Data Quality Management Control Program Report

Data Quality Management Control Program Report
TSgt Jody Callender Air Force Data Quality Manager AFMSA/SGSR

Overview Revenue Cycle Team Composition and Responsibilities
Commander’s Statement Provider Files Data Quality Issue Examples References Useful Links Questions

What is Data Quality? Is the accurate reflection of the work performed in the MTF that can be used to make informed leadership/management decisions at all levels of command. You have spent the last two and a half days getting an overview of the Data Quality Program. I hope what you took away from it is a broad understanding of the magnitude of your program Bottom Line: What is put into your systems effects the outcomes of the various programs that rely on it.

MTF Patient Accounting & Revenue Cycle
Data quality Management Controls are the driving force and conduit for ensuring effective and efficient operations Visual review for validating and streamlining major clinical business and resource management processes MTF Patient Accounting & Revenue Cycle Claims Submissions Account Follow-up Production Value (RVUs/RWPs) Cost per RVU/RWP (Efficiency) Coding Denial Management CCE Utilization/ Referral Management EWRAS TPOCS/ CMBB Payment Posting ADM/ P-GUI/ CHCSII Data Quality Management Electronic Billing Pre-cert/ Auth Appeals CHCS (Files & Tables) M2 Data Mart Encounter Document Payer Education The first thing I want to go over is the revenue cycle. How do you effect change in your MTFs? Start by understanding that although we are not for profit, the revenue cycle still has an effect on our business processes. We are the watch dogs of the Revenue Cycle, what we do effects manning and budget decisions As you can see this is a cycle and not the way the military has viewed the revenue process in the past… It used to be if your budget was 10M last year and you spent all of it than you would get 10M plus inflation factors…it is going to take a cultural change to look at what is the amount of medical care your MTF is providing as the “revenue” or “profitability” verse the expenses. How will this cycle success be measured? By comparing MEPRS cost (expenses) to Coding Value (revenue/profit). Of course there are some military only things that have to be taken into effect but the change in the way we think is necessary to support ODRA/PPS. Performance Based budgeting What is your position in the cycle? Right at the center…your program touches everything that we do in the system…we are going to go over some of the files and tables that you can set up to make your life easier And some helpful hints that will ensure your data quality steadily improves If we have time we will go over the coding methodology that was developed for the AF by AFMSA South, one thing that you have to keep in mind is that if you do not have any targeted clinics for a given month, you still need to do a coding audit for the DQ program. Which clinic you decide to do should be based on the needs of your MTF…you could audit a clinic that had an issue last time it was audited…to see if it has improved. You could choose pay patients, patients with OHI, over 65 patients…but at least 139 records which is a reasonable sample We are currently revamping the coding methodology, the sample size will be changing. If you take care of the front end of the business cycle files/tables and coding the back end metrics and reimbursements will take care of themselves. Ok, let’s go over the basics MEPRS (MEWACS) Patient Check-in Ins Verif & Auth Contract Mgt Patient Access Resourcing (Money, Manpower, and Materiel) MTF Business Plan (Patient Management) Improved patient access, records documentation and coding accuracy Results are increased resourcing with reliable outcomes in the form of usable data AFMSA/SGSR

Data Quality Team Data Quality Manager
Additional duty; full time in some instances Usually a RMO function Clinic Managers Credentials Manager Budget Analyst MEPRS Program Manager Coding Supervisor Billing Supervisor IM/IT Department Including system administrators Others as needed Executive Committee – monthly oversight You need to start with a strong team, your leadership must be involved at every level for you to succeed. In many ways you are a facilitator and advisor, this is a relatively new program in the DoD; however, not really in many ways we have been doing this program in bits and pieces for years…the point behind this program is to bring the various pieces together.

Data Quality Team Approach
Multi-specialty DQ team established and meet monthly Keep meeting minutes for at least two years – so you can track progress Report monthly to Executive Committee Ensure the minutes reflect your efforts to improve Data Quality Review Metrics together to work toward solutions It is great to look – But are you working toward improvement? Monthly Statement is signed and forwarded to Service DQ Manager monthly Ensure your commander knows what they are signing It takes a team from many different areas to effect the data in our corporate in a positive manner. You need to brief your commander(s) to ensure they understand the criticality of your program. In the past commander involvement in this program as been spotty but as LtGen Taylor is paying increasing attension to this program…your commanders will be coming around and if the questions I have been getting lately are an indicator you will be getting additional support.

Data Quality Management Review List
Section A: Organizational Factors Section B: Data Input Section C: Data Output Section D: Security Section E: System Design, Development, Operations, and Education/Training Ok, Now let’s go over the Data Quality Management Review List Section A – we talked about this already so we will go over it only briefly Sections B/C – we will be spending a lot of time on Section D/E – are pretty straight forward so we will get them out of the way

Data Quality Management Review List Section A: Organizational Factors
A.1. The MTF Commander signed last month's Data Quality Statement acknowledging responsibility for the quality of data reported from the MTF. A.2. The MTF DQ Manager submitted the completed Commander's Data Quality Statement to the Service's respective DQ Manager(s). A.3. The Data Quality Assurance Team or other designated structure met during the reporting month to complete the DQMC Review List. (Recommend attaching meeting minutes.) A.4. The DQ Manager briefed the reporting month's DQMC Review List and Financial and Workload Data Reconciliation and Validation results to the MTF Executive Committee. These are pretty straight forward, did you brief the executive staff…is your commander aware of your issues and what you are doing to fix them If you are a very small clinic than you can be a subgroup of the executive committee

Data Quality Management Review List Section A: Organizational Factors
A.5. Does your MTF have a Coding Compliance Plan which has been reviewed annually for updates and quarterly for compliance? A.6. Does your MTF have a UBO Compliance Plan which has been reviewed annually for updates and quarterly for compliance? A.7. Has your Data Quality Manager/Assurance Team members attended: a) TMA Data Quality Course? Date attended: __________ b) Working Information to determine Optimal Management (WISDOM) Course? Date attended: __________ (If the Site has an M2 account holder) c) MEPRS Application and Data Improvement (MADI) Course? Date attended:__________ There is a MTF Coding compliance template available if you need it. The UBO compliance plan is in the DoD Manual. It is important that at least one person at your MTF has access to the M2, so you know what TMA is looking at The M2 is golden…what is in there is what you get credit for.

Data Quality Management Review List Section B: Data Input
B.1. Are the most current written procedures, in accordance with MHS and Service guidelines, readily available and used by staff for entering, identifying, correcting and reprocessing data into the systems? (See TRICARE Data Quality Web Page/Hyper-Links and appropriate Service Web Sites.) a) MEPRS/EAS b) ADM c) CHCS d) TPOCS B.2. List the current version of software being used? (See TRICARE Data Quality Web Page/Hyper-Links and appropriate Service Web Sites for Approved Versions.) List Current Approved Version below: a) MEPRS/EAS a)_________________ b) ADM b)_________________ c) CHCS c)_________________ d) TPOCS d)_________________ B.3. Are reporting month central system upgrades (and associated loading activities) being received and loaded within 30 days of release? (See TRICARE Data Quality Web Page/Hyper-Links and appropriate Service Web Sites.) Examples are as follows: List reporting month Upgrades/Loads completed (examples include, but are not limited to CPT, ICD, DRG, etc): Note: (Examples of associated loading activities include, but are not limited to Medical Center Division File update, Department Service Location File update, MEPRS Code File update, etc.) B1. Do you have a copy of the latest guidelines available? - Recommend you read them, you make find out where some of your problems are just from trying to understand the interdependent relationship this programs have. B2/3 Why do we ask you this every month? Because we have found systems that have not been updated with the latest patches

Data Quality Management Review List Section B: Data Input (con’t)
B.4. Were all rejected records corrected and retransmitted? (As applicable.) a) MEPRS/EAS b) ADM c) CHCS d) TPOCS (ADM to TPOCS) e) If the system is rejecting records, has a trouble ticket with the MHS Help Desk and/or Service help desk been filed (if required)? f) Do you have any open trouble tickets that have not been resolved within 14 calendar days or have a plan of action in place to resolve it? System___________Number_________Expected Resolution Date______ B4. Who is checking the error logs to ensure the data was transmitted? How do you know it has been fixed, develop some kind of an audit trail

B.5. In the reporting month: Question 1 a) What percentage of clinics have complied with "End of Day" processing requirements, "Every clinic - Every day?" (Question 1a of Commander's Statement.) b) What percentage of appointments were closed in meeting your "End of Day" processing requirements, "Every appointment - Every day?" (Question 1b of Commander's Statement.) #Closed Appts/Total Appts x days How do I do that? Initiate EOD Delinquent Report daily after last clinic closes, but before 2400 Document results To complete EOD processing on outstanding records, return to EOD processing, find the appointment by date and time, select the record and complete it The EOD is now completed and the ADM (SADR) file has been generated B5. Every clinic/Every Day Critical to outpatient workload reporting process 2400 deadline will capture delinquent EOD for a given day – if you set your report to run after 2400, you will capture the next day’s appointments as well\ Intended to make sure the process remains current Helps ensure data are correct EOD processing must be completed for EVERY ENCOUNTER, EVERY OUTPATIENT CLINIC, EVERY DAY! Even your non-count clinics, non-count appointment types must be closed out or they will show up on this report When correcting EOD, do NOT use the <Do> key or the “^” key in EOD screens <Return> through all fields Sets important (but unseen) data elements (e.g. entries in the Appointment Audit Trail) that CHCS uses for workload reporting Hint: change the appointment status to kept, canceled or no show to help your Access to Care measures. Why? Because the measure doesn’t look at the walk-in appointment status

B.6. In accordance with legal and medical coding practices have all of the following occurred (See Applicable DoDD/DoDI on Medical Records Retention and Coding) : (Question “2” of Commander’s Statement) a) What percentage of Outpatient Encounters, other than Ambulatory Procedure Visits (APVs), have been coded within 3 business days of the encounter? All B*** Clinics and FBNA Timeliness is in 3 business days – Completeness is in 28 days b) What percentage of Ambulatory Procedure Visits have been coded within 15 days of the encounter? All B**5/6/7/8 Clinics Why? are APVs special because the use an abbreviated inpatient record c) What percentage of inpatient records have been coded within 30 days after discharge? Only bedded facilities need to answer this question All MTFs need to complete SIDRs for AD patients admitted downtown in the same 30 day window Do you have a copy of the latest DoDD/DoDIs on Medical Records Retention and Coding? ADM Compliance Report Locally developed Adhoc BDQAS Remember this is a tool to get the enterprise to move in a positive direction to improve our data sets. Now we are going to depart from the DQ Checklist to as Mr. Harvey would say – The rest of the story about Data Input and how it relates to Quality at the end of this briefing I will show you how it relates to MONEY and MANPOWER Remember that if you have an NFH admission that you need to complete these records within 30 days of discharge, this has been an on going problem…make sure that you have the Active Duty member sign a release of information form for you to send to the hospital in order to get a copy of the medical record…it will save you a lot of hassles…also set up a MOU with local hospitals to get copies of medical records on Active Duty patients

Data Quality Management Review List Section C: Data Output
C.1. 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: (Question 3 of Commander's Statement.) a) Was the monthly MEPRS/EAS financial reconciliation process completed? b) Were monthly Inpatient and Outpatient MEPRS/EAS reconciliation processes completed (excluding coding audits performed in C.5 and C.6)? You need to do this before your transmit! MEPRS/EAS Financial reconciliation process Did your Budget analyst and MEPRS Manager agree on the on distribution of costs? This can be/should be done before EAS data is transmitted

Data Quality Management Review List Section C: Data Output (con’t)
c) Has the MTF DQ Manager/MEPRS Manager reviewed the following facility information presented in the current version MEPRS Early Warning and Control System (MEWACS) Report? 1. EAS IV Repository MEPRS data load status and compliance with 45-day reporting suspense. If the facility has a pattern (2 or more) of flagged cells on this tab, have they corrected it or developed a plan to correct it. Provide an explanation in the space below (Comments). 2. MTF-specific summary data outliers and variance assessments. If the facility has any Prior Fiscal Year or Current Fiscal Year flagged cells on this tab, provide an explanation in the space below (Comments). 3. WWR – EAS IV total ambulatory visit comparison. If the facility has any Prior Fiscal Year or Current Fiscal Year fiscal month data where WWR vs. EAS IV visit counts differ by greater than 5%, provide an explanation in the space below (Comments). 4. Ancillary and Support expense allocation tests. If the facility is flagged in Prior Fiscal Year or Current Fiscal Year due to incomplete allocation of ancillary or support expenses, provide an explanation below (Comments), including projected date for submitting corrected data. Is your MEPRS data what you want your MTF to get credit for? Have you checked it? Remember this is the “GOLD” your individual system is not visible to the corporation. Have you transmitted your EAS data by the 45th following the reporting month I.E. Oct data should be transmitted by 15 Dec Or there should be a comment to why it did not happen. Is a bit more problematic to explain Let’s start with what are variances and outliers, they are data sets that fall outside the norms for your MTF – Reasons for spikes could be related to a flu outbreak What they are looking for is there are explainable spikes and errors, if your data spiked in an area but it is explainable – fine If it is not, why does the data look like that? Is there a computer problem? Has there been a change? Firewall – data not received Corrected data can be sent and will update on the MEWACS web page! It only updates once a month so you will have to wait to see the results.

C.2. Was CHCS software used during the reporting month to identify duplicate patient registration records? a) What was the number of potential duplicate records in the reporting month? b) Do you have a process to reduce the number of duplicate records? c) Have the clinics with duplicate appointments/encounters been made aware of the error? Have clinics determined how to correct the duplicate appointments/encounters and avoid the errors in the future? C.3. Were system outputs transmitted to central repositories by date specified in TMA and Service guidelines? (Question 4 of Commander's Statement.) a) MEPRS/EAS (45 days) b) SIDR/CHCS (5th working day following month) c) WWR/CHCS (10th calendar day following month) d) SADR/ADM (Daily) # of Successful daily transmissions / # of days in the month. C2: Often times this problem is because the provider needed more time with a patient and the staff believes that the time in CHCS is being tracked as part of the visit – No Fix your template times 15, 20 mins, whatever to fit your provider, not the systems office If your provider needs 30 minutes with a patient and all of their appointments are 15 mins than either join two appointments or cancel the 2nd one. C3: Pretty simple on the 15th of each month there is a MEPRS report due for not last month but the month before that On the 10th your WWR is due On the 5th business day for the inpatient records section the SIDR transmition is due Your system should automatically send the SADR and DOWR every night to AFMSA south – How do you know? Check BDQAS

C.5. In a random review of CHCS dispositions from the reporting month, the medical records staff determined the following percentages from a minimum sample of 30 records and/or sampling size as set by Service-Level Guidance, whichever is more, the degree to which: (See applicable DoDD/DoDI on Medical Records Retention and Coding and Service specific guidance) a) Percentage of inpatient medical records located? Note: Formula: Number of records available or documented as checked out/Number of records requested for audit b) Percentage of documentation that was complete. c) Percentage of inpatient records whose assigned DRG codes were correct? (Question 5 of the Commander's Statement.) Note: This is a comparison of the paper record to computerized coded information. d) Percentage of inpatient records whose DRG-related data elements were correct? e) Percentage of SIDRs completed (in a "D" status.) C5. Every month you must complete a review of dispositions, and check at least 30 inpatient records This is not really an issue for us since most inpatient records never left the inpatient records room. – If asked could you produce the record? Was the documentation in the record? Audit the inpatient records for complete coding – Normally done by the coding supervisor, coders can not audit their own records Of the number of discharges in a the given month, how many are complete Example if in Oct you had 100 discharges and in December when you checked 89 were complete the percentage is 89%; that gives you full opportunity to have completed discharges from the 30th of the month with in the 30 days following discharge JACHO standard – the goal is 100%

C.6. In a random review of CHCS outpatient encounters from the reporting month, the medical records staff determined the following percentage from a minimum sample of 30 records and/or the sampling size as set by Service-Level guidance, whichever is greater: (Question 6 of Commander's Statement.) a) Percentage of outpatient medical records on-hand containing the documentation and/or the loose documentation of the encounter selected to be audited or documented as checked out? (Denominator equals sample size.) b) What is the percentage of E & M codes deemed correct? (E & M code must comply with current DoD guidance.) Note: If the paper record does not indicate an E&M code was required and the computerized record does not have an E&M, the record is deemed correct. 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.) Note: If the paper record does not indicate a CPT was required and the computerized record does not have a CPT, the record is deemed correct. e) What is the percentage of current DD Form 2569s (TPC Insurance Info) maintained in the medical record (non-active duty only)? (See DoD M, MTF UBO Manual) Note Formula: Number of Current DD2569s/Number of Non-Active Duty records audited. This question is often misunderstood The question is: Is the record available for audit? Documentation must be in the record for the record to be considered available. If you have the loose documentation the “visit” is available for audit…. The new coding methodology is located on BDQAS for download.

C.7. In a random review of CHCS Ambulatory Procedure Visits (APV) appointments from the reporting month, the medical records staff determined the following percentages from a minimum sample size of 30 "on-hand" records (extended/abbreviated) or maximum available if fewer than 30, (documentation of visit is included in record) and/or the sampling size as set by Service-Level guidance, whichever is greater: (Question 7 of Commander's Statement.) a) Percentage of outpatient medical records on-hand containing the documentation and/or the loose documentation of the encounter selected to be audited or documented as checked out? (Denominator equals sample size.) b) What is the percentage of E & M codes deemed correct? (E & M code must comply with current DoD guidance.) Note: If the paper record does not indicate an E&M code was required and the computerized record does not have an E&M, the record is deemed correct. Note Formula: Number of Records with Correct E&M codes/Number of Records Audited requiring E&M codes. c) What is the percentage of ICD-9 codes deemed correct? Note Formula: Number of Records with Correct ICD codes/Number of Records Audited. d) What is the percentage of CPT codes deemed correct? (CPT code must comply with current DoD guidance.) Note: If the paper record does not indicate a CPT was required and the computerized record does not have a CPT, the record is deemed correct. Note Formula: Number of Records with Correct CPT codes/Number of Records Audited. e) What is the percentage of current DD Form 2569s maintained in the medical record (non-active duty only)? Note Formula: Number of Current DD2569s/Number of Non-Active Duty outpatient medical records audited. DD Form 2569s must be in all Non-Active Duty Medical Records and they must be current to count correct. So if of your 139 records, 100 are non-active duty the equation is # of current 2569s/# of non-active duty records 50 current/100 non-active duty records = 50% compliant

C.8. Was a list of outpatient records, which were checked out of the record section more than 30-days, forwarded to the Medical Records Committee or higher authority for resolution? (Recommend using the CHCS Medical Records Tracking (MRT) module) (specify # records >30 days.) Can you account for your medical records? Do you have a process to account for missing records? We are going to begin a central pull of records availability based on the MRT – this module has not been constantly used throughout our MTFs…we need to change this as soon as possible…Maj Hyzy is working on an AdHoc that will pull this information centrally, however it is slow going and is expected to be ugly on its first pull…but it is important that we work toward doing more centralized pulls verse self reporting it is more reliable

C.9. Comparison of reported workload data. (Question 8 of Commander's Statement) a) # SADR encounters * / # WWR visits b) # SIDR dispositions* / # WWR dispositions c) # EAS visits / # WWR visits d) # EAS dispositions / # WWR dispositions e) # of IBWA SADR (RNDS appt type only) encounters (FCC=A***) / # SUM WWR Bed days Note: FY05 data collection only, FY06 Goal 80% If you are coding all of your encounters, both count and non-count the number of SADRS will be higher than WWR visits because WWR only captures count visits The Number of SADRS should be equal to the monthly statistical report total visits number. SIDR Dispositions/WWR dispositions should equal, but might be off buy 1 or 2 EAS/WWR visits should match EAS/WWR dispositions should match

Data Quality Management Review List Section D: Security
D1: Were responsibilities for computer security formally assigned? Does your MTF have a Computer Security Program? – Yes Is that person(s) appointed in writing? - Yes D2: Is there a Security/Privacy Program in place to address HIPAA compliance for Password Protection? Access to systems? Confidentiality of data? Level of access to MEPRS/EAS, CHCS, ADM, TPOCS? D.3. Are there internal controls and procedures in place to approve and manage assignment of security key privileges? Have all Security Key holders been identified and their need for security key privileges validated by the CIO or designee? Have Security Key privileges been withdrawn from inappropriate users? It is a well know fact that AF Computer Security is some of the tightest out there Your systems office must have someone appointed in writing so you are covered For D2 make a copy of your systems office OI for computer security and a copy of the base SATE training in a binder and you are covered For D3 on SAVs that have been done sometimes people have access to areas in CHCS they shouldn’t

E1. Was a System Administrator appointed in writing for each system?
Data Quality Management Review List Section E: System Design, Development, Operations, and Education/Training E1. Was a System Administrator appointed in writing for each system? MEPRS/EAS, CHCS, ADM and TPOCS E2. Are procedures and documentation in place to ensure that all assigned personnel responsible for data entry receive training and education on CHCS, MEPRS/EAS, TPOCS and ADM E3. Was a process in place that allows users to submit suggestions concerning new or enhanced requirements through the Systems Change Request process – Yes, the AF has a policy E1: It is a good idea to have a copy of the appointment letters in your compliance binder, just so you know who to call with issues. E2: Before anyone gets access they have to complete SATE training and be approved to get a password on a given system – Check with system administrators, if they don’t have a process in writing it would be a good idea to develop one…that would be what you recommend to them…we do not expect you to develop the program…but, since who has access to what can have a profound effect on your data…I would highly recommend a plan be developed We are starting to track who is being trained, since training has been such a problem. E3: Yes we have a process, however, unfortunately a large number of SCRs are in the system. We are not saying we have to approve your SCRs, however, if we have the information on your SCR we are in a better position to defend your SCR in the funding process.

Data Quality Management Review List Section E: System Design, Development, Operations, and Education/Training (con’t) E4: Was a process in place, such as System Incident Report, where users can identify issues affecting system functioning and operations? E5: Were written procedures in place to assure routine system software and hardware maintenance? E6: Are their points of contact identified for equipment failure issues? E7: Are there contingency plans in place, such as creating nightly backup tapes? E4: Same form E5: Who do users call to get system problems solved at the local level? Does your systems office have a policy? Put a copy in your compliance binder E6: Ditto E7: Don’t let this one fall through the cracks

Provider Profiles Civilian (Outside) Provider File
Pharmacy adds the most Civilian Provider to CHCS Is there a local policy? Educate your pharmacy staff on how to input the provider files Default Provider Specialty Code for Civilian Providers is 000 General Medical Officer or 001 Family Practice Physician 000/001 gets the claim to TPOCS 000 is the minimum provider who can write scripts Provider naming convention and DEA/License number needs to be strictly enforced and monitored, serious loss of revenue due to billing rejects Smith / Johnson,S / Provider / Outside Provider DEA/License # can be research on the web, if not provided Do not use SSN (internal Providers only) HIPAA Taxonomy number needs to be correct to prevent fraudulent billing or inability to bill Consistency is the key to getting this right One single point of entry for the provider file is recommended Why? Because you want your data to flow and make sense We are going to bring this back to a cost per visit at the end of the briefing

Provider Profiles (con’t)
PROVIDER: SMITH,JOHN R Name: SMITH,JOHN R Provider Flag: PROVIDER Provider ID: SMITHJR Provider Class: OUTSIDE PROVIDER Person Identifier: Person ID Type Code: Select PROVIDER SPECIALTY: 001 (FAMILY PRACTICE PHYSICIAN) Primary Provider Taxonomy: 207Q00000X CMAC Provider Class: - Select PROVIDER TAXONOMY: HCP SIDR-ID: Location: CHAMPUS SUPPORT Class: OUTSIDE PROVIDER Initials: JRS SSN: DEA#: BM License #: PROVIDER: SMITH, JOHN R Name: SMITH, JOHN R Provider Flag: PROVIDER Provider ID: Provider1234 Provider Class: Doc Person Identifier: Person 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: DEA#: License #: Consistency is the key to getting this right One single point of entry for the provider file is recommended Why? Because you want your data to flow and make sense We are going to bring this back to a cost per visit at the end of the briefing *Handouts will be provided for this slide (this statement will be removed before brief)

Potential Revenue Impact
Average # Claims for Outside Provider Scripts Large Facility Medium Facility 700 Small Facility 300 Average Amount Billed $50 per claim If your provider file has 100 outside providers that issued at least one script per month with a blank or incorrect provider specialty code Potential Loss is $5,000 in billable claims per month Potential Loss is $60,000 in billable claims per year

Provider Profiles (con’t)
Enter Provider Specialty Code (Be specific – not general) All PA’s – Provider Specialty Code 901 All Nurses (RNs) – Provider Specialty Code 600 All Technicians – Provider Specialty Code 900 Potential lost revenue for codes 500 series, 910 & above Zero out RVU in FY07 Prevent Encounter from flowing to TPOCS Fraudulent billing can occur with incorrect provider specialty codes Non-credentialed provider (Tech) 900 Credentialed Providers for example (PA) 901 Provider Specialties Above 905 represent Clinical Services 923-Family Practice Clinic/001-Family Practice Physician 949-Pediatric Clinic/040-Peditrician

Value of Care *Handouts will be provided for this slide
(this statement will be removed before brief) PEDIATRICS – BDA Provider Specialty Code = 040 Pediatrician Diagnosis Codes 204 Lymphoid Leukemia 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 = $ 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 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 RVU/Reimbursement = ZERO!!!!!!

EAS IV Total Cost Medical Expense Performance Reporting System “MEPRS”
RVUsb “E” – Support “D” – Ancillary “A” – Inpatient “B” – Outpatient “C” – Dental “F” – Special Programs “G” – Readiness EAS IV Money Manpower Workload Financial Data System Personnel CHCS / WAM (Count only) R E C O N I L Direct Care “Step Down” Defense Health Program Cost Accounting U T P Total Cost RVUs RWPs ICD/E&M/CPT DRGs SIDR SADR CHCS AFMSA/SGSR Medical Expense Performance Reporting System “MEPRS” Before we go into Section C Data Output – Let’s go over some MEPRS basics EAS gets its information from three basic sources Financial from MircoBas or Cris – Expenses and Obligations Personnel – What you report on your timesheets/templates determine the salary expenses applied to your MTF – DHMRSi is going to replace EAS SA Workload – CHCS information via the WAM When I say WAM do you know what I mean? E codes are overhead and their costs are stepped down to A,B,C,D, F and G accounts Then D codes – ancillary costs are stepped down based on a percentage to A,B,C, F, G To figure out the cost per visit or cost per RVU it is important that you understand MEPRS because it is MEPRS data that is used to make a lot of management decisions. It is important that you see the relationship between MEPRS (Cost) data and Coding (Value) data,

MEPRS.INFO

Important References DODI 6015.1-M, DOD Glossary
DODI M, MEPRS Program for Fixed MTFs and DTFs DODI M, Uniform Business Office DODI , Data Quality Program DODI , Medical Records Retention and Coding at MTF DODI, , Medical Encounter and Coding at MTF DODI, , Custody and Control of Medical Records AFI , AF MEPRS Program for Fixed MTFs and DTFs AFI , Resource Management Operations AFI , Patient Administration Functions DoD Professional Coding Guidelines AF Workload Standardization Guidelines EASIV Reference Guide These are recourses you should be familiar with, if not you can download them from the web.

Useful Web Sites Data Quality - BDQAS – P2R2 - Virtual Analyst - Resource Management - Fin Management - Tricare (CMAC Rates) - Quarterly UBO Reports - Sales Codes - Reimbursements - DFAS - Pop Health - AFCHIPS - UBU - 3M - Medicare - AHIMA - American Family Physicians - HIPAA - SAIC - EAS - MEWACS - So many things impact DQ, that the view of things can become muddy.

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Data Quality Management Control Program Report

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