Presentation on theme: "2010 UBO/UBU Conference 1 Title: Using M2 to Manage MTF Data Quality Speaker: Dr. Rich Holmes and Wendy Funk Session: R-6-1000."— Presentation transcript:
2010 UBO/UBU Conference 1 Title: Using M2 to Manage MTF Data Quality Speaker: Dr. Rich Holmes and Wendy Funk Session: R-6-1000
Objectives After completing this session, the attendee can: Characterize the following DQ Issues Affected by Recent Changes to PPS: – Treatment of Units of Service in RVU Calculations – Substituting the Ceiling on Maximum Units of Service – Usage of “J” Codes in B-Clinic SADRs and... Characterize the following ongoing DQ Issues: –... Usage of other HCPCS Codes in B-Clinic SADRs – Usage of New E&M code for Established Patients – Coding Creep – Admitting Same Day Surgeries – Inpatient Procedures Coded in Ambulatory Clinics – Usage of Individual CPT Codes for Group Therapy 2
3 After completing this session, the attendee can: Characterize the following DQ Issues Affecting Readiness or Continuity of Care: – Case Management Workload and FTEs – MDC 23 Explosion in Utilization Leverage the MHS Data Mart (M2) – Describe the M2. – Describe the process of retrieving and using a corporate document. – Describe how M2 can be used to write ad-hoc reports about data quality. Objectives
Implementation of Unit of Service Limits in RVU Calculations 5
Units of Service Limits 6 There are three components associated with CPT coding: – The code itself – The code modifier – intended to add additional information about a procedure code – Units of service: Indicates the number of times a procedure code is performed on a data record. Proper RVU assignment takes all of these into account, as well as: – Setting – Type and Number of Providers
There are three types of RVUs. – Work RVUs: represents provider costliness and effort – Practice Expense RVUs: Represents a provider’s overhead costs, such as supplies, nurses, admin staff, etc.. Two types: “In Office” and “Out of Office” – Malpractice RVUs: intended to assist in covering malpractice premiums. Initially, HA/TMA used only the work RVU for PPS, with no other adjustments for units of service, modifiers, etc. (Simple RVU) Eventually, PPS implemented units of service, so that multiple instances of one CPT code could be credited. (Enhanced Simple RVU) Units of Service Limits
PPS also incorporated practice expense RVUs. This was very important – Without units of service, the Services were underfunded; especially for physical therapy and mental health. – The work RVU usually is reflective of only about half of the cost of ambulatory care – was not the best resource allocation method. Implementing “total RVUs” (work + PE) and units of service was a significant improvement in the PPS. Units of Service Limits
The initial implementation of the new RVU data elements that included units of service (UOS) was done without respect to the quality of the reporting of UOS. Many of the records received, however, contained units of service that simply could not be true. Limits were developed for each CPT code by TMA/BEA. These limits can be obtained from M2, in the CPT/HCPCS table. All SADR data were reprocessed to incorporate the limits. – When this was done, users were not notified – Many questions have arisen from MTFs whose RVUs dropped as a result. These MTFs typically had data quality problems. Units of Service Limits
Service-Wide Impact of UOS Changes in FY10 ServiceSimple RVU Enhanced Simple (ES) RVU Enhanced Simple RVU w/ Limits Simple vs. Enhanced Simple Enhanced Simple vs. Limited ES Simple vs. Limited ES A 16,759,382 17,576,133 17,292,7355%-2%3% F 8,072,882 8,378,461 8,291,2454%-1%3% N 9,408,982 9,967,646 9,867,8746%-1%5% Total 34,241,247 35,922,241 35,451,8555%-1%4% Excludes nurse workload, which will no longer be credited in PPS
MEPRS Code Impacts of Unit of Service Limits 11 For most MEPRS Codes; impacts of changes in RVU methodologies were minimal However, a few had major changes CodeAFNTotal BA: Medicine6%5%6% BF: Mental Health5%2%15%6% BL: PT/OT18%28%37%25% All MEPRS Codes 3% 5%4% Both PT/OT and Mental Health utilize several codes that indicate a time increment. The impact in medicine is mostly from the Nutrition Clinic.
CPT Impacts of Unit of Service Limits Some selected extreme examples from SADRs Each SADR represents care provided to one patient on one day. The first three SADRs indicate that there were 80 patients were given more than 900 vaccinations at one visit! The last SADR shows 159 encounters where the patients had up to 52 days of psych counseling in one day! CPTDescriptionUOS RawLimit# SADRs 90471 Administration of a Single Vaccine906148 90471 Administration of a Single Vaccine907115 90473 Administration of a Single Vaccine - Oral906117 90801 Psychiatric Eval (covers up to 24 hours)522159
14 Quantity Limits in Clinic Records TMA BEA sets “ceilings” on the maximum reasonable number of times a procedure could occur in an encounter. If an MHS provider reports more than that number, the data are overwritten using the TMA BEA ceiling. PPS calculates earnings based on the overwritten new number, and third-party billing when centralized would also see only the new number. Here are some examples!
15 Quantity Limits in Clinic Records MTF Military Department CPT Code, Meaning QuantityCeilingPPS change if ceiling was 1 AllS0810, PRK vision fix 123, 55 * 2 -$913 Army96118, hour of psychiatric test 3120 -$2,369 AF Ext RS (same encounter) 12032 (suture up to 7” scalp) 11404, excise 4” circle lesion 81 77 1 18 -$2,900 Navy (same encounter) 17311, 17312 (Moh’s Surgery to 5 tissue blocks) 4343 1313 -$726 * Meant modifier “55” (follow up) These are single encounters in MTFs in FY10
16 Quantity Limits in Clinic Records Impact on Replacing Impossible Quantities with “1”: Army$3,260,417 Navy$1,448,307 Air Force$ 812,071 MHS$5,520,795
18 Clinician-Administered Drugs Represent $38 million dollars in the FY10 records. PPS funded in FY2010, but will not in FY2011. Can be billed for third-party collections. In FY2010, $5.2 million was coded in clinician administered medications (J HCPCs) to patients who had other health insurance (OHI). Not included in this are some outrageous quantities, although PPS did use them for reimbursement! Clinician-Administered Drugs (HCPCS “J”)
21 BUT “J” IS NOT THE ONLY HCPCS THAT MATTERS!) HCPCS groupSADRs Procedure Groups PPS Earnings A Transporting Pts 58,368 83,364 $ 2,040,869 B Enteral feeding 14 15 $ 2,038 C Outpt PPS - - $ - D Dental 10,234 11,008 $ 460,434 E DME 42,570 51,107 $ 2,656,458 G Temp Prof Svcs 58,799 63,930 $ 4,379,494 H Alc-Substance Abuse 267,270 406,744 $ 22,428,509 J Drugs 591,998 713,616 $ 37,513,974 K DME (Temp) 146 158 $ 22,614 Clinician-Administered Drugs
22 HCPCS groupSADRs Procedure Groups PPS Earnings L Orthotics 167,267 187,411 $ 22,064,312 M Other Med Svcs 101 $ 4,297 P Pathology 496 520 $ 179,299 Q Temp Codes 420,336 453,564 $ 16,849,055 R Radiology 13 $ 360 S Temp Non-Medicare 88,837 90,867 $ 29,802,579 T Medicaid 3,571 3,751 $ 375,752 V Vision 14,056 16,834 $ 1,516,502 Total 1,724,076 2,083,003 $ 140,296,545 BUT “J” IS NOT THE ONLY HCPCS THAT MATTERS!) Clinician-Administered Drugs
New Patient E&M Codes 24 Evaluation and Management Codes describe the nature of a provider to patient interface An important feature of some E&M codes is the distinction between a new patient and an established patient. – New patients require more work that established patients – And therefore, providers receive higher reimbursement and RVUs for new patients CodeDescriptionWeight 99201 - 99205New PatientsLowest intensity work RVU = 0.96 Highest intensity work RVU = 6.34 99211 – 99215Established PatientsLowest intensity work RVU = 0.36 Highest intensity work RVU = 4.22
New Patient E&M Codes 25 What is a new patient? – Defined based on CPT Coding Rules – A new patient is one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years. The definition of a new patient doesn’t only mean “new to the provider”, it can mean “new to the practice” also. To determine the extent to which new patient E&M codes are properly used: – Developed a history file – Person ID, MTF, date of service, specialty and MEPRS code – Compared with coding on each new/established SADR – Compared 2007 to 2010
New Patient E&M Codes Year MTF Service Properly Coded New Patient Improperly Coded New Patient Total New Patient % That Appear to be Coded Incorrectly PPS Impact of Improper Coding 2007Army682,121107,655789,77614% $ 3,075,185 2007Air Force288,43145,164333,59514% $ 1,347,508 2007Navy390,75475,699757,82010% $ 2,234,421 2010Army601,67766,009667,68610%$ 2,003,614 2010Air Force250,54729,209279,75610%$ 889,554 2010Navy154,58332,005186,58817%$ 996,275
New Patient E&M Codes Coding of new patient E&Ms has improved for 2 of the three Services from 2007 to 2010. Service20072010 Army14%10% Air Force14%10% Navy10%17% % of records that seem to be improperly coded
New Patient E&M Codes At MTF-level, some MTFs have shown improvement in new patient E&M coding, while others have not. YearMTF Properly Coded New Patient Improperly Coded New Patient Total New Patient % That Appear to be Coded Incorrectly 2007 Lemoore5,6682,9998,66735% 2007 Dover2,0021,1803,18237% 2007 Scott6,8401,5188,35818% 2007 Fort Riley20,5474,84925,39619% 2010 Lemoore4,3781614,5394% 2010 Dover1,4243371,76119% 2010 Scott3,7992794,0787% 2010 Fort Riley10,7391,24511,98410%
New Patient E&M Codes At MTF-level, some MTFs have shown improvement in new patient E&M coding, while others have not. YearMTF Properly Coded New Patient Improperly Coded New Patient Total New Patient % That Appear to be Coded Incorrectly 2007 00432,7531182,8714% 2007 00191,100891,1897% 2007 00305,3336916,02411% 2007 00296,4729,72574,45313% 2010 00431,2946341,92833% 2010 00192638234524% 2010 00301,1232571,38019% 2010 002917,2264,13921,36519%
Admitting Same Day Surgeries 36 Over the past several decades, the settings for many procedures has changed from inpatient to ambulatory Using an ambulatory setting when appropriate is beneficial to both the patient and the health system. Many health plans require pre-authorization for hospitalizations for care that is routinely provided in ambulatory settings. – This is because some patients have complications or co- morbidities that may require the admission. No such pre-authorizations are required for MTF care. Reimbursements are far greater for inpatient settings than for ambulatory
AHRQ published a list of procedures where 90% or more of cases are done in an ambulatory setting; based on data from their Health Care Utilization Project (HCUP) – Russo, C.A., Elixhauser, A., Steiner, C., and Wier, L. Hospital- Based Ambulatory Surgery, 2007. HCUP Statistical Brief #86. February 2010. Agency for Healthcare Research and Quality, Rockville, MD. – http://www.hcup-us.ahrq.gov/reports/statbriefs/sb86.pdf http://www.hcup-us.ahrq.gov/reports/statbriefs/sb86.pdf For this analysis, we selected tonsillectomies (with adenoid removal) Admitting Same Day Surgeries
MTF SIDR records were classified using the AHRQ Clinical Classification Software (CCS) for Procedures – AHRQ CCS groups either ICD-9 procedures or CPT procedures into categories – http://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp#download Provides a handy crosswalk. http://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp#download All procedure codes on each SIDR were grouped and records that contained only the 4 selected procedures were retained. Admissions from same day surgery and ER were excluded, as were cases with complications and co-morbidities. Admitting Same Day Surgeries
PPS Earnings for these ambulatory-type services were then calculated from the SIDRs And using SADRs, for these same MTFs, PPS earnings were calculated for the same procedures (based on AHRQ CCS groupings), but when done in an ambulatory setting. 7,474 uncomplicated tonsillectomies/adenoiodectomies were performed at MTFs in FY10. For most MTFs, only 3% were performed in an inpatient setting Admitting Same Day Surgeries
MTFs and Tonsillectomies MTF# Inp % of All MTFs# AmbTotal% InpPPS IP $ Would be PPS OP $ Tripler16130%42558627% 1,879,379344,843 Walter Reed448%13818224% 546,94594,243 Landstuhl418%14518622% 311,12487,817 BAMC367%18722316% 351,64277,108 Seoul265%669228% 207,76355,689 Wilford Hall255%18020512% 261,28053,547 Lejeune183%10812614% 272,85738,554 All Others19436%5,6805,8743% 1,588,609415,525 Total545100%6,9297,4747% 5,419,5991,167,325
Tonsils: – About half of all uncomplicated tonsillectomies done as inpatients were done at 3 MTFs. – These three MTFs earned almost 3 million dollars for these surgeries – If these had been done on an outpatient basis, there three sites would have earned only about a half a million dollars! Admitting Same Day Surgeries
43 Inpatient Procedures Coded in B Clinics PPS includes in its RWP (inpatient) earnings a “price per RWP” that includes both the hospital and all clinicians’ work for the inpatients. UBU and CHCS create SADRs in B-Clinics, sometimes labeled as inpatients and sometimes not, but for patients who are clearly inpatients. If a B-clinic SADR is created, PPS pays RVU earnings in addition to the inpatient RWP earnings. There are enormous differences on the extent to which B-Clinic SADRs are reported for inpatients, both between services, and between MTFs.
44 Inpatient Procedures Coded in B Clinics Mil Dep Total PPS Earnings Nurse PPS Earnings Non-Nurse PPS EarningsEncountersAdmissions A $ 55,140,020 $ 381,346 $ 54,758,673 306,560 86,347 N $ 25,678,645 $ 235,100 $ 25,443,545 157,173 50,680 F $ 11,805,190 $ 105,312 $ 11,699,878 43,000 23,193 Total $ 92,623,855 $ 721,758 $ 91,902,097 506,733 160,220
45 Inpatient Procedures Coded in B Clinics A single patient admitted for a broken hip, reduced at one MTF but then transferred to a Medical Center for wound debridement, had as an inpatient: – 417 B-clinic SADRs – Which earned $50,089 for the medical center – In ADDITION to the PPS earnings for the 5 month stay.
47 Group Service Records Group encounters require coding with special CPT or HCPCS to reflect that group counseling or other therapies are less effort per patient than individual care. Appointment times (MDR only) show when groups are treated instead of individuals. Conclusions are only as valid as the appointment times – “cattle call” sessions would appear to be groups. Oddly, a handful of CPT codes give MORE weight for a group than for an individual, like H0004 and H0005 (alcohol and drug counseling). Perhaps it was intended that billing for such groups would not be individually identified? On the next slide, the FY10 data are corrected into groups.
48 Group Service Records Number of SADRs Difference in RVUs Difference in Earnings Army 45,195 -13,303 -$ 497,913 Navy 38,691 -19,746 -$ 739,091 Air Force 4,791 -258 -$ 9,672 MHS 88,677 -33,307 -$ 1,246,677
49 Group Service Records Clinic Appt DateTime Pat UniqCPTUOSRVU Grp CPT Grp RVU Orig Earnings Correct Earnings Diff in Earnings BFEA9/165:12xx297496151127.44961531.44 $ 278.48 $ 53.90 -$ 224.58 BFEA9/165:12xx07029615184.96961530.96 $ 185.65 $ 35.93 -$ 149.72 BFEA9/165:12xx80849615163.72961530.72 $ 139.24 $ 26.95 -$ 112.29 BFEA9/165:12xx770896151127.44961531.44 $ 278.48 $ 53.90 -$ 224.58 $ 881.85 $ 170.68 -$ 711.17 Same doctor, same day and clinic, same appointment time
Data Quality Affecting Readiness or Continuity of Care
Case Management MTFs have special requirements for coding of case management – Significant Congressional Interest – Congress is requiring reporting of # of case managers and their case loads. New coding guidelines utilize SADRs to capture information And MEPRS to capture full-time equivalent case managers Contained in UBU Coding Guidelines, Appendix E 53
54 Case Management Coding MEPRS codes: – Tri-Service consensus was not reached with regard to the use of MEPRS codes for case management. – The following codes are to be used exclusively for case management: ServiceWTU FundedNon-WTU Funded Army MTFFAZ2ELAN Navy MTFELA2ELAN Air Force MTFELAN
Characteristics of Case Management Records Case Managers are required by HA to submit at least one SADR per month that represents an acuity assessment – Not necessarily a provision of healthcare services, like most SADRs. CM SADRs contain the same data elements as regular SADRs. Provider ID represents the case manager. Two new provider specialty codes were created: – Nurse Case Manager (613) – Social Worker Case Manager (714) 55
56 Dx Code & ExtenderDescription V4989 2Initiation of Case Management Services V4989 3Case Management Maintenance V4989 4End of Case Management Services Tri-Service case management work group decided that case managers would not make diagnoses. Rather, case managers would use the following diagnosis codes on CM SADRs: Characteristics of Case Management Records
57 CodeAcuityInterventionsContactPsychosocial G900210-2/month1+/monthMinimal G900521-4/month3-4/monthMinimal G900931-4/month1-2/weekModerate G901041-6/month3/weekModerate to Complex G901151-6+/month3+/weekComplex Characteristics of Case Management Records Procedure Code is used to represent the case manager’s assessment of the patient’s acuity.
Coding of Case Management The M2 SADR table can be used to review CM SADRs. (Corporate document or ad-hoc) Some issues have been identified with reporting Use of MEPRS codes (FY10 data) MEPRS CodeEncountersTotal RVUs All Others9,88430,742 B Codes18,46143,357 ELA211,35942,509 ELAN80,669253,078 FAZ255,104369,685 Total 175,477739,371 Red Font indicates that these RVUs would have earned PPS $ in 2010
Coding of Case Management Completeness of Data – There is no perfect method to identify how many case managed patients there should be. – The following chart shows selected MTFs that treat patients enrolled in Warrior in Transition Units (WTUs). Selected MTFs and % of Patients Treated in WTU MEPRS codes who have a case manager # reported in WTU# with CM% with CM 0052: Tripler178148% 0075: Fort Leonard Wood2332310% 0057: Fort Riley5426412% 0110: Fort Hood1,07014714% 0037: Walter Reed78411114% 0049: Fort Stewart39423760% 0047: Fort Gordon78149463% 0029: San Diego835465% 0089: Fort Bragg80155369% 0091: Camp Lejeune 473983%
Coding of Case Management Completeness of Data – Requirement includes coding of CM data for active duty and non active duty. First priority was to implement coding for AD DMISID # AD# NADTotal 0089: Fort Bragg 1,549 897 2,446 0014: Travis AFB 70 511 581 0039: Pensacola 93 354 447 0038: Jacksonville 138 340 478 0032: Fort Carson 857 291 1,148 0049: Fort Stewart 236 9 245 0109: Brooke AMC 337 9 346 0110: Fort Hood 99 6 105 0064: Fort Polk 137 4 141 0061: Fort Knox 59
Coding of Case Management Effect on MEPRS costs – One purpose of MEPRS is to allocate overhead costs to the areas that benefit (stepdown). – Costs recorded in MEPRS codes that begin with D and E are allocated. – Army uses FAZ2 for WTUs, and thus costs are not allocated. MEPRS Code Receiving CM $ Army Air Force Navy Total A4,870,902381,5582,938,8878,191,347 B18,696,4803,849,1121,575,88634,121,478 C5,966998,027758,3821,762,376 D 1,579,828 3,913,8945,493,721 F911,5741,941,9942,109,4714,963,039 Total24,484,9228,750,51921,296,52154,531,961
Increases in Encounters for MDC 23 (Other Factors Influencing Health)
MDC 23 Trend by Service: MEPRS B Codes and FBI/FBN Service200820092010% Chg A7,984,2208,707,9379,420,86418% F3,497,4553,867,4864,037,58815% N4,366,6094,765,8905,195,58719%
MDC 23 as a % of total ambulatory encounters; by bencat and Service (FY2010; MEPRS B Codes; FBI and FBN) ServiceADADFMRETOthersTotal Army5,617,1352,072,584609,6801,121,4659,420,864 Air Force1,883,8541,067,196428,836657,7024,037,588 Navy2,885,5911,206,229399,892703,8755,195,587 Total MDC 2310,386,5804,346,0091,438,4082,483,04218,654,039 Total Encounters20,786,32510,182,1083,760,6415,858,72140,587,795 % MDC 2350%43%38%42%46%
Types of Care Being Recorded in MDC 23 Top Diagnoses in “Other” Encounters for Unspecified Administrative Services (16% of other) Periodic Preventive Exam (6%) Issue of Repeat Prescription (4%)
Unrealistic MDC 23 Workload One provider did more than 65,000 encounters in 212 work days. – Averages more than 300 encounters per day. – Averages more than 580 Total RVUs per day. – In FY10, these RVUs would have earned PPS $. RVUs per Day# Days 0-10040 100-50047 500-100088 1000-500037 Total Days Worked212 Total RVUs Earned124,527
Introduction of M2 What is M2? – MHS Mart – Data Mart containing a subset of the MHS Data Repository. – 1700 users of M2, across the MHS. – Includes DEERS, Direct Care and Purchased Care. – Easy to query; no programming knowledge required. – Analytical Tools, such as “Slice and Dice”. – Can upload and download data. – Significant advantage with multiple data sources all contained in one system. – Data Dictionary: http://www.tricare.mil/ocfo/bea/functional_specs.cfm 70
Live M2 Screen with Menu of Data Files 71 M2 Query Panel
72 Folders are called “Classes” Directories which contain the data files people query from Behaves like directory structures in Windows Live M2 Screen with Menu of Data Files
MTF Data in M2 M2 contains several data files sent from MTFs Detailed event-level records: – Standard Inpatient Data Record – Standard Ambulatory Data Record (to be renamed “CAPER”) – MTF Laboratory, Radiology and Pharmacy Summary records: – Medical Expense and Performance Reporting System – Worldwide Workload Report M2 also contains several files that don’t originate at MTFs – For example, claims or DEERS records 73
Using M2 Users can write ad-hoc reports or can use already written “Corporate Documents” Corporate Document Handbook is available – Describes the purpose, content and how to use each report – Financial Reports, Clinical Reports and Data Quality Reports Corporate Reports are very easy to use – Users simply need to know their MTF DMISID – Tools within M2 (slice and dice) allow for analysis of data within the reports 75
Data Quality Corporate Documents Some examples of Data Quality Corporate Documents Completeness of Data: – Inpatient Completeness (WWR vs. SIDR vs. MEPRS) – Ambulatory Completeness (WWR vs. SADR Count/No-Count vs. MEPRS) Accuracy: – Ungroupable MS-DRGs on SIDRs – Unlisted Provider Specialty on SADR – Record Level Uncoded SADR Report – PDTS Most Expensive Drug Report – Invalid Provider ID 76
Steps for retrieving a corporate document: 1.File 2.Retrieve From 3.Corporate Documents The following box will appear…
Select the document you wish to retrieve and then select “Retrieve”. If the “Open on Retrieval” box is selected, the document will open automatically.
Ad-Hoc Use of M2 The possibilities for analysis of data quality issues using ad-hoc M2 are limitless. M2 records can be retrieved at detailed level, enabling easy visibility of the coding at each MTF. To write an ad-hoc query, users: – Select the data file to use. – Select the data elements needed. – Create “filters” to limit the data to answer a specific question. Recommend that users who write ad-hoc queries obtain training on the use and interpretation of MHS data.