CODING STATEMENT OF WORK – CHEYENNE VA MEDICAL …



UNITED STATES DEPARTMENT OF VETERAN AFFAIRS

PERFORMANCE WORK STATEMENT (PWS)

TITLE: MEDICAL CODING SERVICES

CHEYENNE VA MEDICAL CENTER (VAMC)

1. CODING PROCESSES

Performance Requirements – The Vendor Shall

• Carefully read and review health record documentation for inpatient and outpatient cases as provided by Cheyenne VA Medical Center (CVAMC).

• Assign appropriate ICD-9-CM and CPT/HCPCS codes at 95% accuracy rate and enter the codes into the system in accordance with the documentation and the provider’s scope of practice.

• Adhere to all coding guidelines and accepted VA regulation, including:

1. The Official Guidelines and Reporting as found in the CPT Assistant, a publication of the American Medical Association for reporting outpatient ambulatory procedures and evaluation and management services,

2. The Official Guidelines for Coding and Reporting in the Coding Clinic for ICD-9-CM, a publication of the American Hospital Association, and VHA Guidelines for coding as found in the Handbook for Coding Guidelines current version, Health Information Management, Department of Veterans Affairs. Note: While VHA does ask for reimbursement from third party payers, the VHA coding policy is to code according to coding guidelines. Our own compliance audits use only this definition when determining if any encounter is correct.

3. The Correct Coding Initiative. The CPT Evaluation and Management codes assure documentation substantiates the code level assigned.

4. VHA Resident Supervision Handbook.

5. VA Coding Guidelines.

• CVAMC will provide access to VHA publications.

• When assigning multiple CPT codes, verify they are not components of a larger, more comprehensive procedure that can be described in a single code.

• Assign modifiers as appropriate to override Correct Coding Initiative edits.

• Identify and document those encounters created in error because the patient was not seen.

• Provide a workload report each week indicating the events coded for the prior week in the following categories:

o Number of inpatient events coded

o Number of inpatient pro fees coded

o Number of outpatient encounters coded

o Number of lab encounters coded

o Number of NSQIP events coded

• Provide a backlog report weekly which shows events suspended and events to be coded as follows:

o Inpatient events: Events not coded due to lack of documentation

o Inpatient events: Events not coded for any other reason

o Inpatient Pro Fees: Number of records requiring inpatient pro fee coding

o Outpatient encounters: Number of outpatient encounters to be coded

o Outpatient encounters: Number of outpatient encounters suspended

o Lab encounters: Number of lab encounters to be coded

o Lab encounters: Number of lab encounters suspended

o Number of NSQIP events to be coded

• Expected turnaround time is 5 work days from receipt of work for all types, provided there is sufficient documentation. Lack of documentation for any work type must be communicated to CVAMC within the expected turnaround period. Work is considered completed when it is received back at CVAMC with data entry done for all online work. Inpatient events are considered complete when the event has been closed and released. CVAMC will transmit inpatient events.

• Expected average productivity due to hourly invoicing is:

o Inpatient – 4/hours

o Outpatient – 10/hour

o NSQIP – 7/hour

• Errors will be corrected at no cost to CVAMC.

2. OUTPATIENT ENCOUNTERS INCLUDING RADIOLOGY, LAB OR OTHER ANCILLARY SERVICES

Contractor will:

• Use primarily 1995 Evaluation and Management guidelines on encounters except when 1997 guidelines provide a better code.

• Enter complete data entry, including CPT codes, modifiers, and diagnoses for the encounter or occasion of service when on-line coding is performed into PCE. Associate the provider with the CPT code performed by him/her at that encounter. Note: The association in VistA is very important to create a correct bill and for the budget allocation for each fiscal year for VA. Contractor will correct any missing associations when doing on-line coding at no charge to CVAMC.

• When coding, it is expected the contractor will search the record for an appropriate diagnosis.

• Not validate any cases that already have initials and a date (of validation) in comments in PCE as these have already been validated by VA staff.

• Link CPT procedure codes with the proper diagnosis.

• Radiology encounters need to have the ordering physician listed as a secondary provider in the encounter. The ordering provider’s name should also be entered in CCM Comments.

• Resident services: The primary provider for all clinics is the attending if there is attending documentation that meets VHA Resident Supervision guidelines. If the attending documentation does not meet the guidelines, is incomplete, or is not present, the primary provider is changed to the resident and the encounter is marked not billable by entering reason code 25 in CCM comments so that the facility charge can be billed even if the professional fee cannot be billed.

• Contractor will use the appropriate reason codes in Comments in CCM, not in Claims Tracking, for making an encounter not billable – CVAMC reason codes are listed in the CVAMC procedures.

• If contractor re-codes an event with changes, comments will be placed in the Comments field in CCM, not Claims Tracking. CVAMC will review whether event has been billed and needs action due to code changes.

3. EMERGENCY DEPARTMENT

Contractor will code:

• CPT and ICD-9-CM for emergency room service or a level 1 office visit for encounters for prescription refills only.

4. INPATIENT PTF AND PRO FEES

Contractor will:

• Follow VA Coding Guidelines and coding procedures for coding the inpatient PTF’s and Professional Fees (Pro Fees).

• Contractor will use the 801 screen to code the Pro Fees.

• Contractor will complete all inpatient PTF’s and Pro Fees within the fourteen (14) day rolling closeout period.

5. GENERAL SPECIFICATIONS

• Contractor is responsible for providing personnel to perform coding activities.

• Contractor will maintain frequent communications with the CVAMC Chief of Heath Information Management Service (HIMS), regarding progress, workload status and/or problems.

• Upon request of the CVAMC Chief of HIMS, Contractor will remove any contractor staff that do not comply with VA Coding Guidelines or policies or meet the competency requirements for the work being performed.

• Contractor will abide by the American Health Information Management Association established code of ethical principles as stated in the Standards of Ethical Coding, published by AHIMA.

• Contractor will provide all labor, material (hardware and software, including coding books) and supervision necessary to perform coding for this contract. Contractor shall provide the list of software to CVAMC Chief of HIMS, and a list of the coders’ names that will perform their duties under this contract.

• Coder will ensure their materials are the current version, including books and software.

• Contractor will be notified of any official QuadraMed training held at CVAMC and invited to attend at contractor’s expense.

• Contractor is required to maintain records that document competence / performance levels of employees working on this contract in accordance with JHACO and other regulatory body requirements, including any VA guidelines or requirements.

• Contractor will provide a current copy of competence assessment checklist and annual performance evaluation to the COTR (CVAMC Chief of HIMS) for each employee working on this contract.

• Contractor must keep abreast of regulation changes affecting coded information, required Centers for Medicare and Medicaid System (CMS), the Office of Inspector General and others as appropriate, including all VA Guidelines and Regulations.

• Contractor shall be responsible for providing a contact person(s) and telephone numbers for the duration of the job.

• Contractor will possess all licenses, permits, accreditation, and certificates as required by law.

• Contractor must perform work in accordance with JCAHO standards.

• Contractor is required to validate any order for test procedures, in the medical record, to validate medical necessity.

• All deliverables, associated working papers, and other material deemed relevant by VA generated by the contract in the performance of this task order are the property of the United States Government. All individually identifiable health records shall be treated with the strictest confidentiality. Access to records shall be limited to essential personnel only.

• On-line records shall be secured at all times.

• At the conclusion of the contract all copies of individually identifiable health records shall be destroyed with certification of destruction. The contractor shall comply with the Privacy Act, 38 USC 5701, 38 USC 7332 and the Health Insurance Portability and Accountability Act (HIPAA regulations).

• Contractor will be responsible for insuring the confidentiality of all patient information and shall be held liable in the event of any breach of confidentiality.

• Access requirements to VA information system by contractors and contractor personnel shall meet or exceed those requirements as described in VHA Directives. Access shall be granted to non-VA users only if the purpose of access meets criteria of the Privacy Act, HIPAA and confidentiality regulations.

• Contractor must certify that all employees working on this contract have received Privacy Training and Cyber Security Training.

• Contractor’s employees will be required to sign access forms before starting work under the contract that require them to abide by the VA computer access security and confidentiality agreement.

• Contractor will be paid monthly, in arrears, upon receipt of a proper invoice for the services furnished in the previous month. The contractor will submit a monthly statement of cases coded. The COTR (CVAMC Chief of HIMS) will compare the invoice cost to the monthly statement of cases coded. Payment will be made upon written certification from the COTR (CVAMC Chief of HIMS) that services have been performed. Invoice must include the following:

o Company’s name

o Tax ID number

o Funding Obligation number

o Description of services (to include the total number of encounters coded)

o Hours worked by each coder

o Period of service

o Amount

o Address to remit

Invoices may be submitted via US Postal Service or fax:

Cheyenne VA Medical Center

Chief of HIMS, 136

2360 East Pershing Blvd

Cheyenne, WY 82001

6. REQUIRED CODER KNOWLEDGE AND SKILLS

Coders performing work must:

• Read and interpret health record documentation to identify all diagnoses and procedures that affect the current outpatient visit or ancillary service.

• Possess formal training in anatomy and physiology, medical terminology, pathology and disease processes, pharmacology, health record format and content, reimbursement methodologies and conventions, rule and guidelines for current classification systems (ICD-9-CM and CPT).

• Apply knowledge of current Diagnostic Coding and Reporting Guidelines for outpatient services.

• Apply knowledge of CPT format, guidelines, and notes to locate the correct codes for all services and procedures performed during the encounter/visit and sequence them correctly.

• Apply knowledge of procedural terminology to recognize when an unlisted procedure code must be used in CPT.

• Code in accordance with CCI Bundling Guidelines.

• Use the HCFA Common Procedural Coding Systems (HCPCS), where appropriate.

• Exclude from coding information such as symptoms or signs characteristic of the diagnoses, findings from diagnostic studies or localized conditions that have no bearing on current management of the patient.

• Clarify conflicting, ambiguous or nonspecific information appearing in the record by consulting with their supervisor who will, if necessary, discuss with CVAMC Chief of HIMS.

7. REQUIRED CODER EDUCATION AND EXPERIENCE

Coders must be credentialed and have completed an accredited program for coding certification, an accredited health information management or health information technician. A certified coder is someone credentialed by the:

• American Health Information Management Association (AHIMA) and includes RHIA, RHIT, CCS and CCS-P, or

• American Association of Procedural Coders (AACP) as a CPC or CPC-H,

Credentialed Coders must have a minimum of two years experience in the area they will be coding.

Contractor may utilize an experienced, but non-credentialed coder who is eligible to sit for the coding exams, provided: Each instance of using a non-credentialed coder is pre-approved by the Chief of HIMS via email; 100% of the non-credentialed coder’s work is reviewed by a credentialed contractor’s supervisor prior to returning work to CVAMC and the name of the non-credentialed coder appears on each invoice for those records s/he has coded.

8. QUALITY CONTROL PROCESSES

The contractor shall:

• Provide a list of coded records bi-weekly.

• Perform on-going assessment of not less than 5% of all coded services and provide bi-weekly (every other week) result to CVAMC to ensure that the 95% accuracy rate is met. Track results by coder to assure appropriate follow-up. Failure to provide the results of the audit on a bi-weekly basis will result in a 20% reduction in the negotiated price for work generated that week. Failure to report results within the specified time frame three times during a calendar year will result in termination of the contract.

• Monitor to ensure that the 95% quality standard is being met on an on-going basis. If monitoring demonstrates that work has fallen below the quality standard, the contractor must develop a corrective action plan and include it with the data for that week. The table below indicates the adjustment level in negotiated price for reduced accuracy rates.

|When accuracy rate is 94% |The reduction will be 5% for that week |

|When accuracy rate is 93% |The reduction will be 15% for that week and the following week |

• Re-review any coded data where VA finds a question during our pre-bill process or when a denial is received to either make changes or substantiate the coding with appropriate coding rules and references. This service is included in the price of the work.

• Use the following during the review processes:

1. Select a representative sample of all coding.

2. Count each one of the following as an error:

▪ Those codes that were coded and not supported in the documentation, violate a coding rule and/or

▪ Those CPT or diagnosis codes that should have been coded and were not and/or

▪ Unbundled codes.

9. METHOD OF AWARD

The award will be made on the basis of best value (the proposal which optimizes, quality, cost, and efficiency) to the most responsive and responsible proposer as determined in the evaluation process. The contract will not be awarded solely on the basis of lowest price. Instead, the award shall be made to the respondent(s) whose proposal demonstrates the best technical and professional expertise, and financial value to Cheyenne VAMC (436), Wyoming (hereafter shall be known as VAMC).

10. EVALUATION--COMMERCIAL ITEMS (October 2013)

(a) The award shall be made on the basis of best value (the proposal which optimizes, quality, cost, efficiency, and responsibly) to the most responsive and responsible proposer as determined in the evaluation process. The contract will not be awarded solely on the basis of lowest price. Instead, the award shall be made to the respondent(s) whose proposal demonstrates the best technical and professional expertise, and financial value to the Cheyenne VAMC (436) (hereafter shall be known as VAMC). The following factors shall be used to evaluate offers: (The following evaluation factors are listed in descending order of importance.  Any sub factors within an evaluation factor are equal in importance). 

10.1 FACTOR A:  Technical Capability – Describes an offerors overall ability to perform medical coding as it relates to the following:

1. Technical Excellence – Describe the process you have in place to ensure the coders maintain 95% accuracy in coding.

(a)  Discuss your method used for verifying that all cases are coded using the VA’s encoder system.

(b)  Provide detailed information that verifies staff adequacy to perform the contract (see paragraph 1.3.1 of the solicitation).

(f) Provide a list of coders currently employed by your company who will be used in the performance of this contract.

2.  Experience – Describe your overall experience performing and managing medical coding services, and your process for hiring certified coders.  Describe your experience in the medical coding business, include number of years.  Describe offeror’s experience in performing government contracts.  Describe any unique features or experience that differentiates your offeror from competitors;

3.  Quality Assurance – Describe offeror’s quality assurance program.  Describe the offeror’s continuous quality improvement program.

(a)  Provide a list and summary of administrative and technical QA personnel, including position and credentials, office location, hours available and telephone numbers.

(b)  Provide a list and summary outlining the position and authority of all administrative and management personnel, including position and credentials, office location, hours available and telephone numbers.

4.   Key Personnel – Describe the qualifications of proposed key personnel, their responsibilities and their experience performing and managing transcription contracts with the Government

10.2 FACTOR B: Price – Define as the all inclusive unit and estimated total price to provide coding services for the VAMC.

10.3 FACTOR C:  Past Performance - Offerors will be evaluated on their ability to perform the contract successfully.  Past performance evaluation will consider reliability of past performance information, source of information, and the relevance of information.  Offerors without relevant past performance or for whom past performance information is not available, will receive a neutral rating.  Relevant past performance information shall include key personnel who have relevant experience, predecessor companies, and subcontractors who will perform major elements of this solicitation.  Provide documentary evidence that your company’s primary business is medical coding and that your company (not another company acting with your oversight, or on your behalf, under a contractual arrangement) has actually performed and provided medical coding service for the past three years. Failure to provide documentation that your company provides medical coding service as described above will render your proposal nonresponsive. Provide at least three references whereby you have provided the same or similar services, of the magnitude described in this solicitation, to include company name, point of contact, current telephone number, type of contract, and period of performance.

Technical and past performance, when combined, is significantly more important than price.

(b) Options. The Government will evaluate offers for award purposes by adding the total price for all options to the total price for the basic requirement. The Government may determine that an offer is unacceptable if the option prices are significantly unbalanced. Evaluation of options shall not obligate the Government to exercise the option(s).

(c) A written notice of award or acceptance of an offer, mailed or otherwise furnished to the successful offeror within the time for acceptance specified in the offer, shall result in a binding contract without further action by either party. Before the offer's specified expiration time, the Government may accept an offer (or part of an offer), whether or not there are negotiations after its receipt, unless a written notice of withdrawal is received before award.

11. U.S DEPARTMENT OF VETERANS HEALTH ADMINISTRATION RESERVES THE RIGHT TO:

a. Determine a competitive range

b. Reject any or all proposals received in response to the RFP;

c. Withdraw the RFP at any time, at the agency’s sole discretion;

d. Make an award under the RFP in whole or in part;

e. Pursue any or all of the services described herein from alternate sources;

f. Disqualify a proposer whose conduct and/or proposal fail to conform to the requirements of the RFP;

g. Seek clarifications and revisions of proposals;

h. Require correction of arithmetic or other apparent errors for the purpose of assuring a full and complete understanding of a proposer’s proposal and/or to determine a proposer’s compliance with the RFP requirements;

i. Prior to the opening of proposals, amend the RFP specifications to correct errors or oversights, or to supply additional information about the services sought as such information becomes available;

j. Prior to the opening of proposals, direct proposers to submit proposal modifications addressing subsequent amendments or addenda to the RFP;

k. Change any date set forth in this RFP;

l. Waive any informality or any non‐material requirements of the RFP;

m. Negotiate with the successful proposer within the scope of the RFP in the best interests of Cheyenne VAMC;

n. Require proposers to submit best and final offers (“BAFOs”);

o. Award contracts to more than one successful proposer;

p. Negotiate with selected proposers prior to contract award;

q. Make any payment contingent upon the submission of specific deliverables; and

12. CONFIDENTIALITY OF PROPOSALS

Confidential, trade secret, or proprietary materials must be clearly marked and identified as such upon submission by the proposer. Proposers must provide specific justification as to why disclosure of particular information in the proposal would cause substantial injury to the competitive position of the proposer.

Properly identified information that has been designated confidential, trade secret, or proprietary by the proposer will not be disclosed except as may be required by the Freedom of Information Law or other applicable state or federal laws. In the event that the VAMC determines that the law requires that confidential information be disclosed, the VAMC will notify the proposer so that it may take whatever steps it deems appropriate.

13. PROPOSAL EVALUATION ‐ OVERVIEW

The ability to perform the requested services is most important in the evaluation proposals. In addition, proposals will be evaluated for: existing or potential conflicts of interests, financial and operational stability, as well as adequacy and completeness. The VAMC reserves the right to disqualify a proposer if, in the VAMC’s sole opinion, the proposal does not satisfy any or all of the evaluation criteria.

Proposals shall be evaluated based on subfactors described below - weighted measure of 100 points

• Technical Excellence ‐ 30 points

• Experience ‐ 20 points

• Quality Assurance – 20 points

• Key Personnel ‐ 10 points

• Past Performance ‐ 15 points

• Added Value Services ‐ 5 points

14. EVALUATION

Technical and past performance, when combined, shall be evaluated greater than price

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