, and public reporting for healthcare services rendered. This makes capture of a complete and accurate picture of the patient s health status at each encounter, and thus clinical documentation improvement, critically important.

When reviewing the health record for completeness and timeliness of documentation, CDI Specialists (CDIS) are often challenged by conflicting, incomplete, or ambiguous documentation. Their role is to review the entire health record to determine the specific reason for the encounter and ensure that all conditions treated, monitored, evaluated, or that impact the patient s care are documented.

The contractor shall conduct a comprehensive analysis of clinical documentation practices at the various VAMHCS clinical services in order to identify and understand potential deficiencies. At a minimum, the analysis will include interviews with VA staff (such as providers and clerks), analyze coding data, and perform documentation reviews. The report shall also include actionable recommendations for improvement.