Q601--RFI – Information Sought: Code Sets

Form / Attachment / Pricing Sheet

This document provides a code set example for cardiology community care referrals, outlining allowable services that do not require prior authorization and specifying quantity limits for certain diagnostic tests and studies. It also details guidelines for in-clinic medications.

• Allowable Services: Outpatient evaluation and management (E/M) services related to the specific condition noted on the consult/referral order within the VA authorization duration.
• Scope Requirements: Services must be related to the referred condition, FDA-approved, medically necessary, usual and customary, evidence-based, and within generally accepted medical practice standards.
• Quantity Limits for Diagnostic Services:
  • Cardiac-related diagnostic imaging tests: Up to 5 (VA CodeSet 00002)
  • Cardiac-related diagnostic labs: Up to 15 (VA CodeSet 00003)
  • Cardiac-related diagnostic studies (e.g., stress tests, echocardiograms): Up to 10 (VA CodeSet 00004)
  • Device interrogations and/or programming (e.g., AICD, pacemaker): Up to 6 (VA CodeSet 00005)
• In-Clinic Medications: FDA-approved, clinically indicated infusions or injections are permitted if related to the referred condition and appropriate to the specialty. This includes administration in specialty care infusion centers, medical provider offices, and specialty care clinics.
• Medications Not on Prior Authorization List: Community providers must obtain a New VA Formulary Advisor or Specialty Care Criteria for Use (CFU). A Request for Services (RFS) is not required in this specific instance.

This attachment provides specific details on the types and quantities of cardiology services that are pre-approved or have defined limits. Bidders offering cardiology services should review these guidelines to understand the scope of services that can be provided without prior authorization, the associated code sets, and quantity limitations. This information is crucial for accurately defining service offerings and potentially for pricing proposals related to cardiology care within the VA system.

Other / Unclassified

This document is a Request for Information (RFI) from the U.S. Department of Veterans Affairs (VA) seeking market research on vendors capable of developing, maintaining, and delivering comprehensive billing code sets that align with VA’s Community Care Referral Guidelines (CCRGs). The VA needs vendors to translate clinical guidance into validated, up-to-date code sets (CPT, HCPCS, ICD10, DRG, APC, etc.) and provide recurring deliverables. This includes incorporating new codes, retiring obsolete codes, applying pricing and bundling rules, and ensuring alignment with national standards and VA payment policy.

This RFI is relevant to potential bidders who have expertise in healthcare billing codes and the development/maintenance of such code sets. The VA is gathering information to support acquisition planning, determine cost, feasibility, technical approaches, and industry capabilities for a future procurement. The RFI includes detailed questions covering:

• General Information: Company details, ownership, socio-economic designations, contract vehicles, SINs, and NAICS codes.
• Capability and Experience: Past experience in developing/maintaining healthcare billing code sets, tools used, similar work performed, and lead time for services.
• Code Set Development Approach: Methodology for mapping clinical guidance to billable codes, ensuring accuracy, incorporating updates, and avoiding overutilization.
• Deliverables and Update Cadence: Recommended update frequency, standard formats, and validation processes.
• Quality Assurance and Validation: Methods for validating code accuracy, completeness, and alignment with reimbursement rules.
• Scalability and Volume Management: Capacity to handle numerous specialties, high volumes, and expansion needs.
• Tooling, Technical Integration, and Interoperability: Platforms used, delivery mechanisms, and integration with claims systems.
• Staffing and Expertise: Qualifications of coding staff, anticipated staffing levels, and continuity of operations.
• Contractor-VA Interaction Model: Information requirements from VA, coordination with oversight teams, and recommended responsibilities.
• Risks, Challenges, and Recommendations: Anticipated risks and mitigation strategies.
• Cost and Pricing Structure: Estimated costs and pricing models.

Vendors are encouraged to respond with detailed information to assist the VA in its acquisition planning.

Request for Information (RFI)

This RFI seeks information on the availability and technical capabilities of qualified sources capable of developing, maintaining, and regularly delivering comprehensive billing code sets. The Department of Veterans Affairs (VA) is gathering this information for planning purposes and to determine potential acquisition approaches. This is not a solicitation, and no contract will be awarded based on this RFI.

• Capabilities related to the development, maintenance, and delivery of comprehensive billing code sets.

• Response Date: May 14, 2026, by 3:00 PM Eastern Time.

• Submission Method: Responses must be emailed to Jeffery.Fithen@va.gov and Justin.Sink@va.gov.

• Subject Line: All correspondence must reference the RFI Number (36C10G26Q0063), Project Identifier, and Project Title (Code Sets).

• Responses are for information and planning purposes only.

• This RFI does not constitute a solicitation and does not obligate the government to issue a solicitation.

• Unsolicited proposals will not be accepted.

• All costs associated with responding are the sole responsibility of the respondent.

• Submissions will be treated as business confidential and become government property.

• Attachment 1 - RFI Questions

• Attachment 2 - Code Set Example