1. 1 Data Quality Management Control Program Army – Mr. Angel Padilla

2. 2 Overview Regulatory GuidanceRegulatory Guidance Program ManagementProgram Management Organizational FactorsOrganizational Factors System Inputs, Processes, and OutputsSystem Inputs, Processes, and Outputs –CHCS –ADM –MEPRS/EAS –TPOCS –MEWACS Patient Records Accountability Coding Audits  Sampling Size and Techniques  Inpatient Records  Outpatient Records Workload Comparison System Security System Design, Development, Operations, and Education and Training

3. 3 Regulatory Guidance DODI 6040.40 Military Health System Data Quality Management Control Procedures Department of Defense INSTRUCTION

4. 4 Regulatory Guidance DODD 6040.41 Medical Records Retention and Coding at Military Treatment Facilities Department of Defense DIRECTIVE

5. 5 Regulatory Guidance DODD 6040.42 Medical Encounter and Coding at Military Treatment Facilities Department of Defense DIRECTIVE

6. 6 Regulatory Guidance DODD 6040.43 Custody and Control of Outpatient Medical Records Department of Defense DIRECTIVE

7. 7 Program Management Data Quality ManagerData Quality Manager Data Quality Assurance TeamData Quality Assurance Team Intermediate Command DQ ManagerIntermediate Command DQ Manager Service Data Quality ManagerService Data Quality Manager DQMC Review ListDQMC Review List Commanders Monthly Data Quality Statement (internet based)Commanders Monthly Data Quality Statement (internet based)

8. 8 System Inputs, Processes, and Outputs Composite Health Care System (CHCS)Composite Health Care System (CHCS) Armed Forces Health Longitudinal Technology Application (AHLTA)Armed Forces Health Longitudinal Technology Application (AHLTA) Ambulatory Data Module (ADM)Ambulatory Data Module (ADM) Medical Expense and Performance Reporting System (MEPRS) / Expense Assignment System (EAS)Medical Expense and Performance Reporting System (MEPRS) / Expense Assignment System (EAS) Third Party Outpatient Collection System (TPOCS)Third Party Outpatient Collection System (TPOCS) MEPRS Early Warning and Control System (MEWACS)MEPRS Early Warning and Control System (MEWACS)

9. 9 Data Input MEPRS/EAS, ADM, CHCS, TPOCS Written ProceduresWritten Procedures Current VersionsCurrent Versions Upgrades & UpdatesUpgrades & Updates Rejected RecordsRejected Records End of Day ProcessingEnd of Day Processing –Percentage of Clinics –Percentage of Appointments Timely Coding CompletionTimely Coding Completion

10. 10 Commander’s Data Quality Statement Q. 1. In the reporting month:Q. 1. In the reporting month: –a) What percentage of clinics have complied with “End of Day” processing requirements, “Every clinic – Every day? (B.5.(a.)) –b) What percentage of appointments were closed in meeting your “End of Day” processing requirements, “Every appointment – Every day?” (B.5.(b))

11. 11 Commander’s Data Quality Statement Q. 2. In accordance with legal and medical coding practices, have all of the following occurred:Q. 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? (B.6.(a)) –b) What percentage of APVs have been coded within 15 days of the encounter? (B.6.(b))

12. 12 Commander’s Data Quality Statement Q. 2. In accordance with legal and medical coding practices, have all of the following occurred:Q. 2. In accordance with legal and medical coding practices, have all of the following occurred: –c) What percentage of Inpatient records have been coded within 30 days after discharge? (B.6.(c))

13. 13 Data Output MEPRS/EAS, ADM, CHCS, TPOCS EASEAS –Financial Reconciliation –Inpatient and Outpatient Workload Reconciliations –MEWACS Review –Timely Data Transmittal –Workload Comparison

14. 14 Commander’s Data Quality Statement Q. 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: (C.1.)Q. 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: (C.1.) –a) Was monthly MEPRS/EAS financial reconciliation process completed, validated and approved prior to monthly MEPRS transmission?

15. 15 Q. 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: (C.1.)Q. 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: (C.1.) –b) Were monthly Inpatient and Outpatient workload reconciliation processes completed? Commander’s Data Quality Statement

16. 16 Commander’s Data Quality Statement Q. 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: (C.1.)Q. 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: (C.1.) –c) 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?

17. 17 Commander’s Data Quality Statement Q. 4. Compliance with TMA or Service-Level guidance for timely submission of data (C.3.).Q. 4. Compliance with TMA or Service-Level guidance for timely submission of data (C.3.). –a) MEPRS/EAS (45 days)

18. 18 Data Output MEPRS/EAS, ADM, CHCS, TPOCS CHCSCHCS –Duplicate Records –Timely Data Transmittal Standard Inpatient Data Record (SIDR)Standard Inpatient Data Record (SIDR) Worldwide Workload ReportWorldwide Workload Report –Inpatient Records AccountabilityAccountability DocumentationDocumentation CodingCoding SIDRs completed (in a “D” status)SIDRs completed (in a “D” status) –Workload Comparison

19. 19 Commander’s Data Quality Statement Q. 4. Compliance with TMA or Service-Level guidance for timely submission of data (C.3.).Q. 4. Compliance with TMA or Service-Level guidance for timely submission of data (C.3.). - b) SIDR/CHCS (5 th and 20 th calendar day of the month)

20. 20 Commander’s Data Quality Statement Q. 4. Compliance with TMA or Service-Level guidance for timely submission of data (C.3.).Q. 4. Compliance with TMA or Service-Level guidance for timely submission of data (C.3.). - c) WWR/CHCS (10 th calendar day following month)

21. 21 Commander’s Data Quality Statement Q. 4. Compliance with TMA or Service-Level guidance for timely submission of data (C.3).Q. 4. Compliance with TMA or Service-Level guidance for timely submission of data (C.3). – d) SADR/ADM (daily)

22. 22 Data Output A minimum of 30 records/encounters should be pulled randomly from the entire population of MTF inpatient medical records for the audit data month.A minimum of 30 records/encounters should be pulled randomly from the entire population of MTF inpatient medical records for the audit data month. A random audit of 30 records per MTF will provide a statistical confidence level of 90%, with a confidence interval/sampling error range of plus or minus 15%.A random audit of 30 records per MTF will provide a statistical confidence level of 90%, with a confidence interval/sampling error range of plus or minus 15%.

23. 23 Data Output Inpatient Coding CodingCoding –DRG Codes –Related Data Elements (C.5) All DiagnosesAll Diagnoses Any ProceduresAny Procedures SexSex AgeAge Discharge/DispositionDischarge/Disposition Percentage of SIDRs Completed (D-Status)Percentage of SIDRs Completed (D-Status)

24. 24 Commander’s Data Quality Statement Q. 5. Outcome of monthly inpatient coding audit: (C.5.c.f.g,h)Q. 5. Outcome of monthly inpatient coding audit: (C.5.c.f.g,h) - a) Inpatient Records (DRG) # Records Reviewed:_________ % Correct _______ - a) Inpatient Records (DRG) # Records Reviewed:_________ % Correct _______

25. 25 Commander’s Data Quality Statement Q. 5. Outcome of monthly inpatient coding audit: (C.5.c.f.g,h)Q. 5. Outcome of monthly inpatient coding audit: (C.5.c.f.g,h) - b) Inpatient Professional Services Rounds encounters E & M codes audited and deemed correct?- b) Inpatient Professional Services Rounds encounters E & M codes audited and deemed correct?

26. 26 Commander’s Data Quality Statement Q. 5. Outcome of monthly inpatient coding audit: (C.5.c.f.g,h)Q. 5. Outcome of monthly inpatient coding audit: (C.5.c.f.g,h) - c) Inpatient Professional Services Rounds encounters ICD-9 codes audited and deemed correct?- c) Inpatient Professional Services Rounds encounters ICD-9 codes audited and deemed correct?

27. 27 Commander’s Data Quality Statement Q. 5. Outcome of monthly inpatient coding audit: (C.5.c.f.g,h)Q. 5. Outcome of monthly inpatient coding audit: (C.5.c.f.g,h) - d) Inpatient Professional Services Rounds encounters CPT codes audited and deemed correct?- d) Inpatient Professional Services Rounds encounters CPT codes audited and deemed correct?

28. 28 Data Output MEPRS/EAS, ADM, CHCS, TPOCS ADMADM –Timely Data Transmittal Standard Ambulatory Data Record (SADR)Standard Ambulatory Data Record (SADR) –Error Logs –Workload Comparison

29. 29 Data Output Outpatient Coding Sample SizeSample Size AccountabilityAccountability –Percentage Located or Properly Checked Out –Checked-out Over 30-Days? DD Form 2569 (Third Party Insurance Information)DD Form 2569 (Third Party Insurance Information)

30. 30 Commander’s Data Quality Statement Q.6. Outpatient Records. (c.6.a,b,c,d,e,f)Q.6. Outpatient Records. (c.6.a,b,c,d,e,f) – a) Is the documentation of the encounter selected to be audited available? Documentation includes documentation in medical record, loose (hard copy) documentation or an electronic record of the encounter in AHLTA?

31. 31 Data Output Outpatient Coding E&M CodesE&M Codes ICD-9 CodesICD-9 Codes CPT CodesCPT Codes

32. 32 Commander’s Data Quality Statement Q. 6. Outpatient Records.Q. 6. Outpatient Records. –b) What is the percentage of E & M codes deemed correct? (E & M code must comply with current DoD guidance.) (C.7.(b))

33. 33 Commander’s Data Quality Statement Q. 6. Outpatient Records.Q. 6. Outpatient Records. –c) What is the percentage of ICD-9 codes deemed correct? (C.6.(c))

34. 34 Commander’s Data Quality Statement Q. 6. Outpatient Records.Q. 6. Outpatient Records. –d) What was the percentage of CPT codes deemed correct? (CPT code must comply with current DoD guidance.) (C.7.(d))

35. 35 Commander’s Data Quality Statement Q. 6. Outpatient Records.Q. 6. Outpatient Records. –e) What percentage of completed & current (signed within the past 12 months) DD Form 2569s (TPC Insurance Info) are available for audit? (C.7.(e))

36. 36 Commander’s Data Quality Statement Q. 6. Outpatient Records.Q. 6. Outpatient Records. - f) What percentage of available, current and completed DD Form 2569s are verified to be correct in the Patient Insurance Information (PII) module in CHCS? - f) What percentage of available, current and completed DD Form 2569s are verified to be correct in the Patient Insurance Information (PII) module in CHCS?

37. 37 Commander’s Data Quality Statement Question 7 Ambulatory Procedure Visits (C.7.a,c,d,e,f)Question 7 Ambulatory Procedure Visits (C.7.a,c,d,e,f) Questions 7.a,c,d,e,f are the same as Questions 6.a,c,d,e,fQuestions 7.a,c,d,e,f are the same as Questions 6.a,c,d,e,f

38. 38 Commander’s Data Quality Statement Q. 8. Comparison of reported workload data (C.9).Q. 8. Comparison of reported workload data (C.9). – a) # SADR Encounters / # WWR visits – b) # SIDR Dispositions / # WWR Dispositions – c) # EAS Visits / # WWR Visits – d) # EAS Dispositions / # WWR Dispositions – e) # IPSR SADR encounters (FCC=A***)/# Sum WWR (Total Bed Days + Total Dispositions) Note: FY07 Goal is 80%

39. 39 Data Output Workload Comparison SADR Encounters / WWR VisitsSADR Encounters / WWR Visits –Should Have More Encounters Than Visits –Encounters – Omit Appt. Status of “No-Shows,” “Canceled,” and Disposition Code “Left Without Being Seen” –Encounters – Include Appt. Status “TelCon” – Only SADR Records Marked with an Appt. Status of “C” (complete) Are To Be Included

40. 40 Data Output Workload Comparison SIDR Dispositions / WWR DispositionsSIDR Dispositions / WWR Dispositions –Must Match –Only SIDRs With a Disposition of Status of “D” Are To Be Included –SIDRs – Exclude Carded for Record Only (CRO) and Absent Sick Records

41. 41 Data Output Workload Comparison EAS Visits / WWR VisitsEAS Visits / WWR Visits –Must Match –Include MEPRS Functional Cost Code B** (Outpatient) and FBN (Hearing Conservation) –Include APVs

42. 42 Data Output Workload Comparison EAS Dispositions / WWR DispositionsEAS Dispositions / WWR Dispositions –Must Match –Only SIDRs with a Disposition Status of “D” are to be included

43. 43 Data Output Workload Comparison IPSR encounters (FCC=A***)/# Sum WWR (Total Bed Days + Total Dispositions)IPSR encounters (FCC=A***)/# Sum WWR (Total Bed Days + Total Dispositions) Note: FY07 Goal is 80% Note: FY07 Goal is 80% Insure WWR calculation includes live births (section 01) and Bassinet Days (section 00).Insure WWR calculation includes live births (section 01) and Bassinet Days (section 00).

44. 44 Commander’s Data Quality Statement Q.9. - System Design, Development, Operations and Education/Training (E.4.c).Q.9. - System Design, Development, Operations and Education/Training (E.4.c). - # AHLTA SADR encounters/# of Total SADR encounters Note: FY07 not scored. For management use and tracking purposes only. (* It is understood that not all clinical modules are deployed in the current version of AHLTA.)

45. 45 Commander’s Data Quality Statement Q. 10. – I am aware of data quality issues identified by the DQMC Review List and when needed, have taken action to improve the data from my facility.Q. 10. – I am aware of data quality issues identified by the DQMC Review List and when needed, have taken action to improve the data from my facility.

46. 46 Security Responsibilities for computer security formally assigned?Responsibilities for computer security formally assigned? Is there a Security/Privacy Program in place to address Security threats (internal/external) and HIPAA ComplianceIs there a Security/Privacy Program in place to address Security threats (internal/external) and HIPAA Compliance –Password Protection? –Access to systems? –Confidentiality of data? –Level of Access to MEPRS/EASi, CHCS, AHLTA, ADM, TPOCS, CCE, DMHRSi

47. 47 System Design, Operations, and Education/Training System Administrator Appointed In Writing for Each SystemSystem Administrator Appointed In Writing for Each System Training and Education Procedures and DocumentationTraining and Education Procedures and Documentation System Change Request ProcessSystem Change Request Process System Incident ReportSystem Incident Report Routine MaintenanceRoutine Maintenance Points of Contact for Equipment Failure IssuesPoints of Contact for Equipment Failure Issues Contingency PlansContingency Plans

48. 48 Data Quality Section, PASBA Mr. Joseph (Tim) Bacon (Chief DQ Section, PASBA / Army DQ Mgr) Telephone: (210) 295-8725 DSN: 421 Ms. Deborah Lundberg (NARMC) (210) 295-8923 DSN: 421 Mr. Angel Padilla (18 th MEDCOM/PRMC/WRMC) (210) 295-8842 DSN: 421 Mr. Joe Alley (ERMC/SERMC) (210) 221-0467 DSN: 421 Ms. Vicki Vestal (GPRMC) (210) 295-8931 DSN: 421