Date post: | 13-Dec-2015 |
Category: |
Documents |
Upload: | jeffery-brooks |
View: | 214 times |
Download: | 0 times |
Headquarters U. S. Air ForceI n t e g r i t y - S e r v i c e - E x c e l l e n
c e
U.S. AIR FORCEU.S. AIR FORCEU.S. AIR FORCEU.S. AIR FORCE
Data Quality Management Control (DQMC) Program
Air Force Data Quality Manager
Shirley Williams/David Brunner
CHCS Data Analysis
AFMOA/SG3YR
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Overview
Data Quality (DQ) Program Systems DQ Composite Healthcare Computer System
(CHCS) Initiatives FY08 Updates Take Away Questions
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
DQMC Program
Data Quality Manager
Data Quality Assurance Team
DQMC Review List
Commander’s Monthly Data Quality Statement
INSTRUCTION
Department of Defense
DODI 6040.40Military Health System
Data Quality Management Control Procedures
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
DQ Team Roles and Responsibilities
Team Key Players DQ Manager Group Practice Manager (GPM) Medical Expense Reporting System (MEPRS) and Credentials Manager Budget Analyst/Uniform Business Office (UBO) Coding/Billing Supervisor Clinical Systems Administrator(s)
DQ team meets monthly Keep meeting minutes for at least two years Review Metrics Report monthly to Executive Committee
It is great to look – But are you working toward improvement?
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
“E” – Support “D” – Ancillary “A” – Inpatient “B” – Outpatient “C” – Dental
+ “F” – Special Programs
+ “G” – Readiness
EAS IVMoney
Manpower
Workload
CRIS
EAS-SA
CHCS / WAM
(Count only)
RECONCILE
Direct Care “Step Down”
Medical Expense Performance & Reporting System“MEPRS” -- Valuation
Defense Health Program Cost Accounting
OUTPUT
TotalCost
RVUs RWPs
ICD/E&M/CPTDRGsSIDR
SADRCHCS
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
DQ Team Responsibilities Cont…
DQMC Review List Maintained locally Tool to assist Military Treatment Facilities (MTFs) in identifying and
correcting financial and clinical workload data problems monthly
Commander’s Data Quality Statement Facility Report Card Specific information from the DQMC Review List Commander signs/approves monthly Forwarded through the MAJCOM to AF DQ Manager
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Commander’s DQ StatementCompleteness
Question 1. In the reporting month (include only B*** and FBN* accounts):
a) What percentage of clinics have complied with “End of Day” processing requirements, “Every clinic – Every day?
Sum of Daily Totals of Open Clinics Successfully Completing EOD Processing Sum of All Daily Totals of Open Clinics
b) What percentage of appointments were closed in meeting your “End of Day” processing requirements, “Every appointment – Every day?” (B.5.(b))
Sum of Daily Totals of Successfully Closed Appointments
Total Appointments
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Commander’s DQ StatementTimeliness
Question 2. In accordance with legal and medical coding practices, have all of the following occurred:
a) What percentage of Outpatient Encounters, other than APVs, have been coded within 3 business days of the encounter?
BDQAS b) What percentage of APVs have been coded within 15 days of the
encounter?
BDQAS c) What percentage of Inpatient records have been coded within 30 days
after discharge?
Internal Process
CCE Report (Un-coded records report)
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Question 3. In accordance with TMA policy, “Implementation of EAS/MEPRS Data Validation and Reconciliation,” dated 21 Dec 99 and “MEPRS Early Warning and Control System,” dated 28 May 02, along with the most current Service-Level Guidance
a) Was monthly MEPRS/EAS financial reconciliation process completed, validated and approved prior to monthly MEPRS transmission?
MEPRS Manager and RMO Office b) Question 3b-has been omitted for FY08 and Questions 3c was
renumbered 3b b) Were the data load status, outlier/variance, WWR-EAS IV, and allocations
tabs in the current MEWACS document reviewed and explanations provided for flagged data anomalies?
MEPRS Manager
Commander’s DQ StatementValidation and Reconciliation
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Commander’s DQ StatementCompliance
Question 4. Compliance with TMA or Service-Level guidance for timely submission of data (C.3.).*
a) MEPRS/EAS (45 days)
MEPRS Manager/MEWACS b) SIDR/CHCS (5th Duty of Day of the month)
BDQAS c) WWR/CHCS (10th Calendar Day Following Month)
BDQAS d) SADR/ADM (Daily)
BDQAS
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Question 5. Outcome of monthly inpatient coding audit:
a) Percentage of inpatient records whose assigned DRG codes were correct?
b) Inpatient Professional Services Rounds encounters E & M codes audited and deemed correct?
c) Inpatient Professional Services Rounds encounters ICD-9 codes audited and deemed correct?
d) Inpatient Professional Services Rounds encounters CPT codes audited and deemed correct? a) Percentage of inpatient records whose assigned DRG codes were correct?
Commander’s DQ StatementCompliance
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Question 6. Outpatient Records
a) Is the documentation of the encounter selected to be audited available? Documentation includes documentation in the medical record, loose (hard copy) documentation or an electronic record of the encounter in AHLTA. (Denominator equals sample size.)
b) What is the percentage of E & M codes deemed correct? (E & M code must comply with current DoD guidance.)
c) What is the percentage of ICD-9 codes deemed correct?
d) What is the percentage of CPT codes deemed correct? (CPT code must comply with current DoD guidance.)
a, b, c, d-Audit Tool Generated
Commander’s DQ StatementAvailability/Accuracy
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Question 6. Outpatient Records. CONT…
e) ) What percentage of completed and current (signed within the past 12 months) DD Form 2569s (TPC Insurance Info) are available for audit?
Audit Tool Generated/Internal Process (This metric only measures whether or
not a DD2569 was collected/current in the record at the time of the encounter.
How the patient answered is only relevant to answering “Question 6f”)
f) What percentage of available, current and complete DD Form 2569s are verified to be correct in the Patient Insurance Information (PII) module in CHCS?
Internal Process based on Question 6e (Only current and signed DD2569
whether there yes or no are checked)
Commander’s DQ StatementAvailability/Accuracy
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Question 7. Ambulatory Procedure Visits (C.7.a,b,c,d,e)
Question 7b deleted and c,d,e,f renumbered Questions 7.a,b,c,d,e Are the same as Questions 6.a,c,d,e,f
Commander’s DQ StatementAvailability/Accuracy
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Question 8. Comparison of reported workload data.
a) # SADR Encounters (count + non-count) / # WWR visitsBDQAS
b) # SIDR Dispositions / # WWR DispositionsBDQAS
c) # EAS Visits / # WWR Visits BDQAS
d) # EAS Dispositions / # WWR DispositionsBDQAS
e) # of Inpatient Professional Services Rounds SADR encounters (FCC=A***)/#Sum WWR (Total Bed Days + Total Dispositions) Note: FY08 Goal 80%
Internal Process (Monthly Statistical Report)
Commander’s DQ StatementCompleteness
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Question 9. System Design, Development, Operations, and Education/Training (E.4.a).
a. # of AHLTA SADR encounters / # of Total SADR encounters
Note: Exclude APV (B**5, 7,8,9) and ER (BIAA)
FY08 not scored. For management use and tracking purposes only.
BDQAS Question 10. I am aware of data quality issues identified by the
completed Commander’s Statement and Review List and when needed, have incorporated monitoring mechanisms and have taken corrective actions to improve the data from my facility. (Electronic Signature Authorized)
Commander’s DQ StatementAwareness
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Air Force
DQ System Architecture
MDRMDR
M2M2
WWR(Count Visits)
EAS IVEAS IV“Eligible” Encounters
CPT Codes Units of Service
WAMWAMCount Visits & Raw Services
SADR(Encounters)
TPOCSTPOCSBillable
Encounters
PDTSPDTS
Worldwide Workload Report
Standard Ambulatory Data Record
EAS Repository
ADMExtract
MHS Data Repository
MHS Mart
Service Repository (BDQAS)
Pharmacy Data Transaction System
Pop HealthPortal
CCE
Coding Compliance Editor
ClinicalData Mart
TRICAREOps Center
DoD/VA SHARE
SADR 1/SADR 2
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
DQ Monitoring Tools
MHS Management Analysis and Reporting Tool (M2) Used to extract data for PPS and AF Business Plan Need to identify the M2 user in your facility Tricare Management Activity (TMA) WISDOM course
EASIV Repository MEPRS data
Cost per data 45 day processing period for current month
MEPRS Manager TMA MADI Course
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
MEWACS Trend analysis tool Outlier indications
Review and correct data accordingly Outliers are not always incorrect data
BDQAS Data Quality Statement Reports
Compare and report values on DQ statement Consistent reporting for questions:
2a-b, 4b-d, 8a-d, 9 “Point-in-time" reports
Updated on the 20th of the month Display by MTF or MAJCOM
Contact BDQAS helpdesk for data inconsistencies or questions
DQ Monitoring Tools Cont…
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
BRAC Monitor efficiency of the healthcare system Performance Based Budgeting – PPS Medicare Accrual Fund MTF Business Plans Provider/Clinic Workload Productivity Determine Level of Effort by all clinic staff Reimbursements (TPC, Coast Guard, NOAA…etc) Enable the Leadership to make informed decisions
How is your data used?
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Provider File
Civilian (Outside) Provider File Pharmacy/Lab/Rad are required to add the Civilian Provider to CHCS
Create a local policy/standard operating procedure Educate and train the ancillary staff Use correct PSC linked to HIPAA Taxonomy
Provider naming convention and DEA/License number should be strictly enforced and monitored Last Name Middle Name or Initial (if available)
Last name,First Name No spaces between first and last name No punctuation other than comma between names, with the
exception of hyphenated names No professional titles in name, e.g., MD, DO
Example: Smith / Johnson,S / Provider / Outside Provider NPI/DEA/License # can be researched on the web using the HCIDEA or
the NEPPES websites
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Provider Profiles (con’t)PROVIDER: SMITH, JOHN R Name: SMITH, JOHN RProvider Flag: PROVIDERProvider ID: Provider1234NPI Type/ID: Provider Class: DocPerson Identifier: 123-45-6789Person ID Type Code: Select PROVIDER SPECIALTY: 517 (DENTAL CONSULTANT)Primary Provider Taxonomy:CMAC Provider Class: -Select PROVIDER TAXONOMY:HCP SIDR-ID:Location: CHAMPUS SUPPORT Class: OUTSIDE PROVIDER Initials: JRS SSN: 123-45-6789 DEA#: 99999999License #:
PROVIDER: SMITH,JOHN R Name: SMITH,JOHN R Provider Flag: PROVIDERProvider ID: SMITHJRNPI Type/ID: 01/0125899Provider Class: OUTSIDE PROVIDERPerson Identifier: Person ID Type Code: Select PROVIDER SPECIALTY: 001 (FAMILY PRACTICE PHYSICIAN)Primary Provider Taxonomy: 207Q00000XCMAC Provider Class: -Select PROVIDER TAXONOMY:HCP SIDR-ID:Location: CHAMPUS SUPPORT Class: OUTSIDE PROVIDER Initials: JRSSSN: 123-45-6789 (Not Mandatory)DEA#: BM1212127 License #:
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Pharmacy makes up 70 to 80% of your MTFs collections Average # Claims for Outside Provider Scripts per Month
Large Facility 1500-3000 Medium Facility 700 Small Facility 300
Average Amount Billed per claim: $50
If your provider file has 100 outside providers that issued at least one script per month with missing data in their profile: provider specialty codes, DEA #, provider name and ID.
Potential Loss is $5,000 in billable claims per month Potential Loss is $60,000 in billable claims per year
Potential Revenue Impact
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Enter Provider Specialty Code (Be specific – not general) All PA’s – Provider Specialty Code 901 All Technicians – Provider Specialty Code 900 Independent Duty Medical Technician – Provider Specialty Code 521
Lost revenue for codes 500 – 518 and 910 – 999 Zero workload RVU Prevent Encounter from flowing to TPOCS Impact on PPS
Provider Specialties 910 and above are Clinical Services 923-Family Practice Clinic/001-Family Practice Physician 949-Pediatric Clinic/040-Peditrician
Provider Specialty Codes
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Value of Care
PEDIATRICS – BDA Provider Specialty Code = 040
Pediatrician
Diagnosis Codes 204 Lymphoid Leukemia 112.89 Candidial Endocarditis
Procedure Code 90780 Intravenous infusion for
therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour
90781 – Each additional hour
E&M Code 99214 – Level 4 Established Patient
OHI – Yes
CMAC Value = $130.73 Class 1 Provider
Will you bill for this patient? Yes Reimbursement - $130.73
PPS RVU = 1.44 Reimbursement = $106.56
PEDIATRICS – BDA Provider Specialty Code = 949
Pediatrics
Diagnosis Codes 204 Lymphoid Leukemia 112.89 Candidial Endocarditis
Procedure Code 90780 Intravenous infusion for therapy/diagnosis,
administered by physician or under direct supervision of physician; up to one hour
90781 – Each additional hour
E&M Code 99214 – Level 4 Established Patient
OHI – Yes
CMAC Value = UNKNOWN
Will you bill for this patient? NO Reimbursement $0
PPS Workload = ZERO!!!!!!ZERO!!!!!!
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Today’s Situation
Lack of Training No standard guidance and policies across the AFMS Minimal accountability Potential fraudulent billing Inaccurate Data
Missing Critical Data Elements Incorrect Critical Data Elements
Loss revenue opportunities
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
CHCS DQ Initiative Roadmap
CHCS DQ Initiative Roadmap
Site Preparation Package – Initiate Site Visit Templates
Complete Langley AFB Site Visit , and Follow-Up Analysis
Data Analysis – Validate and identify DQ problems, Additional Site Visit, and Performance Metrics
Monitor and Follow-up SAR Feedback ; Complete LA/Vandenberg AFB Site Visit
Complete Luke AFB Site Visit, and Follow-up Analysis
CHCS DQ Second Release Site Analysis Report
Update Technical Guide and Patient File Continuity Book, Additional Site Visit
Begin Phase IIl Site Analysis; Complete Academy/Buckley/Peterson AFB Site Visit
Complete CHCS DQ Training Questionnaire, and Feedback
Oct-Nov 07
Nov-Dec 07
Dec- Jan 08
Jan – Feb 08
Feb–Mar 08
Mar- Apr 08
Apr-Jun 08
June-Aug 08
We are here:•Site Analysis of 63 sites
Aug- Sep 08 Performance Metric, Complete Site Visits
Sep-Oct 07
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
FY08 DQ Updates
FY08 Review List Changes Removed many redundant questions Consolidated questions
FY08 Commanders Statement Changes Question 3b- Removed--Were monthly inpatient and outpatient workload reconciliation
processes completed? Question 5a- Wording change - What percentage of inpatient records whose assigned DRG
codes were correct? Question 7b-Removed Question 8a-Added “count + non-count” to the statement Question 9-Now excludes ER (AF no change) Question 10-Wording Change--I am aware of data quality issues identified by the completed
Commander's Statement and Review List and when needed, have incorporated monitoring mechanisms and have taken corrective actions to improve the data from my facility.
Audit Tool Monthly Patient record pull list will now be released on the 13 of every month
Workload Guidelines version 2.0 Supersedes version 1.1 Release Date 1 Oct 07
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
DQ Tool Kit
DQ Guide Reporting Consistency Assistance with answering questions General DQ information
CHCS DQ Continuity Handbook CHCS standards Processes/procedures for addressing CHCS issue and resolution Reports
FY07 Workload Guidelines Version 2 Brings together DQ, MEPRS, Coding and Billing AF supplemental guidance to DOD coding guidelines
Data Quality Web Page AFMS Knowledge Exchange Documents (Site Analysis Report), briefings, policies/directives, training,
links, discussion threads
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
DQ Web Page
Contact:
Ms. Michele Gowen, RHIA, CCSAir Force Data Quality Program Manager
Tel (703) 681-6504 DSN 761Fax (703) 681-6011 DSN 761
https://kx.afms.mil/kxweb/dotmil/kj.do?functionalArea=DataQuality
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Take Away
DQ is not just the DQ statement.
Data needs to be accurate, complete and timely.
Cleaning the front end will show a return on the back end
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Important References
DODI 6015.1-M, DOD Glossary DODI 6010.13M, MEPRS Program for Fixed MTFs and DTFs DODI 6010.15M, Uniform Business Office DODI 6040.40, Data Quality Program DODI 6040.41, Medical Records Retention and Coding at MTF DODI, 6040.42, Medical Encounter and Coding at MTF DODI, 6040.43, Custody and Control of Medical Records AFI 41-102, AF MEPRS Program for Fixed MTFs and DTFs AFI 41-120, Resource Management Operations AFI 41-210, Patient Administration Functions DoD Professional Coding Guidelines AF Workload Standardization Guidelines EASIV Reference Guide
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Useful Web Sites
Data Quality - http://tricare.osd.mil/ocfo/mcfs/dqmcp/training.cfm BDQAS – https://bdqas.brooks.af.mil/index2.htm P2R2 - https://p2r2.hq.af.mil/ UBU - http://tricare.osd.mil/ocfo/bea/ubu/index.cfm UBO - http://tricare.osd.mil/ocfo/mcfs/ubo/index.cfm MEPRS – http://meprs.info MEWACS -
http://www.tricare.osd.mil/ebc/rm_home/mewacs/index.html AF/SGY-https://kx.afms.mil/kxweb/dotmil/kj.do?
functionalArea=DataQuality DFAS - http://www.dash.mil/money/milpay/ Pop Health - https://phsd.afms.mil/phso/ HIPAA - http://tricare.osd.mil/ocfo/mcfs/ubo/hipaa.cfm SAIC - http://www.chcs-dm.com/