R--Face to Face Training ICD-10
Department of Veterans Affairs, Columbia (SC) VAMC | Published August 21, 2015 - Deadline August 24, 2015
BACKGROUND: The WJBD VAMC and satellite outpatient clinics (CBOCS) located in Anderson, Greenville, Florence, Orangeburg, Rock Hill, Sumter, and Spartanburg encompasses primary, secondary, some tertiary care, acute medical, surgical, psychiatric, and long-term care. The main medical center is located in Columbia, South Carolina.
3. PEROID OF PERFORMANCE: To be determined but not later than 09/30/15
4. PLACE OF PERFORMANCE: William Jennings Bryan Dorn VA Medical Center (WJBD VAMC), 6439 Garners Ferry Road, Columbia, SC 29209.
5. PERFORMANCE REQUIREMENTS:
a. Vendor shall provide Face to Face training, which consists of a general overview to ICD-10 coding and specialty training to be delivered on site by at least 2 credentialed HIM consultants. Dorn VAMC is contracting for 3 initial days of on-site training and an additional unit of 3 days to be completed either consecutively or at a time to be determined by the facility and the consultants. Dorn reserves the right to increase the number of days of training, which may not be consecutive to initial training days and realizes this may impact travel, training and per diem costs. Dorn will contract to up to six general sessions or four specialty sessions per day. A maximum of three different specialty presentations can be selected from as many as 12 presentations, per day. Some presentations may be multi-specialty based. Specialty or general presentations may be repeated, based on facility's need.
b. HIM Consultants will hold either the AAPC or AHIMA credentials and a current ICD-10 CM/PCS Trainer Certificate from AHIMA. Up to three different specialty content presentations can be selected for each day. Vendor will agree to provide training via Power Point presentations and will be able to provide simulation of "real-patient processes" through Dorn's existing software. HIM Consultants will agree to have all sessions records through Dorn's Medical Media for future viewing, at no future costs through this contract or any other.
c. All facility providers, to include ancillary care providers, will attend the general overview ICD-10 training and may attend the specialty sessions, as needed. There will be no limit to those who attends the sessions to be provided.
d. Examples of content for multi-specialty areas/groups (12 in total):
" Primary Care
" Internal Medicine Hospitalist
" Psychiatry and Behavioral Health
" Physical Rehabilitation and Polytrauma
" Orthopedic Surgery
" General Surgery
" Emergency Medicine
e. Predetermined groups may consists of but may be subject to change based upon availability:
Specialty Training Content: ___________Can also be attended by these Specialty Providers:
Cardiology Internists, General Medicine
Primary Care______________________ Geriatric
Internists, General Medicine
Internal Medicine Hospitalist ________Internist
Psychiatry and Behavioral Health__Mental Health Providers to include Social Workers and
counselors and other Behavioral/Mental Health providers
General Surgery_________________ _ Any Surgical Specialty
Emergency Medicine______________ Urgent Care
6. Dorn VAMC will provide the following:
a. Number of attendees is unlimited as long as training room space can accommodate the training. VA will provide equipment to facilitate training such as but not limited to: microphones, projection screen and projector, internet connection, if needed to facilitate training. The consultants may furnish their own laptops or Dorn VA may furnish laptops, to facilitate training.
b. Medical Media is allowed during the presentation.
c. Dorn will make CPRS, VISTA, or other VA software available to conduct training, i.e during simulation of test patients.
7. Contractor will provide credentialed HIM consultants and any training materials.
8. CONTRACT PERFORMANCE MONITORING: The government reserves the right to monitor services in accordance with the Quality Assurance Surveillance Plan (QASP).
9. POINT OF CONTACT:
Contracting Officer's Representative (COR):
Name: Jerry Jones
Title: Supervisor, Record Room
Department: Business Office/HIMS
Telephone: 803-776-4000 x6283
10. TERMINATION FOR CONVENIENCE: Subject to a 14 day advance notice, the Government reserves the right to terminate this contract for convenience if the need for this service changes or is no longer required.
a. Payment will be made upon receipt of a properly prepared detailed invoice, prepared by the Contractor and submitted through Tungsten Network (formerly known as OB10) http://www.tungsten-network.com/us/en/. A properly prepared invoice shall contain:
" Invoice Number and Date
" Contractor's Name and Address
" Accurate Purchase Order Number
" Supply or Service provided
" Period Supply or Service Provided
" Total Amount Due
b. Please begin submitting your electronic invoices through the Tungsten Network for payment processing, free of charge.
c. If you have questions about the e-invoicing program or Tungsten Network, contact information is as follows:
" Tungsten e-Invoice Setup Information: 1-877-489-6135
" Tungsten e-Invoice email: VA.Registration@Tungsten-Network.com
" FSC e-Invoice Contact Information: 1-877-353-9791
" FSC e-invoice email: firstname.lastname@example.org
d. Web Address: HTTP://WWW.FSC.VA.GOV/EINVOICE.ASP
a. PERSONNEL SECURITY: The contractor and all personnel employed by the contractor shall be required to observe the requirements imposed on sensitive data by law, federal regulations, VA status and DE&S policy and the associated requirements to ensure appropriate screening of all personnel because of the inherent sensitivity of data at the facilities concerned and the level of security clearance carried by the Health Care Facility (HCF) personnel for the function under contract. The Contractor shall ensure that their personnel meet the above restrictions and that confidential and proprietary information shall be divulged only to those officers and officials of the VA Medical Center that ar authorized to receive such information.
b. BACKGROUND INVESTIGATION: Contractor personnel performing work under this contract shall satisfy all requirements for appropriate security belonging to or being used on behalf of the Department of Veterans Affairs. To satisfy the requirements of the Department of Veterans Affairs, a low risk level Background Investigation (BI) shall be conducted prior to performing work under this contract. Appropriate Background Investigation (B)I) forms will be provided upon contract award, and are to completed and returned to the VA Office of Security and Law enforcement (OSL&E) within 30 days for processing. Access to VA protected health information and personally-identifiable information cannot be made available until the Security Investigations Center submits the investigatory packet to OPM for processing. At that time, the investigation is considered initiated" and access can be provided. Contractors and Contracting Officers/CORs will be notified by OSL&E when the BI has been completed and adjudicated.
The investigation history for contractor personnel working under this contract must be maintained in the databases of either the Office of Personnel Management (OPM) or the Defense Industrial Security Clearance Organization (DISCO). Should the contractor use a contractor other than OPM or Defense Security Service (DSS) to conduct investigations, the investigative company must be certified b OPM/DSS to conduct contractor investigations.
Further, the contractor shall be responsible for the actions of all individuals provided to work for the VA under this contract. In the event the damages arise from work performed by the contractor provided personnel, under the auspices of this contract, the contractor shall be responsible for all resources necessary to remedy the incident.
c. PRIVACY TRAINING: All Contractor employees under this contract are required to complete the Privacy Awareness Training Course annually. Contactors must provide signed certifications of completion to the CO during each year of the contract. This requirement is in addition to any other training that may be required of the contractor. The Contractor shall complete the VHA Privacy Training at https://www.ees-learning.net.
d. SYSTEM of RECORDS: The Veteran Administration system of records to which the contractor personnel shall have access to in order to maintain patient medical records is described annually in the Federal Register. Contractor personnel who obtain access to hardware or media which stores drug or alcohol abuse, AIDS , or sickle cell anemia treatment records or medical quality assurance records protected by code U.S.C 4132 or 3305, as defined by the Department of Veterans Affairs, shall have access only to those records absolutely necessary to perform their contractual duty for which access was obtained. Violation of these statutory provisions by the contractor or contractor employee as stated in agency regulations may involve imposition of criminal penalties.
e. CONTRACTOR SYSTEM SECURITY: If personally-identifiable information is stored on IT equipment, the contactor shall ensure adequate LAN/Internet, data, information and system security in accordance with VA Standard operating procedures and Federal standards, laws and regulations as noted in VA Directive 6504, which can be obtained at www.va.gov. The contractor's firewall and web server must provide full desktop and laptop encryption on their systems. Any security violations or attempted violations shall be reported to the COR and VA Information Security Officer (ISO) immediately upon detection. The contractor shall adhere to applicable VA policies and procedures governing information security, especially those that pertain to certification and accreditation.
Upon receipt, the contactor shall provide VA with access to information pertaining to the way in which the contractor maintains VA patient data and step taken on an ongoing basis to assure the privacy and security thereof. This includes, but is not limited to information regarding computer network architecture, configuration of firewall(s), routers, and other pieces of networking equipment, information about installed security software, and audits of patches of unknown security vulnerabilities. All relevant security-related patches and anti-virus updates must be installed within 15 days of initial release.
f. The contractor will be required to execute a Business Associate Agreement with the Dorn VAMC.
13. RECORDS MANAGEMENT LANGUAGE FOR CONTRACTS:
The following standard items relate to records generated in executing the contract and should be included in a typical Electronic Information Systems (EIS) procurement contract:
a. Citations to pertinent laws, codes and regulations such as 44 U.S.C chapters 21, 29, 31 and 33; Freedom of Information Act (5 U.S.C. 552); Privacy Act (5 U.S.C. 552a); 36 CFR Part 1222 and Part 1228.
b. Contractor shall treat all deliverables under the contract as the property of the U.S. Government for which the Government Agency shall have unlimited rights to use, dispose of, or disclose such data contained therein as it determines to be in the public interest.
c. Contractor shall not create or maintain any records that are not specifically tied to or authorized by the contract using Government IT equipment and/or Government records.
d. Contractor shall not retain, use, sell, or disseminate copies of any deliverable that contains information covered by the Privacy Act of 1974 or that which is generally protected by the Freedom of Information Act.
e. Contractor shall not create or maintain any records containing any Government Agency records that are not specifically tied to or authorized by the contract.
f. The Government Agency owns the rights to all data/records produced as part of this contract.
g. The Government Agency owns the rights to all electronic information (electronic data, electronic information systems, electronic databases, etc.) and all supporting documentation created as part of this contract. Contractor must deliver sufficient technical documentation with all data deliverables to permit the agency to use the data.
h. Contractor agrees to comply with Federal and Agency records management policies, including those policies associated with the safeguarding of records covered by the Privacy Act of 1974. These policies include the preservation of all records created or received regardless of format [paper, electronic, etc.] or mode of transmission [e-mail, fax, etc.] or state of completion [draft, final, etc.].
i. No disposition of documents will be allowed without the prior written consent of the Contracting Officer. The Agency and its contractors are responsible for preventing the alienation or unauthorized destruction of records, including all forms of mutilation. Willful and unlawful destruction, damage or alienation of Federal records is subject to the fines and penalties imposed by 18 U.S.C. 2701. Records may not be removed from the legal custody of the Agency or destroyed without regard to the provisions of the agency records schedules.
14. Any changes referencing the PBSW will be communicated to and approved by the contracting specialist/officer in writing throughout the life of the contract.
15. CODING REQUIREMENTS:
WJB Dorn VAMC
Proposed Workload Audit
Type of Record to be reviewed
Inpatient Patient Treatment File (PTF) Records
Inpatient and Outpatient Surgical Encounters
Outpatient Encounters (Primary Care and Designated Specialty Clinics)
Coding responsibility: HIM coding Staff ONLY
FY 2015 Q1-Q2 - Total Surgical encounters (inpatient and Outpatient) - 1658 (10% to be audited (166))
Audit should include all coding staff and surgical Specialties listed below.
Coding staff employee names:
Need coding staff names from Laurice Hymes
Thoracic-(only Q2 data-100% review)
Coding responsibility: HIM coding Staff ONLY
FY 2015 Q1-Q2 - Total Inpatient PTF Records - 2315 (15% to be audited (347))
Audit should include all coding staff and (Coding staff listed below)
Coding staff employee names: Need coding staff names from Laurice Hymes
A random sampling of all Medical Service areas within the Patient Treatment Files (PTF) to include but not limited to Medicine, Mental Health (psychiatry), rehab medicine, surgery, etc.
A special focus within the Medicine service line for diagnoses of Pneumonia and heart failure.
Non-VA (NVCC-FEE) PTF records will NOT be audited.
Coding responsibility: HIM coding Staff AND provider/Clinical Staff
The HIM department validates 100% of all outpatient encounters that have a third party insurance carrier identified to the Veteran and the clinic has been flagged as a billable clinic; this is estimated to be approximately 20-25% of the Veteran population with the Dorn VAMC. There are outpatient clinics that the HIM staff will validate at a 100% depending on the workload volume of encounters with third party insurance ( i.e. Primary Care).
All clinical/provider staff enters ICD9 and CPT/Evaluation and Management codes in to encounters.
There will need to be an audit on the Coding staff and the clinic staff for identified stop coded areas.
There will need to be a review of encounters validated by coders AND encounters only coded by clinical staff.
The below are the outpatient auditing target areas.
Service Line Stop Code Total Encounters
Primary Care 323 102,988
Rock Hill 323
Women's Clinic 322 3,111
Total for below 133,695
Cardiology- Cardiac Caths 329,333,369
Interventional Radiology 153
GI Eval clinics 307
GI - Procedures 321
Hepatitis Clinics 337
Pain Clinics 420
Pulmonary - Procedures 104
Mental Health 502,509,510,512,513,533,534,548
Emergency Department 130,131
The newly developed "COLUMBIA VA MOBILE CLINIC" Columbia Division will need a 10% audit of all encounters coded.
FY 2015 Q1-Q2 - Total Encounters - 456 (10% to be audited (46))
Assumptions for Auditors Number of Charts Suggested Number of Charts Suggested % of Charts
Surgical 166 166 100% of Total
Inpatient Treatment File 347 347 100% of Total
Outpatient 23,979 2,398 10% of Total
Columbia VA Mobile Clinic (outpatient) 46 46 100% of Total
Total 24,538 2,957
**** The outpatient encounters are primarily Evaluation and Management codes NOT procedures; therefore they
should not have the same rate per chart as Surgery.
The exception to this would be the Cardiac cath and interventional radiology clinics and we could move these under
the surgery category for cost per chart.
****The Columbia VA Mobile clinic is primarily Evaluation and management coding with EKG's and echocardiograms.
These should have the same rate per chart as outpatient encounters.
External Auditing Service:
A. The facility task order will specify the period of performance for all audit services.
B. All medical coding audits conducted by the contractor shall be performed by an AHIMA or AAPC certified coding professional; i.e., CPC, CCS, RHIT, RHIA [CT: All of our auditors hold one or more of the specified credentials so this is not a problem if he adds this language.]
B. External audits provide validation of the integrity, quality, and assignment of codes to the data contained in the Patient Care Encounter and inpatient Patient Treatment File at each medical center as evidenced by proper documentation of the care or service provided to the patient. External Audits of coded data will be performed on any of the Veterans Health Administration required coding activities (e.g., inpatient, outpatient, surgery). These audits will be performed separate from normal coding activities and will conform to the task order as developed by the site. These audits will address accuracy of coded data, health record documentation issues, to include recommended remediation of specific documentation deficiencies, process improvement and identify educational needs. Audit accuracy expectations are 95% and above.
C. The contractor shall be responsible for reviewing all national coding guidelines, Veterans Health Administration Handbooks, Health Information Management Consolidated Patient Agreement Center Service Level Agreement, Veterans Health Administration Coding Guidelines, etc. as well as each facility's policies prior to commencement of an audit. References will be provided by the facility as needed. (we may want to speak with HIMs to acquire the facility level coding policies up front) [CT: This is part of the auditing planning meeting up front - language is not a problem]
D. To ensure the review findings have value to the facility, the facility will specify the data collection elements to be captured for the audit. The contractor may submit a suggested data collection tool; any changes must be mutually agreed to/approved by the facility task order Contracting Officer.
E. All reviews will utilize electronic auditing of the Computerized Health Record System whenever possible. Veterans Affairs and Non-Veterans Affairs records may be either scanned documents or hardcopy. The reviews will be conducted by remote data view and remote image view. Should the information not be contained in the Computerized Health Record System or Veterans Health Information Systems and Technology Architecture, the medical center will overnight the documentation to the vendor.
F. A detailed project plan may be requested by a facility should the audit require a significant level of effort and expertise. If the plan elements are not spelled out in the task order, the project plan at a minimum should include:
1. Specific timelines for completing the audit
2. Timeframe for the facility reports
3. Number of reviewers
G. If a sample size or the number of records to be audited is not stated in the task order the contractor shall develop a sample size that assures a 95% confidence level of accuracy for each of the auditing tasks specified on the task order, and should include inpatient hospitalizations, outpatient visits (E/M and Procedures), Ambulatory surgeries, and non-Veterans Affairs records (what are we asking for review here, NVCC??). [CT: I'm not sure what they are asking either " non-VA care"? Language in red is not an issue] The contractor shall submit with the proposal for each task order a detailed description of how they arrived at the sample size. At a minimum the sample size must include a review of the coding activities as specified on the task order and may include any or all of the following: inpatient hospitalizations, ambulatory surgery, diagnostic tests (endoscopy, bronchoscopy, cardiac catheterization, Percutaneous Transluminal Coronary Angioplasty, pulmonary function, radiology, laboratory, etc.), primary care, mental health, medicine sub-specialty, surgery, observation, neurology, and non-Veterans Affairs records [CT: Again, not sure if they mean "non-VA care?]. The facility may also provide a list of specific records to audit.
H. Outpatient, Inpatient Professional, Surgery, and Inpatient facility Audits:
1. Audit includes Evaluation and Management, Common Procedural Terminology procedures, and International Classification of Diseases diagnosis codes. Encounters/quarter are identified by billed episode and then audited against these three criteria. If the encounter does not have a Common Procedural Terminology procedure code associated with the visit, then that data point is not audited.
2. Use the 1995 or 1997 Evaluation and Management guidelines as specified in the facility policy. Review the Evaluation & Management code to determine if correct and identify the reason(s) if not. (please ask Laurice to specify on this. The last MCM I was involved in I thought stated 1995 guidelines. I can look for the MCM on my return to work. HIM national made each facility determine which set of guidelines would be used. [CT: I have seen some specify that only the 1995 E/M Guidelines be used.. This is a local determination and is being provided as guidance to the auditors.]
3. Determine the accuracy and sequencing of the diagnoses coded and identify the reason(s) if not.
4. Determine the accuracy of Common Procedural Terminology/Healthcare Common Procedural Coding System codes and modifiers and the reason(s) if not accurate.
5. Inpatient review criteria may include: principal and secondary diagnosis code (accuracy, omission, etc.), Diagnosis Related Groups accuracy, correct Present on Admission assignment.
6. The contractor shall have a methodology for resolving coding questions by reviewers and ensuring inter-reviewer consistency and reliability.
8. The contractor will provide a valid reference source when an error is identified within a patient record. [CT: sounds vague with lot of room for interpretation but I don't think it would be an issue. We would have to discuss if there is any impact.]
7. The contractor shall review findings with Chief, Health Information Management, facility Contracting Officer's Representative, management, and other designated medical center personnel. Any discrepancies identified during this process must be resolved prior to final written report.
8. The contractor shall be responsible for conducting at a minimum an exit conference with management officials at the discretion of the medical center to be coordinated with the Contracting Officer's Representative at the facility.
I. Reports on findings will be prepared to allow use by medical center staff in re-reviews, education or to provide management updates. Final report elements may be specified in the individual task order or developed with assistance from the facility Contracting Officer's Representative. Documentation of audit findings will be as requested by the facility and may include record ID, breakdown of record type (i.e., outpatient, inpatient, surgery), coder name (this is needed to provide one on one education to the coder), breakdown by code (Common Procedural Terminology, International Classification of Diseases, Evaluation and Management, modifier, etc.) of total number of codes reviewed; number of correct codes, accuracy rate, Diagnosis Related Groups reviewed (# correct; accurate); any code changes/errors and reason/reference for error; identified weaknesses and recommendation for correction. Also include any documentation issues/deficiencies and recommendation for improvement/remediation. [CT: I don't seen any issues with the additions to the paragraph.]
J. The contractor shall provide a final written report to the facility Contracting Officer's Representative within 15 business days following the review(s).
K. The contractor shall document in writing all records reviewed and provide such documentation to the facility Contracting Officer's Representative with the final report.
L. Education Plan: To be included in the audit process, weaknesses identified during the audit shall be used to provide a facility specific education/training plan, based on Veterans Health Administration coding and documentation regulations and guidelines, and local policy to present to Veterans Integrated Service Network/Veterans Affairs Medical Center management officials, physicians/clinicians, sub-specialties if needed, and for Veterans Health Administration coding staff to include any recommended remediation. Plan shall be submitted to the local Contracting Officer's Representative within seven (7) calendar days following the audit.
M. Task Two Deliverables:
1. Project Plan with description of sample size determination
2. Audit: Inpatient facility (Diagnosis Related Group) coding
3. Audit: Inpatient professional encounter coding including surgery coding
4. Audit: Ambulatory Surgeries [CT: I don't see an issue with this addition.]
4. Audit: Outpatient encounter/services coding
5. Report on audit results
6. Education Plan
VERA reviews will be conducted simultaneously with all selected records for coding reviews. The VERA review will identify any potential VERA Allocation loss associated with the documentation and/or coding of the chart. The VERA review will focus on the specified VERA Patient Classifications as defined on attachment A. (see attached)
Additional VERA elements to the coding reviews:
1. Coding guidelines (documentation) supports the VERA models requirements for diagnosis codes being listed as Primary and secondary in an outpatient or inpatient record.
2. Verify ICD-9 codes that have a VERA allocation impact are entered in to the 501 screen within the PTF record.