DHHS/OS/ASMB/OGAM/Division of Contract Operations, 200 Independence Avenue, S.W., Room 443H, Humphrey Bldg., Washington, D.C. 20201

R -- TARGETING DIAGNOSTIC RELATED GROUP CODE VALIDATION STUDY SOL RFP-42-96-HHS-OS POC Gaynel M. Abadie (202) 690-7506 This is a combined synopsis solicitation for commercial items prepared in accordance with the format in Subpart 12.6, as supplemented with additional information included in this notice. THIS ANNOUNCEMENT CONSTITUTES THE ONLY SOLICITATION; PROPOSALS ARE BEING REQUESTED AND A WRITTEN SOLICITATION WILL NOT BE ISSUED. This is a request for proposal, RFP-42-96-HHS-OS. This solicitation document and its incorporated provisions are those in effect through Federal Acquisition Circular #40. This is a full and open competition acquisition. The requirement is as follows: BACKGROUND: The Office of Inspector General (OIG) has an oversight responsibility for the Medicare and Medicaid programs, and as such, must determine that these programs are operating as free as possible from fraud, waste and abuse and assure that the controls the Department places on the system and all effected parties are effective. Personnel resources are not available with in the Office of Evaluation and Inspections (OEI) to provide the services requested. It would not be cost effective to provide all of this expertise in-house. STATEMENT OF WORK: Since 1983, Medicare has paid hospitals for the care of its beneficiaries under a prospective payment system using Diagnostic Related Groups (DRGs.) The use of these Groups depends upon the accurate underlying ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modifications) coding that takes place in each hospital. Each DRG has assigned a weight which is considered a rough indicator of the relative costliness of a discharge. The higher the weight, the greater the reimbursement. The Case Mix Index (CMI) is the weighted average of the discharges. The CMI is calculated for each hospital every year and is indicative of the relative costliness of the case mix of each facility. Again, the higher the CMI, the greater the value of the discharges observed in a facility. The purpose of this procurement is to develop and test mechanisms to identify hospitals with potentially inappropriate upcoding. The contractor will conduct this work in two phases. In the first phase, working in close conjunction with personnel from the Office of Evaluation and Inspections, OIG, the contractor will develop and deliver a written design. This design will include an identification of indicators to classify hospitals with respect to their coding practices. The identification of alternate indicators may involve testing third party software or programs. One or more indicators, including the Hospital Case Mix Index, may be used but in any case, only one sample will be selected. The contractor shall also develop a sampling methodology to provide for the selection of appropriate and sufficient number of hospitals and medical records to test the efficacy of the indicators. In the second phase of the study, the contractor will execute the design developed in the first phase. The Office of Evaluation and Inspections (OEI) will identify the appropriate hospitals and medical records based upon the sampling plan and will obtain copies of the medical records using OIG authority. These records will be delivered by the OIG to the contractor. The OIG will also provide to the contractor computer data showing the codes used by the hospital in billing for the patient's care. Through a blinded process, the contractor shall review these Medicare beneficiary records. The contractor must maintain the confidentiality of the records and billing information during the review process. The contractor shall return the records to the OIG or their designate at the end of the review. The objective of the second phase review is to determine if the diagnostic and procedural information supplied by the hospitals, upon which fiscal intermediaries make DRG assignment determinations, is substantiated by information in the medical records. The coding errors must then be analyzed for areas of systematic concern. The contractor shall use the criteria and standards of the Committee of the International Classification of Disease and the Uniform Hospital Discharge Data Set. When a coder has completed coding a record, the contractor shall compare the new codes to the previously-hidden codes used by the hospital. When the codes differ, the contractor shall conduct a second review of the chart by a different coder. The contractor shall maintain records of the results of these re-reviews for internal quality control as well as for reporting purposes. The contractor shall deliver the initial recording and the results of any coding review for each case in a form to be mutually agreed upon between the contractor and OIG. The contractor shall also provide the results of their analysis in a report format to be mutually agreed upon. The contractor must also provide for specialized medical review of those records (estimated to be at 35 percent) where the coders believe that the narrative diagnoses and procedures are not supported by the medical record, whether they are coded correctly or not. In those instances, expert medical opinion is necessary. The contractor's physician reviewer shall arrive at a diagnosis of the patient's condition based on the content of the medical record. The physician-reviewer must be guided by what is documented in the record. The physician-reviewer shall record the diagnoses and procedures which he or she identifies. The physician shall list the principal diagnosis, up to four secondary diagnoses, and up to three procedures. A brief note indicating the basis for the physician's opinion shall be included. The coders will then provide the proper coding for this medical record. Technical details, such as when a long- standing disorder should be included as a secondary diagnosis, will be clarified by consensus among the contractor and OEI representatives. If more than one medical reviewer is used in the study, the contractor will need to conduct appropriate tests for consistency of opinion among the various reviewers. These tests will be developed in conjunction with OEI representatives. The contractor shall characterize and tabulate the type and degree of coding errors. The forms and computer files to maintain these records shall be developed by the contractor, with final approval by the project officer. The contractor shall provide a written report of the results of the coding review in a mutually agreed upon format. A final report of the results of the project shall be delivered subsequent to the coding report at the completion of the contract. One senior project leader must maintain oversight for both phases of the contract. THIS IS PART 1 OF RFP-42-96-HHS-OS - SEE PART 2. (0234)

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