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 Headquarters U.S. Air Force Data Quality Management Program TSgt Jody Callender Air Force Data Quality Manager AFMOA/SGYR

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 UNCLASSIFIED Overview Team Composition and Responsibilities Commander’s Statement Provider Files Data Quality Issue Examples FY07 Initiatives References Useful Links 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 UNCLASSIFIED Data Quality Team Data Quality Manager 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

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 UNCLASSIFIED 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

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 UNCLASSIFIED Population-based Healthcare Delivery Forecast demand and track delivery of preventive services Manage chronic disease/conditions Monitor efficiency of the healthcare system Provider/Clinic Productivity Medicare Accrual Fund Performance Based Budgeting – PPS Reimbursements: Third Party Collections, Inpatient, CG/NOAA/PH Collections, Pay Patients, Foreign Patients Reduce claims denial Document Level of Effort by all clinic staff Enable the Leadership to make informed decisions What is your data used for?

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 UNCLASSIFIED Data Quality Management Control Program Regulatory Guidance DODI , Data Quality Management Control Procedures DQMC Review List Internal tool to assists MTFs monthly/quarterly to identify and correct financial and clinical workload data Commander’s Monthly Data Quality Statement Facility Report Card Specific information from the DQMC Review List Commander signs/approves Sent to MAJCOM/DQ Managers, Service DQ managers and the TMA Management Control Program 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 UNCLASSIFIED Commander’s DQ Statement Completeness Question 1. In the reporting month: 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 10 Sum of All Daily Totals of Open Clinics Clinics with 20 of open clinic 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 70 =97% Total Appointments appointments a day with 20 days of open clinic = 95% Compliant

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 UNCLASSIFIED Commander’s DQ Statement Timeliness 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 or Encoder Group Report (open register numbers) 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 UNCLASSIFIED 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? MEPRS Manager and RMO Office b) Were monthly Inpatient and Outpatient workload reconciliation processes completed? MEPRS Manager 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? MEPRS Manager Commander’s DQ Statement Validation 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 UNCLASSIFIED Commander’s DQ Statement Compliance 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 (5 th Duty of Day of the month) BDQAS c) WWR/CHCS (10 th Callender 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 UNCLASSIFIED Question 5 Outcome of monthly inpatient coding audit: a) Inpatient Records (DRG) # Records Reviewed:_________ % Correct _______ Internal Process b) IBWA Rounds encounters audited and deemed correct? Internal Process (Inpatient coder) at least 30 Records Commander’s DQ Statement Compliance

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 UNCLASSIFIED Question 6 Outpatient Records 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? Audit Tool/Internal Process b) What was the percentage of E & M codes deemed correct? (E & M code must comply with current DoD guidance.) c) What was the percentage of ICD-9 codes deemed correct? d) What was the percentage of CPT codes deemed correct? (CPT code must comply with current DoD guidance.) b,c,d-Audit Tool Generated Commander’s DQ Statement Availability/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 UNCLASSIFIED Question 6. Outpatient Records. CONT… e) What percentage of completed & current DD Form 2569s are maintained in the record (non-active duty)? Audit Tool Generated/Internal Process (This metric only measure whether or not a DD2569 was collected/current in the record at the time of the encounter. How the patient answered on the form is only relevant to answering “Question 6f”) f) What percentage of completed & current DD Form 2569s in the medical record were verified to be correct in the Patient Insurance file in CHCS? Internal Process based on Question 6e (Only current and signed DD2569 whether there yes or no are checked) Commander’s DQ Statement Availability/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 UNCLASSIFIED Question 7 Ambulatory Procedure Visits (C.7.a,b,c,d,e,f) Questions 7.a,b,c,d,e,f Are the same as Questions 6.a,b,c,d,e,f Commander’s DQ Statement Availability/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 UNCLASSIFIED Question 8. Comparison of reported workload data. a) # SADR Encounters / # WWR visits BDQAS b) # SIDR Dispositions / # WWR Dispositions BDQAS c) # EAS Visits / # WWR Visits BDQAS d) # EAS Dispositions / # WWR Dispositions BDQAS e) # of IBWA SADR encounters (FCC=A***)/#Sum WWR (Total Bed Days + Total Dispositions) Internal Process (Month Statistical Report) Commander’s DQ Statement Completeness

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 UNCLASSIFIED Q. 9. – 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. Internal Process Commander’s DQ Statement Awareness

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 UNCLASSIFIED 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

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 UNCLASSIFIED 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 Provider Profiles (con’t)

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 UNCLASSIFIED Provider Profiles (con’t) 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 #: 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 #: *Handouts will be provided for this slide (this statement will be removed before brief)

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 UNCLASSIFIED Value of Care PEDIATRICS – BDA Provider Specialty Code = 040 Pediatrician Diagnosis Codes 204 Lymphoid Leukemia Candidial Endocarditis Procedure Code Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour – Each additional hour E&M Code – Level 4 Established Patient OHI – Yes CMAC Value = $ Class 1 Provider Will you bill for this patient? Yes Reimbursement - $ PPS RVU = 1.44 Reimbursement = $ PEDIATRICS – BDA Provider Specialty Code = 949 Pediatrics Diagnosis Codes 204 Lymphoid Leukemia Candidial Endocarditis Procedure Code Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour – Each additional hour E&M Code – Level 4 Established Patient OHI – Yes CMAC Value = UNKNOWN Will you bill for this patient? NO Reimbursement $0 ZERO!!!!!! PPS RVU/Reimbursement = ZERO!!!!!! *Handouts will be provided for this slide (this statement will be removed before brief)

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 UNCLASSIFIED Average # Claims for Outside Provider Scripts Large Facility MediumFacility700 Small Facility300 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 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 UNCLASSIFIED FY07 Updates Review List Add new systems (AHLTA, CCE and DMHRSi) IBWA (Inpatient Professional Services) Commander’s Statement Question 6a - Is documentation of the encounter selected to be audited available? Documentation includes the medical record, loose (hard copy) documentation or an electronic record of the encounter in AHLTA Question 6e - What is the percentage of non-active duty encounters for which complete and current (signed within the past 12 months) DD Form 2569s (TPC Insurance Info) are available for audit. Note: Availability may be electronic, loose, or signed form maintained in other locations Question 6f - What percentage of available, current and complete DD Form 2569s which are correct in the the Patient Insurance Information (PII) module in CHCS? Note: If no DD Form 2569s are available for audit, the answer to this question is not applicable (N/A)

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 UNCLASSIFIED FY07 Updates New Proposed Questions Question 5c - Inpatient Professional Services Rounds encounters ICD-9 codes audited and deemed correct? Question 5d - Inpatient Professional Services Rounds encounters CPT codes codes audited and deemed correct? Question 8f - # of AHLTA SADR encounters / # of Total SADR encounters Note: FY07 not scored, FY08 Goal 90% (AHLTA Utilization) Remove Questions 7b - What percentage of E&M codes deemed correct? Change IBWA to “Inpatient Profession Services” Approve digital signature for command statement DQ Statement Guide DQ CHCS 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 UNCLASSIFIED FY07 Updates New Proposed Questions Question 5c - Inpatient Professional Services Rounds encounters ICD-9 codes audited and deemed correct? Question 5d - Inpatient Professional Services Rounds encounters CPT codes codes audited and deemed correct? Question 8f - # of AHLTA SADR encounters / # of Total SADR encounters Note: FY07 not scored, FY08 Goal 90% (AHLTA Utilization) Remove Questions 7b - What percentage of E&M codes deemed correct? Change IBWA to “Inpatient Profession Services” Approve digital signature for command statement DQ Statement Guide DQ CHCS 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 UNCLASSIFIED Summary Team Composition and Responsibilities Commander’s Statement Provider Files Data Quality Issue Examples FY07 Initiatives References Useful Links

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 UNCLASSIFIED Important References DODI 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

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 UNCLASSIFIED 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 -

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 UNCLASSIFIED QUESTIONS?