Department of Veterans Affairs VHA DIRECTIVE 1082(1) Veterans

Department of Veterans Affairs VHA DIRECTIVE 1082(1)

Veterans Health Administration Transmittal Sheet

Washington, DC 20420 March 9, 2023

PATIENT CARE DATA CAPTURE AND CLOSEOUT

1. REASON FOR ISSUE: This Veterans Health Administration (VHA) directive states

requirements and responsibilities for a standardized method to capture all clinical

interactions as patient abstracts and establishes timelines required for closeout.

2. SUMMARY OF MAJOR CHANGES:

Amendment dated December 11, 2023:

a. Updates the language for VA medical facility Director patient documentation

responsibilities in paragraph 5.g.(2).

b. Updates Patient Care Data Capture and Closeout Requirements regarding primary

providers in paragraph 6.c.(9).(f).

As of March 9, 2023, this directive:

a. Combines requirements for data capture and closeout into a single directive.

b. Removes reference to the National Patient Care Database, which is no longer in

use.

c. Replaces software-specific terms (e.g., Veterans Information Systems and

Technology Architecture, Computerized Patient Record System) with the general term

“electronic health record” to accommodate future technology system changes.

d. Updates terminology from “encounter” to “abstract” to better describe the focus of

this directive and ensure consistent and clear uses and definitions are applied.

2. RELATED ISSUES: VHA Directive 1907.01, VHA Health Information Management and

Health Records, dated April 5, 2021.

3. RESPONSIBLE OFFICE: The Office of Health Information Governance (105HIG) is

responsible for the content of this directive. Questions may be addressed to

VHAHIGHIMVAStaff@va.gov

4. RESCISSIONS: VHA Directive 1082, Patient Care Data Capture, dated March 24,

2015, and VHA Directive 1233, Closeout of Veterans Health Administration Corporate

Patient Data Files Including Quarterly Patient Census, dated June 14, 2017, are

rescinded.

5. RECERTIFICATION: This VHA directive is scheduled for recertification on or before the

last working day of March 2028. This VHA directive will continue to serve as national VHA

policy until it is recertified or rescinded.

AMENDED

December 11, 2023

March 9, 2023 VHA DIRECTIVE 1082(1)

T-2

BY DIRECTION OF THE OFFICE OF

THE UNDER SECRETARY FOR HEALTH:

/s/ Steven Lieberman, MD, MBA

Deputy Under Secretary for Health

NOTE: All references herein to Department of Veterans Affairs (VA) and VHA documents

incorporate by reference subsequent VA and VHA documents on the same or similar

subject matter.

DISTRIBUTION: Emailed to the VHA Publications Distribution List on March 9, 2023.

March 9, 2023 VHA DIRECTIVE 1082(1)

CONTENTS

PATIENT CARE DATA CAPTURE AND CLOSEOUT

PURPOSE ..........................................................................................................................1

BACKGROUND .................................................................................................................1

DEFINITIONS ....................................................................................................................1

POLICY ..............................................................................................................................2

RESPONSIBILITIES ..........................................................................................................3

PATIENT CARE DATA CAPTURE AND CLOSEOUT REQUIREMENTS......................7

TRAINING ....................................................................................................................... 10

RECORDS MANAGEMENT........................................................................................... 10

REFERENCES................................................................................................................ 11

AMENDED

December 11, 2023

March 9, 2023 VHA DIRECTIVE 1082(1)

PATIENT CARE DATA CAPTURE AND CLOSEOUT

1. PURPOSE

This Veterans Health Administration (VHA) directive states policy requiring the

capture of all clinical interactions as patient abstracts (representing outpatient

professional services, inpatient stays, inpatient visits in outpatient clinics, inpatient

mental health services, rehabilitation treatment program services, inpatient clinical

pharmacy services, surgical services and other professional services in support of

revenue operations) and defines the closeout requirements for entering the abstracted

data into VHA corporate data files. AUTHORITY: 38 U.S.C. §§ 7301(b), 7311(a).

2. BACKGROUND

a. Department of Veterans Affairs (VA) medical facilities are required to

electronically report abstracted data representing the provision of care in VHA, including

inpatient and outpatient VA medical facility and professional services, for inclusion in

corporate data files used by VHA leadership and others for reporting, resource

allocation, research and revenue.

b. This directive provides requirements and definitions to standardize methods for

capture of clinical interactions by VA health care providers.

c. VHA is required to utilize data definitions for clinical and administrative data

promulgated by internationally and nationally recognized standard-setting organizations

and statutes (e.g., Health Insurance Portability and Accountability Act of 1996 (HIPAA)).

3. DEFINITIONS

a. Abstract. An abstract is a record in the electronic health record (EHR) that

contains the coded data elements and additional administrative data used to represent

the clinical interaction. NOTE: Abstracts may refer to Veterans Information Systems and

Technology Architecture (VistA) Patient Care Encounters (PCEs) in the outpatient

setting, formerly referred to as “encounters”, VistA Patient Treatment Files (PTFs) in the

inpatient setting or Cerner Encounters which include both inpatient and outpatient care

settings.

b. C

linical Interaction. A clinical interaction is an encounter between a patient and

clinical professional resulting in surgical services, inpatient visits in outpatient clinics,

inpatient mental health services, inpatient clinical pharmacy services, outpatient

professional services, inpatient stays, rehabilitation treatment program services or other

professional services. A clinical interaction also includes a clinical professional’s request

for opinions or recommendations for treatment plans from another clinical professional.

c. C

loseout. Closeout is the process of recording, completing and submitting an

abstract representing a clinical interaction to the Austin Information Technology Center

and receiving acceptance within the VHA corporate data file without error.

AMENDED

December 11, 2023

March 9, 2023 VHA DIRECTIVE 1082(1)

d. Electronic Health Record. EHR is the digital collection of patient health

information resulting from clinical patient care, medical testing and other care-related

activities. Authorized VA health care providers may access EHR to facilitate and

document medical care. EHR comprises existing and forthcoming VA software including

Computerized Patient Record System (CPRS), VistA and Cerner platforms. NOTE: The

purpose of this definition is to adopt a short, general term (EHR) to use in VHA national

policy in place of software-specific terms while VA transitions platforms.

e. H

ealth Professions Trainee. A Health Professions Trainee (HPT) is an individual

appointed under 38 U.S.C. §§ 7405 or 7406 who is participating in clinical or research

training under supervision to satisfy program or degree requirements. HPT is a general

term to describe undergraduate, graduate and post-graduate students, interns,

residents, chief residents, fellows, VA advanced fellows and pre- and post-doctoral

fellows who spend all or part of their training experiences at VA medical facilities. Some

HPTs may be in non-clinical training fields but train in patient areas or use VA patient

records or data in their training.

f. N

on-Count. Non-count is a designation associated with an abstract based on the

clinic location representing work performed that does not meet the definition of a

reportable clinical interaction or all the requirements in paragraph 6.

g. O

ccasion of Service. An occasion of service is a specified, identifiable instance

of activity provided in conjunction with an overall service which is not an independent

clinical interaction and does not require independent clinical judgment in the overall

diagnosis, evaluation and treatment of the patient’s condition(s). Occasions of service

are the result of a clinical interaction. Examples include clinical laboratory tests,

radiological studies, physical medicine interventions, medication administration and vital

sign monitoring.

h. V

HA Corporate Data Files. VHA corporate data files are copies of VA medical

facility-reported abstracts that have completed closeout within 7 calendar days of the

last treatment date. VHA corporate data files are utilized for national reporting, funding

allocation determinations, health care planning, cost accounting and performance

monitoring.

4. POLICY

It is VHA policy that VA medical facilities capture, report and document complete

abstracts, including representation of clinical care by coded data governed by HIPAA,

for inclusion in VHA corporate data files within 7 calendar days of the last treatment

date for all clinical interactions that occur at VA medical facilities or are paid for by VA,

in accordance with standard HIPAA data recording and reporting requirements. For

patients admitted but not yet discharged at the time of the quarterly census, it is VHA

policy that a quarterly census abstract must be captured, reported and completed within

7 calendar days of the end of the quarter representing the care provided during the

quarter. Occasion of service activities must not be recorded as separate abstracts.

March 9, 2023 VHA DIRECTIVE 1082(1)

5. RESPONSIBILITIES

a. Under Secretary for Health. The Under Secretary for Health is responsible for

ensuring overall VHA compliance with this directive.

b. Deputy Under Secretary for Health. The Deputy Under Secretary for Health is

responsible for supporting the VHA Health Information Management (HIM) Program

Office with implementation and oversight of this directive.

c. A

ssistant Under Secretary for Health for Operations. The Assistant Under

Secretary for Health for Operations is responsible for:

(1) Communicating the contents of this directive to each of the Veterans Integrated

Services Networks (VISNs).

(2) Assisting VISN Directors to resolve implementation and compliance challenges in

all VA medical facilities within that VISN.

(3) Providing oversight of VISNs to ensure compliance with this directive and its

effectiveness.

d. Executive Director, VHA Health Information Governance Program Office. The

Executive Director, VHA Health Information Governance Program Office is responsible

for providing oversight of the VHA HIM Program Office to ensure compliance with this

directive.

e. Director, VHA Health Information Management Program Office. The Director,

VHA HIM Program Office is responsible for:

(1) Providing oversight for the VISN and VA medical facility compliance with this

directive and ensuring corrective action is taken when non-compliance is identified

through coordination with other offices and stakeholders, as appropriate.

(2) Providing clarifying guidance for VISNs and VA medical facility staff, including VA

medical facility Chiefs of HIM (CHIMs), regarding all data capture and closeout

processes.

(3) Providing VHA-specific HIM ad hoc training, tools and resources.

(4) Coordinating with other VHA program offices and departments to communicate

and provide guidance on the data capture requirements and closeout process.

f. Veterans Integrated Services Network Director. The VISN Director is

responsible for:

(1) Ensuring that all VA medical facilities within the VISN comply with this directive

and informing leadership when barriers to compliance are identified.

March 9, 2023 VHA DIRECTIVE 1082(1)

(2) Ensuring all clinical interactions represented as abstracts for an outpatient visit or

inpatient stay within the VISN are recorded, complete and have supporting

documentation within 7 calendar days of the last treatment date.

(3) Ensuring EHR systems are current and up to date in accordance with nationally

distributed software, software patches and content as made available by VA’s Office of

Information Technology.

(4) Ensuring the VA medical facility Director holds staff accountable for completion of

the required documentation in the patient’s health record to support any abstract data

recorded within 7 calendar days of the last treatment date.

g. VA Medical Facility Director. The VA medical facility Director is responsible for:

(1) Ensuring clinical staff document clinical information in the EHR in conformance

with legal health records as outlined in VHA Directive 1907.01, VHA Health Information

Management and Health Records, dated April 5, 2021, including defining the provider of

service, identification of patient, date and time of service, place of service, modality in

which the service is provided, patient diagnoses or reason for the visit, services

provided to the patient and treatment related to special authorities for medical care, time

spent providing the care and disposition of the patient (see paragraph 6.c.(9)).

(2) Ensuring abstracts representing outpatient visits or inpatient stays within the

facility are recorded, complete and have supporting documentation no later than seven

calendar days from the date of visit for outpatient care or from discharge date for

inpatient care.

(3) Ensuring psychiatrists, psychologists, licensed clinical social workers,

pharmacists and Advanced Practice Providers (e.g., Certified Nurse Practitioner (CNP),

Clinical Nurse Specialist (CNS), Certified Nurse Midwife (CNM), Certified Registered

Nurse Anesthetist (CRNA) and Physician Assistant (PA)) document in the patient’s

health record and complete the abstract of the clinical interaction on all mental health

professional services provided in an inpatient or residential rehabilitation setting. NOTE:

For minimum clinical data requirements for data entry, see paragraph 6.c.(9).

(4) Ensuring a process is in place for review, acceptance and maintenance of any

VISN or VA medical facility-created electronic encounter form templates or other

documentation templates prior to implementation.

(5) Ensuring a process is in place to implement regular updates for any VHA HIM

Program Office-provided national electronic encounter form templates provided on a

quarterly basis.

(6) Ensuring a process is in place to monitor accuracy, completion and acceptance of

all data abstracts and supporting documentation within 7 days of the last treatment date

for inclusion in VHA corporate data files. This includes reviewing abstract completion

status reports from the VA medical facility CHIM or designee.

March 9, 2023 VHA DIRECTIVE 1082(1)

(7) Ensuring a process is in place for auditing and providing education to VA

clinicians (at least annually) to ensure abstracts are at or above the accepted minimum

standard of 95% accuracy based on documentation in the patient’s health record.

(a) Education must be targeted based on the result of the audit with a plan of action

for any individual falling below acceptable thresholds until the acceptable level of

accuracy is achieved.

(b) Audit results and any corrective action must be reported to the VA medical facility

Integrity and Compliance Committee as a plan to improve abstracted data accuracy

until it reaches acceptable standards consistently. Clinicians identified for review and

audit are limited to Doctors of Medicine (MDs), Doctors of Osteopathic Medicine (DOs),

PAs and CNPs CNMs and CNSs. Additional staff may be included at the VA medical

facility’s discretion and should be outlined in VA medical facility standard operating

procedures for additional disciplines and services.

(8) Ensuring a process is in place to monitor and track that all abstracts representing

clinical care provided are completed within the timeframes outlined and contain

supporting documentation in the patient’s health record.

(9) Ensuring that all authorized community care that is provided is paid for by VA

(e.g., acute inpatient and nursing home care provided to patients in the community) and

is represented in VHA corporate data files, either by completion of an abstract or use of

community provider claims. NOTE: Community care claims may be processed and paid

up to 180 days from the discharge date.

(10) Ensuring a process is in place so all clinic locations are created and maintained

with appropriate Decision Support System (DSS) identifier(s) as outlined by the VHA

Managerial Cost Accounting Office (formerly the DSS Program Office).

h. VA Medical Facility Chief, Health Information Management. The VA medical

facility CHIM is responsible for:

(1) Ensuring a quarterly census abstract is performed and completed for all bed

occupants for which VA is responsible, except Contract Nursing Homes and State

Veterans Homes.

(2) Ensuring VA medical facility HIM coding staff complete the coding and validate

data capture for all inpatient admissions and surgical cases in the appropriate

application.

(3) Ensuring a process is in place for auditing and providing education to VA health

care providers and HIM coders in order to ensure that abstract coding is at or above the

accepted minimum standard of 95% accuracy based on documentation in the patient’s

health record.

(4) Ensuring that trained and competent coding staff perform content validation of the

codes included on the encounter form templates used for code picklists using the

March 9, 2023 VHA DIRECTIVE 1082(1)

Automated Information Collection System.

(5) Ensuring HIPAA code sets, including International Classification of Diseases,

Tenth Revision, Clinical Modification (ICD-10-CM) and Current Procedural Terminology

(CPT)/Healthcare Common Procedure Coding System (HCPCS), for any locally created

encounter form templates conform to the definitions and conventions included in the

appropriate coding publications mandated by HIPAA and VHA coding guidelines. If VHA

HIM nationally provided encounter form templates require installation and association

with appropriate clinics, content updates are provided by VHA HIM Program Office.

(6) Monitoring and reporting status of abstract and health record documentation

completion timeliness to the staff identified by the VA medical facility who is responsible

for ensuring compliance, accountability and developing an action plan when necessary,

including the VA medical facility Director.

(a) Education must be targeted based on the result of the audit with a plan of action

for any individual falling below acceptable thresholds until the acceptable level of

accuracy is achieved.

(b) Audit results and any corrective action must be reported to the VA medical facility

Integrity and Compliance Committee as a plan to improve coding accuracy until it

reaches minimum accuracy standard.

(7) Ensuring VA medical facility HIM professionals edit and update abstracts in the

outpatient setting based on review and validation of documentation to ensure accuracy

for all cases billed to third-party payers in accordance with the HIM and Consolidated

Patient Accounting Center service-level agreement.

i. VA Health Care Provider. VA health care providers are responsible for:

(1) Documenting care in the EHR (e.g., using a progress note) in accordance with

VHA Directive 1907.01 as evidence to support the abstract. NOTE: HPTs must follow

documentation requirements outlined in VHA Directive 1400.01, Supervision of

Physician, Dental, Optometry, Chiropractic, and Podiatry Residents, dated November 7,

2019; VHA Handbook 1400.04, Supervision of Associated Health Trainees, dated

March 19, 2015; and VHA Directive 1400.09(1), Education of Physicians and Dentists,

dated September 9, 2016, based on the VA health care provider who is independently

responsible for care, assessment, delivery, abstract completion and documentation in

the patient’s legal health record.

(2) Completing the abstract for outpatient care, inpatient mental health and

rehabilitation professional services within 7 calendar days of the last treatment date and

ensuring it accurately reflects the minimum required clinical data elements (see

paragraph 6.c.(9)), including but not limited to code assignment for diagnosis and

services provided. NOTE: Documentation to support the reported abstract in the form of

a progress note or equivalent in the EHR must also be present and completed within 7

days of the visit date.

March 9, 2023 VHA DIRECTIVE 1082(1)

6. PATIENT CARE DATA CAPTURE AND CLOSEOUT REQUIREMENTS

a. The abstract contains the coded data elements and additional administrative data

used to represent a clinical interaction. VHA Coding Guidelines are followed to record

the coded data to support the continuity of patient care, resource allocation,

performance measurement, quality management, provider productivity, research and

third-party payer collections and reporting accuracy. NOTE: For more information about

VHA Coding Guidelines, see https://dvagov.sharepoint.com/sites/vhahealth-information-

management/Coding%20Resources/VHA%20Coding%20Guidelines. This is an internal

VA website that is not available to the public.

b. Accuracy of all coding must be maintained at or above the identified acceptable

level of 95% accuracy by both clinical staff and coders. NOTE: For additional

information, see VHA HIM Clinical Coding Program Guide at

https://dvagov.sharepoint.com/sites/vhahealth-information-

management/Coding%20Resources/VHA%20Coding%20Guidelines. This is an internal

VA website that is not available to the public.

c. The provider is responsible for documenting the clinical interaction, including

review, evaluation, assessment and plan, in a progress note or other applicable

document type (e.g., diagnosis or care delivery) and additionally must record in the

abstract the diagnosis or reason for visit with highest degree of specificity known

represented by ICD-10-CM code for the visit and CPT/HCPCS for service(s) provided

as well as location, DSS identifiers (e.g., stop code(s)) and indication of treatment

related to service connected or special authority conditions when applicable. Abstracts

represent care in all settings (e.g., outpatient or inpatient).

(1) Interactions can include face-to-face, video, telephone or secure messaging

interactions if the definition of the abstract is met. In order for audio-only telephone

services to be reportable, there must be interaction between the patient and provider

with the required elements of telephone codes, evaluation and management or

medicine section of CPT, performed and documented as applicable, including time

spent, assessment, chief complaint or reason for visit, history and medical decision

making. Telephone services not meeting this definition must be recorded as historical or

associated with non-count location for tracking only.

(2) Contact can occur through secure messaging related to a visit within the last 7

days but cannot be captured as workload as it is considered part of the actual face-to-

face visit.

(3) Services incidental to and supporting the clinical interaction between the patient

and the primary provider are considered part of the service provided by the primary

provider and do not constitute separate reportable service or abstracts separately (e.g.,

taking vital signs, documenting chief complaint, giving injections, pulse oximetry,

administering medications, review of patient’s health record, phone calls of test results).

(4) A telehealth contact between a provider and a patient is considered a clinical

March 9, 2023 VHA DIRECTIVE 1082(1)

interaction when synchronous video technology or store and forward asynchronous

technology is utilized as the modality to provide care. Additional information on

telehealth services requirements is outlined by the VHA Managerial Cost Accounting

Office at http://vaww.dss.med.va.gov/programdocs/pd_oident.asp

and the Office of

Connected Care Telehealth Program at VHA Telehealth Intranet site at

https://dvagov.sharepoint.com/sites/VHA-Telehealth/docs/Forms/AllItems.aspx. NOTE:

These are internal VA websites that are not available to the public.

(5) All services recorded via an abstract must meet the definition of a clinical

interaction and contain the supporting evaluation and medical decision making

provided. The specific level of service must be recorded by applying American Medical

Association guidelines for CPT/HCPCS code assigned. Additionally, the supporting

documentation, in the form of a patient progress note or equivalent, must be present in

the patient’s health record as evidence of services provided and include these elements

along with the modality and time spent performing the service.

(6) The actual services provided to the patient by the provider must be fully and

clearly documented and coded using CPT/HCPCS code assignment as the nationally

accepted code sets, such as current edition CPT/HCPCS codes.

(7) For purposes of patient care data capture, mental health services include

inpatient and residential rehabilitation professional services performed by a psychiatrist

with the credentials of MD or DO; a psychologist with the credentials of Doctor of

Philosophy (PhD) or Doctor of Psychology (PsyD); licensed clinical social workers; or

licensed advanced practice nurses, and PAs with the credentials of CNP, CNS, CNM,

CRNA or PA.

(8) All services must be associated with a location and accurate DSS identifiers (e.g.,

stop codes), to ensure accurate reporting of work performed and resource consumption.

(9) Minimum Clinical Data Elements. In addition to the current administrative data

elements (e.g., eligibility, period of service and service-related condition information,

patient address, next-of-kin), the minimum required clinical data elements for capture in

the patient abstract are as follows:

(a) Patient. The person receiving health care services, including the full legal name,

date of birth, Social Security Number (SSN) or pseudo-SSN (or other personal identifier)

and eligibility.

(b) D

iagnosis. Reason for visit, diagnosis or conditions that necessitated the clinical

interaction, affected the treatment or were assessed or treated during the clinical

interaction, including treatment plan assessed and continued.

1. T

he following are required to be reported as ICD-10-CM codes: purpose of the

abstract noted by the provider as the problem, reason for visit or diagnoses which

necessitated the clinical interaction.

2. W

hen more than one problem or diagnosis meets the definition of a reportable

March 9, 2023 VHA DIRECTIVE 1082(1)

condition, the provider must determine which one is the primary reason the patient

sought treatment. All additional diagnoses or conditions that affected the treatment of

the patient, were assessed, were treated or where treatment was planned during the

clinical interaction should be included as additional secondary codes.

treatment was related to any adjudicated service-connected condition or treatment of

special authority conditions related to exposure (e.g., Agent Orange, Ionizing Radiation,

Military Sexual Trauma, combat Veterans or environmental contaminants) must be

based on all conditions treated during the clinical interaction and the abstract must be

designated as service-connected or designated as being related to the special authority.

(d) D

ate and Time of Service. Time is a single entry indicating the time that the

clinical interaction was initiated. For all scheduled appointments, the date is the date

services are provided. When unscheduled appointments are entered, the abstract date

is the date and time the patient presented for interaction.

(e) Place of Service. Information about the location where the service was provided.

This includes the three-digit VA medical facility or station identifier, with any applicable

suffixes (STA6A), as well as the DSS identifier(s). The place of service must include the

five-character medical center national VHA division value. The division value must

reflect the location where care was provided.

(f) Primary Provider. A Licensed Practitioner (LP) providing the service, who is the

attending or rendering provider. When advanced practice nurses and physician assistants

are working with physicians, they are considered as working in the same specialty and

same subspecialties as the physician. A "physician or other qualified health care

professional" is an individual who is qualified by education, training, licensure/regulation

(when applicable), and facility privileging (when applicable) who performs professional

services within their scope of practice and independently reports those professional

services. These professionals are distinct from "clinical staff." VHA policies, protocols, and

bylaws may allow specific circumstances in which clinal staff may be listed as the primary

providers when no supervising professionals are involved in the specific clinical interaction

occurring on a date/time. An HPT must never be listed as the primary provider in an

abstract. When the patient is seen by multiple providers during the same clinical

interaction, both licensed and non-licensed, the provider with highest degree of

licensure should be listed as primary. For example, if a nurse and physician both see

the patient, the physician should be listed as primary. If the patient is being seen by a

PA and a physician within the same clinic visit, the physician would be the primary

provider with the PA listed as a secondary provider. If the patient is being seen by a

CNP and a physician within the same clinic visit, the primary provider would be the

physician. However, if the patient is being seen by a CNP or PA and is treated only by

the CNP or PA, the individual who is CNP/PA should be listed as the primary provider

designated on the abstract.

d. All abstracts representing inpatient and outpatient care must be complete and

error free within 7 calendar days of the treatment date (e.g., date of discharge, quarterly

March 9, 2023 VHA DIRECTIVE 1082(1)

census date, visit date of service) for inclusion in VHA corporate data files. Census

abstracts must be complete and error free within 7 calendar days of the end of the

quarter. NOTE: Example of date calculation: if a patient’s Discharge Date is January 31,

2016, then the abstract must be closed and accepted no later than February 7, 2016.

Date of discharge to date of abstract accepted equals 7 calendar days.

e. Abstracts containing any erroneous or inaccurate data based on the health record

documentation available at the time of coding must be corrected when it is discovered.

There is no time limit on correction of abstract based on documentation available at the

time of recording. Changes other than data corrections as mentioned will not be

permitted in accordance with ethical coding practices. There are multiple uses for data

other than workload and it is important to have the data be as accurate as possible.

f. All coded data represented in patient abstracts may not be billable to third-party

payers. Thus, there will be specific circumstances where the abstract, including codes

assigned and code sequence, does not match one to one with the bill created for

submission to third-party payers based on business rules for payment that require

submission in a specific format to support adjudication.

g. Each VA medical facility must be set up with appropriate DSS identifiers. Utilized

both locally and nationally, these identifiers describe DSS clinical work units. The VHA

Managerial Cost Accounting Office maintains and nationally distributes the list of DSS

identifiers which are updated annually. VHA Financial Program Policy Documents and

information about the VHA Managerial Cost Accounting Office can be found at

http://vaww.mcao.va.gov/programdocs/pd_oident.asp

. NOTE: This is an internal VA

website and is not available to the public.

(1) A primary DSS identifier must be assigned to clinic locations in outpatient,

residential rehabilitation and inpatient clinic settings. The primary DSS identifier must

depict the primary clinical workgroup responsible for the type of service provided during

the clinical interaction.

(2) The secondary DSS identifier serves as a modifier to further define the primary

workgroup or type of service provided. The DSS identifier(s) for a patient setting must

meet the definitions outlined by the VHA Managerial Cost Accounting Office.

h. A VA medical facility including all identified divisions and Community-Based

Outpatient Clinics (CBOCs) is considered to be the business entity furnishing health

care at the organizational level. Sub-organizational level entities for which data must be

retrievable include parent and community site, specific clinic (regardless of whether the

site has more than one type of station suffix, e.g., a CBOC), treatment team and

individual provider.

7. TRAINING

The following training is recommended annually and for all new clinical users who

are involved with or responsible for abstract completion: Talent Management System

(TMS) course VA 131001971, Data Capture and Closeout.

March 9, 2023 VHA DIRECTIVE 1082(1)

8. RECORDS MANAGEMENT

All records regardless of format (e.g., paper, electronic, electronic systems) created

by this directive must be managed as required by the National Archives and Records

Administration (NARA) approved records schedules found in VHA Records Control

Schedule 10-1. Questions regarding any aspect of records management should be

addressed to the appropriate Records Officer.

9. REFERENCES

a. 38 U.S.C. §§ 7301(b), 7311(a), 7405, 7406.

b. VHA Directive 1400.01, Supervision of Physician, Dental, Optometry, Chiropractic,

and Podiatry Residents, dated November 7, 2019.

c. VHA Directive 1400.09(1), Education of Physicians and Dentists, dated September

9, 2016.

d. VHA Directive 1907.01, VHA Health Information Management and Health

Records, dated April 5, 2021.

e. VHA Handbook 1400.04, Supervision of Associated Health Trainees, dated March

19, 2015.

f. VHA Coding Guidelines: https://dvagov.sharepoint.com/sites/vhahealth-

information-management/Coding%20Resources/VHA%20Coding%20Guidelines. NOTE:

This is an internal VA website that is not available to the public.

g. VHA HIM Clinical Coding Program Guide:

https://dvagov.sharepoint.com/sites/vhahealth-information-

management/Coding%20Resources/VHA%20Coding%20Guidelines. NOTE: This is an

internal VA website that is not available to the public.

h. VHA Managerial Cost Accounting Office:

http://vaww.mcao.va.gov/programdocs/pd_oident.asp

and

http://vaww.dss.med.va.gov/programdocs/pd_oident.asp. NOTE: These are internal VA

websites that are not available to the public.

i. VHA Office of Connected Care Telehealth Program:

https://dvagov.sharepoint.com/sites/VHA-Telehealth/docs/Forms/AllItems.aspx

. NOTE:

This is an internal VA website that is not available to the public.