PAGE: 1 of 6 / REPLACES POLICY DATED:
EFFECTIVE DATE: May 31, 2004 / REFERENCE NUMBER: HIM.COD.014
SCOPE: All Company-affiliated facilities including, but not limited to, hospitals and all Corporate Departments, Groups and Divisions, including, but not limited to, the following departments:
Facility Health Information Management Finance
Corporate Health Information Management Services Administration
Patient Accounting/Business Office/Central Business Legal
Ethics & Compliance Officer Ancillary Departments
Case Management/Quality Resource Management Nursing
National Agreements/Materials Management Ambulatory Surgery Centers
PURPOSE: To assist facilities to achieve complete, accurate, consistent, and timely coding by ensuring that coding services performed by contract coding/outsourcing vendors are compliant with official coding guidelines, Company coding policies, the Company Code of Conduct and other regulatory requirements, by providing guidelines for vendor selection and recommendations for preferred vendor relationships.
POLICY: Contract coding/outsourcing vendors performing final ICD-9-CM and CPT code assignments will meet the quality and business practice standards established in this policy in addition to those requirements outlined in the Corporate Integrity Agreement (CIA) as a covered contractor, or covered person. Contract coding/outsourcing vendors that are listed as Preferred Vendors must meet the quality and business practice standards in addition to other specified criteria, as specified in this policy. The facility, group, division, or corporate department needing the service may choose a vendor that is not considered a Preferred Vendor as defined in this policy, provided the vendor meets the quality and business practice standards in addition to other specified criteria, as specified in this policy.
DEFINITIONS:
Covered person
(a) Any officer, director or employee of HCA or any of its subsidiaries; or
(b) Any agent or other individual who furnishes health care items or services to any Federal health care program beneficiary at a facility owned or operated by HCA or any of its subsidiaries for which HCA or any of its subsidiaries claims reimbursement from any Federal health care program. Notwithstanding the above, this term does not include part-time or per diem employees, agents or other individuals who are not reasonably expected to work more than 160 hours per year, except that such persons shall become “covered persons” at the point they work more than 160 hours during the calendar year.
Covered Contractor
Any agent or other individual (who is not a covered person) who prepares claims, cost reports, or other requests for reimbursement from any Federal health care program on behalf of HCA or any of its subsidiaries on a regular basis (i.e., for more than 80 hours within the calendar year).
PROCEDURE:
I. The Corporate HIMS Preferred Contract Coding/Outsource Vendor Selection Process
The Health Information Management Services (HIMS) Department is responsible for approving the preferred contract coding/outsource vendors and maintaining the preferred vendor list.
1. Requests from vendors to become a preferred contract coding vendor must be submitted in writing to the HIMS Coding Vendor Project Coordinator. Direct requests will be considered during open bid periods only.
2. The HIMS Coding Vendor Project Coordinator will issue a standard Request for Proposal (RFP) requiring the vendor criteria information in writing.
3. The HIMS Coding Vendor Project Coordinator and another member from the HIMS team will review responses to the RFP to determine if the vendor meets criteria for preferred contract coding/outsource vendor consideration.
4. Vendors meeting the criteria specified in Section I of this policy for a Preferred Contract Coding/Outsource Vendor status must be interviewed by the HIMS Coding Vendor Project Coordinator and a minimum of two (2) other members of the HIMS team. Members must agree to approve the vendor.
5. National Agreements will review the vendor financial information and proposed pricing.
6. National Agreements and the HIMS team will negotiate a standard contract following terms set forth by Corporate Legal and including the RFP requirements listed in Attachment A. Contract negotiations will take place following National Agreements departmental policy that includes contract approval by the Corporate Legal Department. Contract terms will not exceed 24 months.
7. Upon successful completion of contract negotiations, the vendor will be notified and a contract may be initiated.
8. The HIMS Coding Vendor Project Coordinator along with HIMS management will determine annually the necessity of an open bid period. Open bid periods may not be necessary when additional vendors are not needed and/or current vendors’ services are satisfactory.
9. HIMS will determine the number of vendors necessary for a Preferred Contract Coding/Outsource Vendor arrangement based on the company’s’ initiatives.
10. All steps in this process must be documented and maintained in the HIMS vendor file.
Any facility, Group, Division, or Corporate Department wishing to use a vendor not on the preferred vendor list to perform contract coding service must perform the procedure outlined in Section IV of this policy before making a business arrangement with such a vendor.
II. Maintaining the Preferred Contract Coding Vendor List.
HIMS will maintain the Preferred Contract Coding vendor list as follows:1. Vendor information, including vendor contacts, contract information, and other pertinent information will be maintained in the electronic Vendor Database.
2. The HIMS project team will review the Preferred Contract Coding vendor project at least quarterly to achieve the following:
· Evaluate the number of current vendors involved in performing contract coding services in our facilities and determine if there are adequate numbers to assist in accomplishing the necessary contract coding services. If the need for additional vendors is identified, an open bid period will be announced and the procedure for certifying preferred vendors will be followed.
· Discuss outstanding contract and service issues with National Agreements and determine a plan for resolution.
3. Contract renewals or extensions are to be approved by the HIMS Coding Vendor Coordinator and HIMS Management.
4. All requests for contract termination with preferred contract coding vendors must be in writing and approved by the HIMS Coding Vendor Project Coordinator and National Agreements.
5. HIMS will update the Preferred Vendors for Contract Coding/Outsourcing Vendor Policy and Procedure and all attachments as changes occur and communicate these changes throughout the Company following the policy and procedure revision process.
III. Quality and Business Practice Standards for Contract Coding Vendors
ALL contract coding vendors providing ICD-9-CM and CPT coding services shall meet the following quality and business practice standards before entering into a contractual relationship with any company facility, division, group, or corporate department for temporary inpatient or outpatient coding support. The following criteria are priority criteria, which must be met in order for a vendor to be utilized. Specific contract items are listed in Attachment D. The vendor must:1. Abide by the Official Coding and Reporting Guidelines, coding advice published in the Coding Clinic for ICD-9-CM, and the CPT Assistant, except in the instance of unique payer requirements.
2. Abide by HCA HIM/coding policies.
3. Agree to enter into contracts that will be based on time and materials only in accordance with company policy.
4. Agree to enroll in any education programs sponsored by corporate HIMS as requested.
5. Agree to abide by the Company Code of Conduct, or by their own company documented code of conduct provided it is similar to the Company’s.
6. Agree to distribute to all vendor employees working on Company matters, the Company’s Confidential Disclosure Program.
7. Demonstrate that all designated vendor agents are qualified to perform the work assigned.
8. Demonstrate an individual or company plan to obtain training and continuing education. Covered persons must meet the requirements specified in the CIA in regards to on the job training, and continued education. This will be monitored by the facility and reported quarterly with the ECO quarterly reports.
9. Provide a documented plan for compliance and/or quality assurance.
10. Agree to complete HCA confidentiality statements.
11. Provide recommendations for services from knowledgeable references.
12. Agree to immediate contract cancellation for contract violation.
13. Demonstrate a professional certification in this field of expertise with a nationally recognized credential or certification from the American Health Information Management Association or the American Academy of Professional Coders.
14. Documentation that the Vendor, employees, and/or subcontractors (working on behalf of the vendor) are not included on the OIG exclusion list.
The following criteria are required for preferred contract coding/outsource vendors, but left to the facility’s discretion when going through the Contract Coding/Outsource Vendor Selection Process. The vendor should:
1. Have a methodology in place for measuring client satisfaction and agree to make results of this available throughout the company upon request.
2. Agree to 30-day contract cancellation without cause.
3. Provide proof of liability insurance (including errors and omissions policy) with minimum limits acceptable to the Company ($300,000 and $100,000 minimums respectively) that also covers any subcontractors used by the vendor.
4. Agree to have work audited by the facility and/or HIMS upon request.
5. Maintain an internal quality control/compliance program for problem resolution.
6. Maintain documented internal coding policies.
7. Agree to “preferred competitive pricing.”
8. Agree to execute confidentiality statements.
9. Agree to notify the Company of any vendor merger or acquisition.
10. Agree to notify the Company of any external investigation by the Office of Inspector General or other agency for potential fraud and abuse allegations related to coding.
IV. Contract Vendor Selection Process (This section applies only to Facilities that choose to use a vendor other than the preferred contract coding/outsource vendor).
Any facility, group, division, or corporate departments requesting contract coding services support and wishing to use a vendor not on the Preferred Contract Coding/Outsource Vendor list should adhere to the following guidelines before proceeding with making arrangements:1. Submit a request for proposal (RFP) to the vendor.
2. Vendor/contractor must respond to the priority items pertaining to quality and business practice criteria outlined in Section II of this policy.
3. Responses to the RFP must be reviewed and evaluated by the facility HIM Director or his/her designee.
4. Vendors/contractors must meet or exceed business practice standards (see Section III) to be selected.
5. The HIM Director, or designee should interview vendors. Once the vendor is selected, enter into a contract using the standard template (Attachment B). The final contract should be reviewed and approved by Operations Counsel. If facilities choose not to use the standard template, or choose to modify the template, the contract must contain the criteria outlined in Attachment C. A copy of the Contract Coding/Outsource vendor contract should be made available and forwarded to HIMS Coding Vendor Project Coordinator upon request.
6. All steps in this process should be documented and maintained by the facility, division, group, or other department requesting the assistance.
7. Potential coding compliance issues and contract disputes are the responsibility of the facility/department hiring the vendor/contractor and should be handled through established channels.
V. Contract Coding/Outsource Vendor Engagement Arrangements
A facility, group, division, or corporate department, after engaging temporary coding support services from a Preferred or Facility arranged contract coding/ outsource coding vendor, must follow the guidelines below:1. The facility or department where the services are provided is responsible for keeping an activity log of dates and hours worked and numbers of charts coded by the contractor/vendor. Activity is to be reported to the HIMS Coding Vendor Project Coordinator upon request.
2. Provide orientation and training regarding company policies and facility specific policies, and coding tools and resources before the vendor begins performing the services.
3. Potential coding compliance issues are to be resolved at the facility/department level initially. Those issues, which cannot be resolved, should be handled through the facilities’ established channels. Inconsistent coding compliance and low coding quality evaluations, (less than 95 % accuracy) may lead to immediate termination of the agreement.
4. The vendor is subject to a 95% accuracy rate on all coding projects. Quality Control of the coding work must be performed on a routine basis; at least quarterly, or as directed by other company initiatives (coding vendors that do not remain in the facility for a full quarter must be reviewed at least once). Vendors who fall below the required accuracy rate will be subject to an action plan, including a 30 day follow up review at the vendor’s expense.
5. Payment to the vendor for services rendered is the responsibility of the facility.
REFERENCES:
Corporate Integrity Agreement
5/2004
ATTACHMENT A
The following policy statements are required to be included in the Request for Proposal (RFP):
· All vendors chosen must abide by the Official Coding and Reporting Guidelines, coding advice published in Coding Clinic for ICD-9-CM, CPT Assistant, and the Company HIM/Coding policies.
· All work completed by the vendor’s agents may be subject to audit by Health Information Management Services staff.
· All contracts will be based on time and materials only in accordance with Company policy. Proposals including fee structures or guarantees based on a percentage of reimbursement recovered, increase in case mix index or increase in complication/comorbidity (CC) percentage will not be considered.
· All vendors must agree to enroll in any Company sponsored educational programs/orientation sessions as requested.
· The following criteria must be met for certification:
o Abide by the Official Coding and Reporting Guidelines, coding advice published in Coding Clinic for ICD-9-CM, CPT Assistant, except in the instance of unique payer requirements.
o Abide by Company coding policies.
o Agree to have all work completed by the vendor’s agents subject to audit by the facility or Corporate HIMS Department.
o Agree to enter into contracts that will be based on time and materials only in accordance with Company policy.
o Agree to enroll in any Company sponsored education program/orientation sessions as requested.
o Demonstrate that employees are qualified to perform the work.
o Provide employee training and continuing education plan.
o Maintain an internal quality control/compliance program for problem resolution.
o Maintain documented internal coding policies.