SOLICITATION NOTICE
Q -- Medical Coding FY21
- Notice Date
- 9/22/2020 4:55:35 AM
- Notice Type
- Solicitation
- NAICS
- 541519
— Other Computer Related Services
- Contracting Office
- 246-NETWORK CONTRACTING OFFICE 6 (36C246) HAMPTON VA 23667 USA
- ZIP Code
- 23667
- Solicitation Number
- 36C24620Q0973
- Response Due
- 9/23/2020 7:00:00 AM
- Archive Date
- 10/23/2020
- Point of Contact
- Stephanie M Patterson, Contract Specialist
- E-Mail Address
-
Stephanie.Patterson2@va.gov
(Stephanie.Patterson2@va.gov)
- Awardee
- null
- Description
- Page 2 of 2 This Sources Sought Notice is not a formal request for proposals or quotes. No formal solicitation document exists at this time. The government will not reimburse participants for any expenses associated with their response to this notice. The Department of Veterans Affairs, Network Contracting Office (NCO) 6, Regional Procurement Office (RPO) East, is in the process of planning a requirement for Medical Coding Services in support of the W.G. Bill Hefner Veteran Affairs Medical Center (VAMC), 1601 Brenner Ave., Salisbury, NC 28144. Please see the Performance Work Statement (PWS) attached. This potential requirement may be for a base period of 12 month plus four additional 12-month option periods. The applicable NAICS Code is 541519 Other Computer Related Services with a size standard of $30 Million. The VA is seeking written responses to assist with identifying potential sources that are interested in, and capable of, providing the services described. Please review the information contained herein and identify whether your company has the capability and interest to provide the services described herein. Vendors who submit incomplete responses will be considered unresponsive. Capability statement that demonstrates the firm s ability to meet the above requirement, which includes: Company Name: Company Point of Contact Name: Company Point of Contact Email: Company Point of Contact Phone: Company DUNS Number: Company GSA schedule under which these services can be purchased: Describe briefly the capabilities of your company and the nature of the goods and/or services you provide relative to the current requirement of Medical Coding Services. Is your company interested in subcontracting this opportunity? If so, describe in detail what part or parts of this requirement that your company is capable of performing. Also provide the CAGE code and DUNS number for all proposed subcontractors. Describe your company's past experience on previous projects similar in complexity to this requirement, and include contract numbers, a brief description of the work performed, period of performance, agency/organization supported, and individual point of contact (Contracting Officer or Program Manager). What quality assurance processes and test qualification practices does your company employ? Please provide a description of your quality program (ISO 9001, AS9100, etc.). Pricing Information: If available, please attach a price list for the requested services to illustrate typical pricing in the marketplace. Do not attach a quote or offer. The price list is for market research purposes only and will not be used to make an award. Company eligibility for set-asides under the following small business programs: Vets First Program Service Disabled Veteran-owned small business Vets First Program Veteran-owned small business 8(a) Business Development Program participant HUBZone small business Economically Disadvantaged Woman-owned small business Woman-owned small business Small business To be eligible for a VA SDVOSB or VOSB set-aside, the firm must be verified in the VA s Office of Small Business Utilization s (OSDBU) Veteran Information Pages (VIP) database at https://www.vip.vetbiz.va.gov/ as an SDVOSB or VOSB at the time the firm submits its quote to the VA. Additional information on VA s Veterans First Contracting Program can be found on OSDBU s website at https://www.va.gov/osdbu/verification/. In addition, the SDVOSB/VOSB must qualify as a small business under SBA s regulations. The Government reserves the right to contact any respondent and/or respondent reference to obtain additional information. At this time, no solicitation exists; therefore, please do not request a copy of the solicitation. Any resulting procurement action will be the subject of a separate, future announcement. The information is provided for market research purposes and any potential strategy for this acquisition may change prior to any solicitation release. The acquisition strategy, evaluation methodology, contract type, and any other acquisition decisions are to be determined. Vendors having capabilities necessary to meet or exceed the stated requirements are invited to provide information to contribute to this sources sought notice via e-mail to the Contracting Officer, no later than 7 September 2020 at 10:00 AM EST. Responses shall be emailed to: Stephanie.Patterson2@va.gov. PERFORMANCE WORK STATEMENT (PWS) Off-site Medical Coding Services W.G. Bill Hefner Veterans Affairs Medical Center Salisbury, NC Description of Services: 1.1 The contractor shall: 1.1.1 Assign the current appropriate industry standard codes after careful review of the Health Record documentation for all inpatient, outpatient, surgeries, procedures, and ancillary encounters/services. 1.1.2 Assign International Classification of Diseases, 10th Edition, Clinical Modification/Procedure Coding System (ICD-10 CM/PCS) codes upon implementation. 1.1.3 Furnish validation of the integrity, quality, and assignment of codes to the data contained in the outpatient Patient Care Encounter, inpatient Patient Treatment File, and non-Veterans Affairs episodes of care under Veterans Affairs auspices. 1.1.4 The latest United States editions of the International Classification of Diseases, Current Medical Information and Terminology, and Current Procedural Terminology, and Healthcare Common Procedure Coding System shall be used to provide uniform disease and operation terminology, which is complete and scientifically accurate. 1.1.5 Code assignment shall be in accordance with National Center for Health Statistics, Centers for Medicare and Medicaid Services, American Hospital Association, American Medical Association and American Psychiatric Association guidelines, as appropriate. On those occasions when there is a question, Veterans Health Administration Coding Guidelines take precedence. Local policies will direct how coding is accomplished and what quantitative and/or qualitative reviews are performed by the facility. The American Hospital Association Coding Clinic and other publications may be used for training and reference purposes. 1.1.6 Ensure that the contractor s coders providing services through this task order use the facility s national Veterans Affairs encoder product. All coding must be completed through the encoder product. The national Veterans Affairs encoder is a single transparent interface with the Veteran Affairs electronic health record system Veterans Health Information Systems and Technology Architecture and the Graphical User Interface version of Veterans Health Information Systems and Technology Architecture. All coding is required to be done via the national Veterans Affairs encoder; no other system shall be used or interfaced with the Veterans Affairs systems. 1.2 Contractor is responsible for the management and supervision of its staff. Contractor is responsible for training its staff on Veterans Affairs policy, guidelines, and procedures. 1.3 The contractor shall adhere to all coding guidelines as approved by the Cooperating Parties (American Hospital Association, American Health Information Management Association, Centers for Medicare and Medicaid Services, and the National Center for Health Statistics), as mandated by Health Insurance Portability and Accountability Act and accepted Veterans Affairs regulations, including the following applicable documents: 1.3.1 The Official Guidelines and Reporting as found in the Common Procedural Terminology Assistant, a publication of the American Medical Association for reporting outpatient ambulatory procedures and evaluation and management services 1.3.2 The current Official Guidelines for Coding and Reporting in the Coding Clinic for International Classification of Diseases, a publication of the American Hospital Association 1.3.3 The current Veterans Health Administration guidelines for coding as found in the Veterans Health Administration Health Information Management Coding Guidelines, Health Information Management, and Department of Veterans Affairs. This workbook is updated at least once per year with new codes and guidance. The contractor must ensure that they have the current version and the guidance is followed. Note: While Veterans Health Administration does ask for reimbursement from third party payers, the Veterans Health Administration coding policy is to code only according to coding guidelines. Our own compliance audits use only this definition when determining if any encounter or Patient Treatment File is coded correctly. 1.3.4 The Current Procedural Terminology Evaluation and Management codes assure documentation substantiates the code level assigned. 1.3.5 Veterans Health Administration Directive 2009-002 Patient Care Data Capture: http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=3091 1.3.6 Veterans Health Administration Directive 2011-006 Revised Billing Guidance for Services provided by Supervising Practitioners and resident: http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2363 1.3.7 Veterans Health Administration Handbook 1400.01 Resident Supervision: http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=2847 1.3.8 Veterans Health Administration Handbook 1907.03 Health Information Management Clinical Coding Program Procedures: http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2794 1.3.9 Veterans Health Administration Handbook 1907.01 Health Information Management and Health Records: http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=3088 1.3.10 Veterans Health Administration Directive 2011-025 Closeout of Veterans Health Administration Corporate Patient Data Files including Quarterly Patient Census: http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=2419 1.3.11 Other directives that Veterans Affairs may issue from time to time. 1.4 All written deliverables will be phrased in layperson language. Statistical and other technical terminology will not be used without providing a glossary of terms. 1.5 Upon request of the Contracting Officer (CO), the contractor shall remove any contractor staff that do not comply with Veterans Health Administration policies or meet the competency requirements for the work being performed. 1.6 The contractor shall abide by the American Health Information Management Association established code of ethical principles as stated in the Standards of Ethical Coding published by American Health Information Management Association. 1.7 All coding and auditing activities shall be performed remotely and will utilize Veterans Affairs electronic health record. 1.8 The contractor shall provide all labor, materials, transportation, and supervision necessary to perform coding and validation reviews for inpatient, observation, diagnostic tests, ambulatory surgery/medicine procedures and outpatient (clinic) data collection, evaluating the completeness and accuracy of coding diagnoses and procedures in accordance with official coding guidelines (Coding Clinics, Common Procedural Terminology Assistant, Centers for Medicare and Medicaid Services /American Medical Association, Ambulatory Patient Classifications ) in a simulated Medicare payment environment. 1.9 Communication: 1.9.1 The contractor shall specify a contact person and phone number who is available for personal contact, at a minimum, during regular business hours of the facility that owns the work, for the duration of the work. 1.9.2 The contractor shall maintain weekly communication with the Contracting Officer s Representative (COR) or other designee (i.e., coding supervisor/team leader) regarding cost to date, progress, workload status and/or problems. 1.9.3 The contractor shall make every effort to ensure that issues raised by the local facility are addressed within forty-eight (48) hours with the facility COR. 1.9.4 The contractor shall ensure that communications that contain Personally Identifiable Information, Personal Health Information and/or individually identifiable health information/record are encrypted to prevent inappropriate/unauthorized access or disclosure. The Veterans Affairs facility COR will advise the contractor of the encryption to be used. 1.10 Contract coders shall code in accordance with all Current Procedural Terminology / Current Procedural Coding Systems coding rules such as Correct Coding Initiative Bundling Guidelines, and use the Healthcare Common Procedural Coding Systems, level II codes, where appropriate. 1.11 Contract coders shall exclude coding information such as symptoms or signs characteristic of the diagnoses, findings from diagnostic studies, or localized conditions, which have no bearing on current management of the patient or as appropriate. 1.12 Contract coders shall clarify conflicting, ambiguous, or non-specific information appearing in the record through physician inquiries and by consulting with their supervisor who will, if necessary, discuss with the COR. 1.13 The contractor shall code using the appropriate Current Procedural Terminology for inpatient professional services or nursing home professional services as well as the proper current International Classification of Diseases codes for all diagnoses. 1.14 Quality Assessment of Health Information Services: 1.14.1 The contractor shall possess all licenses, permits, accreditation and certificates as required by law. 1.14.2 The contractor shall perform the required work in accordance with The Joint Commission, Veterans Health Administration, and other regulatory standards. The Joint Commission standards may be obtained from: The Joint Commission One Renaissance Blvd Oakbrook Terrace, IL 60181 1.15 Exclusions and Sanction Certification: The contractor shall provide annual written certification to the CO which certifies that all employees, Sub-Contractors, and their employees have been checked to ensure that all agents providing services under the task order have been found not to be listed on the List of Parties Excluded from Federal Programs and the Health and Human Services/Office of the Inspector General Cumulative Sanction Report. The annual certification shall be provided within three weeks after award and within three weeks after the exercise of any options periods. 1.16 The contractor shall be responsible to train new Contract staff (including subcontractors, if applicable) on Veterans Affairs policy and procedures and ensure completion of any Veterans Affairs mandatory training, security clearances, or other tasks required for contractor staff to perform the services outlined in this PWS. 1.17 The contractor staff shall sign confidentiality statements as required. Any person, who knowingly or willingly discloses confidential information from the Veterans Affairs, may be subject to fines. 1.18 Health Insurance Portability and Accountability Act regulations require Veterans Health Administration to execute Health Insurance Portability and Accountability Act compliant Business Associate Agreements with appropriate parties that collect, receive, use, or disclose Veterans Health Administration Protected Health Information to perform activities, functions, or services for Veterans Health Administration. 1.19 The contractor will abide by VHA and National Archives and records Administration (NARA) records management guidelines. 2.0. Specific Mandatory Tasks and Deliverables: 2.0.1 The contractor shall not commence performance on the tasks in this Performance Work Statement (PWS) until the CO has conducted a kick off meeting or has advised the contractor that a kick off meeting is waived. 2.0.2 The contractor shall provide the specific deliverables described below by the timeframes specified. 2.0.3 The contractor and the COR shall meet via teleconference, at minimum, quarterly to review and discuss workload quantities for the quarter and projected workload requirements for the upcoming quarter. Any workload requirements that affect the scheduled quantities shall be mutually agreed upon by contractor and COR. The CO shall approve and execute any revisions to the schedule via modification. 2.1 Task One - Coding Services: 2.1.1 The contractor shall use skills, training, and knowledge of International Classification of Diseases, Current Procedural Terminology, and Healthcare Common Procedural Coding System Level II code sets and guidelines and other generally accepted available resources to review health record documentation and providers scope of practice to assign diagnostic and procedural codes at a minimum 95% accuracy rate and within required performance timelines. 2.1.2 The contractor shall code Outpatient Encounters including Radiology, Lab or other Ancillary Services, Surgical to include pathology and anesthesia services, Inpatient Professional Services; and Inpatient Episodes/Admission Services; shall include required encoder/ Veterans Health Information Systems and Technology Architecture data elements in accordance with Veterans Health Administration Handbooks and protocols as specifically outlined in the task order. Other identified cases to be coded include but not limited to: Veteran Tortfeasor Claims; Veteran Workers Compensation, Humanitarians, beneficiaries of the Military Health System (TRICARE is the healthcare program servicing military beneficiaries), Civilian Health and Medical Program of the Department of Veterans Affairs, Ineligibles, Fugitive Felon, Prosthetics, non-Veterans Affairs Fee Services, and New Insurance/Late Checkout. 2.1.3 New Insurance/Late Check Out encounters may not have been coded due to new insurance identified or late check-out and were not identified in the daily coding reports. New Insurance/Late Check Out encounters shall be coded within seven (7) days of coder assignment. 2.1.4 The contractor shall use the 1995 or 1997 Evaluation and Management guidelines as specified in the facility policy. 2.1.5 Veterans Health Administration provides a wide variety of primary and specialty care services in the outpatient setting. Inpatient admissions include those for acute care/specialty care, observation, and admissions to the Community of Living nursing care, and domiciliary units to include non-Veterans Affairs Fee services. 2.1.6 The contractor shall abstract other identified data items and enter the data into the local Veterans Health Information Systems and Technology Architecture system, encoder program, or write the information on source documents as agreed with the local facility. This information shall include a decision as to whether or not an encounter is billable, based on non-compliance with documentation and resident supervision guidelines. Coders will utilize the Case Comment communication tool to provide billing staff with a standardized reason (case comment) why they believe an outpatient encounter cannot be billed. Encounters believed to be not billable will be marked with the appropriate Case Comment. Case Comments may include, but is not limited to Agent Orange exposure or Ionizing Radiation, telephone care, non-billable provider, insufficient documentation, or other types of care that cannot be billed. Contractor shall be available to answer any follow up questions regarding the episode and provide references in support of their code selection. Contractor will also record episodes as required. 2.1.7 The contractor shall provide all labor, materials, transportation and supervision necessary to perform coding and abstracting using either the 1995 or 1997, per VA Medical Center policy, the Evaluation and Management guidelines on encounters and standard industry guidelines, e.g. Coding Clinics and Current Procedural Terminology Assistant, as specified by the Veterans Affairs Administration Center. 2.1.8 The contractor shall adhere to all coding guidelines as approved by the Cooperating Parties and accepted Veterans Affairs regulations. 2.1.9 The contractor shall utilize Veterans Health Administration national encoder, industry standard guidelines, Veterans Health Administration and local policies, and other generally accepted contractor supplied reference materials to assign and/or validate diagnostic and procedural codes reflective of documentation. 2.1.10 The contractor shall utilize the standardized Case Comments in the encoder application to communicate specific document information to Billing. 2.1.11 The contractor shall utilize Patient Care Encounter / Patient Treatment File / Surgery or other database, if necessary, to reflect code changes and names(s) of provider(s). 2.1.12 The contractor shall review and determine whether documentation is adequate to support billable services. 2.1.13 If requested by the facility, the contractor may place a local coder on-site if available in accordance with the task order when the coder lives in the area of a Veterans Affairs facility requesting work. No travel costs will be charged in this scenario. 2.1.14 The contractor shall ensure that individual coders are clearly identified on all work; any paper documents shall clearly identify the individual coder. 2.1.15 When assigning multiple Current Procedural Terminology codes, the contractor shall verify that they are not components of a larger, more comprehensive procedure that can be described with a single code. 2.1.16 The contractor shall identify those encounters, if any, where documentation does not substantiate an appropriate code(s). 2.1.17 The contractor shall identify duplicate encounters or encounters created in error because the patient was not seen. 2.1.18 The contractor shall code based on reading and reviewing the documentation in the health record including the Computerized Patient Record System and Veterans Health Information Systems and Technology Architecture Imaging. The contractor shall complete data entry into the encoder application that is integrated with the Veterans Health Information Systems and Technology Architecture system as part of this Contract. Completion of source documents in lieu of Veterans Health Information Systems and Technology Architecture entry may be arranged only upon mutual agreement between the facility task order CO and the contractor. 2.1.19 The contractor shall coordinate with the local COR for implementation of contingency plans for data entry when required. 2.1.20 The contractor shall assign modifiers as appropriate to override Correct Coding Initiative edits. 2.1.21 For Inpatient Episodes/Admission Services: Complete all Patient Treatment File Transactions (e.g., 101, 401, 501, 601, and 701/702) in accordance with Veterans Health Administration Handbooks, 1907.03 HIM Clinical Coding Program Procedures and 1907.04 Patient Treatment File Coding Instructions 2.1.22 Opening and transmitting Patient Treatment Files will follow local facility protocol. The contractor shall review documentation to determine why an ancillary or other diagnostic test was ordered and assign an International Classification of Diseases diagnosis code, as appropriate based on date of service, to that test. Contractor shall add the referring providers name in coding case comments. 2.1.23 The contractor shall re-review any coded data when questioned by Veterans Affairs staff due to a billing edit, when a denial is received, or when a retrospective review is completed, to either make changes or substantiate the coding with appropriate coding rules and references. This service is included in the price of the work. The contractor shall use the following during re-review processes: 2.1.23.1 Those codes that were coded and not supported in the documentation, violate a coding rule 2.1.23.2 Those Current Procedural Terminology or International Classification of Diseases diagnosis codes that should have been coded and were not, 2.1.23.3 Inappropriate Current Procedural Terminology or International Classification of Diseases codes 2.1.23.4 Unbundled codes 2.1.23.5 Ancillary encounters with only a diagnosis of V72.5 or V72.6 2.1.23.6 Inaccurate Diagnosis Related Groups assignments 2.1.23.7 All other data elements incorrectly entered by the Contract coder, or not entered when appropriate, e.g. coder case comment, provider, adequacy of documentation. Note: All subsequent reviews completed after the initial review work will be forwarded to the contractor s designated contact person for resolution. The contractor along with the VA facility shall jointly determine a communication mechanism whereby the contractor shall access daily unless otherwise indicated on the task order. Veterans Affairs reserves the right to validate all coding, audit results and/or accuracy statistics submitted. 2.1.25 Inpatient Facility Coding: 2.1.25.1 Inpatient facility coding is to be completed within seven (7) calendar days from the date of discharge. 2.1.25.2 Per VHA Directive 2011-025, all Patient Treatment File data must be accepted by the Austin Information Technology Center and/or Veterans Health Administration Corporate Data Warehouse no later than seven (7) calendar days from the data of patient discharge. The only exceptions are Patient Treatment File discharges from Contract or Community Nursing Home and non-Department of Veterans Affairs Purchased Care patient files. Error corrections must be re-transmitted by the closeout deadline. 2.1.25.3 Inpatient facility coding is performed on all inpatient episodes of care, to include Observation and non- Veterans Affairs care under Veterans Affairs auspices, regardless of billable status. Applicable coding guidelines will be followed. 2.1.25.4 All inpatient facility coding will be entered into the Patient Treatment File utilizing the encoder software. 2.1.25.5 The Veterans Health Administration Handbook 1907.04 establishes procedures and covers the responsibilities and requirements for the appropriate use of the Patient Treatment File and provides specific instructions for completing each Patient Treatment File transaction (e.g., admission transaction (101), Patient Movement Transaction (501), Surgical Transaction (401), etc.). 2.1.25.6 A Present on Admission field entry is required for patients that are admitted to certain levels of care. The Present on Admission field is not required for Community Living Center and Domiciliary patients. The Present on Admission provides information on whether a diagnosis was present at the time of a patient's admission. The indicator is required to be assigned to all diagnosis codes involving inpatient admission. Each diagnosis, principal and secondary, and external causes of injury are required to have a Present on Admission indicator appended. 2.1.25.7 Non- Veterans Affairs purchased care Patient Treatment File coding utilizes the non- Veterans Affairs invoice, as well as submitted clinical documentation if received. 2.1.26 Inpatient Professional Encounters/Services Coding: 2.1.26.1 Inpatient Professional Encounters/Services coding is to be completed within seven (7) calendar days of the date coding is assigned. 2.1.26.2 Veterans Health Administration Directive 2009-002 Patient Care Data Capture: It is Veterans Health Administration policy to capture and report inpatient billable professional services and inpatient professional mental health services to support the continuity of patient care, resource allocation, performance measurement, quality management, provider productivity, research, and third-party payer collections. This directive requires the capture of defined inpatient professional mental health services regardless of the third-party billing status. 2.1.26.3 Mental Health Inpatient Professional Services are inclusive of daily evaluation and management, therapy sessions, consultations, etc. For purposes of patient care data capture, mental health services include inpatient professional services performed by a psychiatrist with the credentials of Medical Doctor or Doctor of Osteopathic Medicine, psychologist with the credentials of Doctor of Philosophy or Doctor of Psychology, master level social workers, or physician extender with the credentials of Nurse Practitioner, Clinical Nurse Specialist or Physician Assistant in an inpatient setting, location of the service notwithstanding. 2.1.26.4 Evaluation and Management services are used to capture the provider s professional encounters/services performed in an inpatient setting. The Diagnostic Coding and Reporting Guidelines for Outpatient Services (Hospital-Based and Physician Office) should guide coders when coding inpatient diagnoses for physician professional services. Use the 1995 or 1997 Evaluation and Management guidelines as specified in the facility policy. 2.1.26.5 Identify and link Current Procedural Terminology and International Classification of Disease codes, identify the provider, and the date(s) of service. 2.1.26.6 Guidelines for capturing the inpatient professional encounter/services are contained within the current Veterans Health Administration Coding Guidelines. 2.1.26.7 Contractor may be required to create the Inpatient Professional Service encounter in the Patient Care Encounter application in order to code the service. 2.1.27 Outpatient Coding: 2.1.27.1 All coding is to be completed within seven (7) calendar days of the date coding is assigned. 2.1.27.2 Outpatient encounters include face-to-face encounters and other occasions of service that are captured within the Patient Care Encounter. These services are captured through completion of electronic encounter forms; review of documentation by qualified coding staff; and automated data capture within radiology and laboratory Veterans Health Information Systems and Technology Architecture packages. 2.1.27.3 Applicable coding guidelines will be followed; outpatient coding guidelines are contained with the current Veteran Health Administration Coding Guidelines. Use the 1995 or 1997 Evaluation and Management guidelines as specified in the facility policy. 2.1.27.4 Assign or validate diagnostic and procedural codes reflective of documentation; correct the Patient Care Encounter, if necessary, to reflect code changes and name(s) of provider(s). 2.1.27.5 Typically outpatient coding does not require the coder to create encounters. Most outpatient encounters are initiated at the location of the visit, at time of patient check- in, and when the provider completes the visit at patient check-out and or completion of the encounter forms. 2.1.28 Surgery Case Coding to Include Anesthesia and Pathology: 2.1.28.1 Surgical coding must be completed immediately after the procedure when possible and no later than one week from the date of the procedure. 2.1.28.2 Surgery case coding includes the entry of coded procedures and diagnoses for all surgery cases. It is necessary to assign or validate diagnostic and procedural codes reflective of documentation for all cases in the surgery package. 2.1.28.3 Assign and enter the diagnostic codes and procedural codes with associated modifiers reflective of documentation using the encoder into the surgery package. 2.1.28.4 Validate that all cases successfully pass from the Surgery Package to Patient Care Encounter using the Patient Care Encounter Filing Status Report. 2.1.28.5 Assign and enter associated billable anesthesia and pathology services related to the surgery using the encoder into the Patient Care Encounter. 2.1.28.6 Anesthesiology visits for surgery performed in the Operation Room may require coders to create encounters for the services as they may not already exist in Patient Care Encounter. 2.1.28.7 Instructions for surgery coding are contained in the Veterans Health Administration Coding Guidelines. 2.1.29 Task One Deliverables: 2.1.29.1 Inpatient Facility Coding 2.1.29.2 Inpatient Professional Encounter/Services Coding 2.1.29.3 Outpatient Coding 2.1.29.4 Surgery case coding to include pathology and anesthesia services. 2.2 Task Two External Auditing Service: 2.2.1 Audit services shall be performed monthly. 2.2.1.1 The VISN 6 External Audit Spreadsheet will be uti...
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