Headquarters U. S. Air Force 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 U.S. AIR FORCE Data Quality Management Control (DQMC) Program TSgt Jody Callender Air Force Data Quality Manager 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  DQ Program  Systems  DQ CHCS Initiative  FY07 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 Military 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  Key Players  DQ Manager  GPM  MEPRS and Credentials Manager  Budget Analyst  Coding/Billing Supervisor  CHCS Administrator  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 IV Money Manpower Workload CRIS EAS-SA CHCS / WAM (Count only) RECONCILERECONCILE Direct Care “Step Down” Medical Expense Performance & Reporting System “MEPRS” -- Valuation Defense Health Program Cost Accounting OUTPUTOUTPUT Total Cost RVUs RWPs ICD/E&M/CPT DRGs SIDR SADR CHCS

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 DQMC Review List  Maintained locally  Tool to assist MTFs monthly in identifying and correcting financial and clinical workload data problems.  Commander’s Data Quality Statement 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 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 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 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 (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) 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 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  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 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  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 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  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 measure 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 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  Question 7. Ambulatory Procedure Visits (C.7.a,b,c,d,e,f)  Questions 7.a,c,d,e,f Are the same as Questions 6.a,b,c,d,e,f  Question 7b-has been omitted for FY07 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  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 Inpatient Professional Services Rounds SADR encounters (FCC=A***)/#Sum WWR (Total Bed Days + Total Dispositions) Note: FY07 Goal 80% 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  Question 9. System Design, Development, Operations, and Education/Training (E.4.c).  # of AHLTA SADR encounters / # of Total SADR encounters Note: Exclude APV (B**5, 7,8,9) and ER (BIAA) FY07 not scored. For management use and tracking purposes only. BDQAS  Question 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. (Electronic Signature Authorized) 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 Air Force DQ System Architecture MDR M2 WWR (Count Visits) EAS IV “Eligible” Encounters CPT Codes Units of ServiceWAM Count Visits & Raw Services SADR (Encounters) TPOCS Billable Encounters PDTS Worldwide Workload Report Standard Ambulatory Data Record EAS Repository ADM Extract MHS Data Repository MHS Mart Service Repository (BDQAS) Pharmacy Data Transaction System Pop Health Portal CCE Coding Compliance Editor Clinical Data Mart TRICARE Ops 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  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 New for FY07 question 9 (AHLTA Utilization)  “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 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

 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 add the most Civilian Provider to CHCS  Is there a local policy?  Educate your ancillary staff  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  Smith / Johnson,S / Provider / Outside Provider  DEA/License # can be research on the web, if not provided  Do not use SSN (internal Providers only)

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 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 #:

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  Medium Facility700  Small Facility300  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 900/521  Lost revenue for codes 910 & above  Zero workload  Prevent Encounter from flowing to TPOCS  Potential fraudulent billing  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  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 Workload = 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 Status We are here: Site Preparation – Initiates functional work plan and process review Oct 06 Data Analysis – collection of CHCS Database Files Baseline assessment – Validate and identify DQ problems Monitor and Feedback – 60 days Determine MAJCOM site priority CHCS DQ contract awarded Internal Program Planning and Development – Initiates work plan Sep 06 Site Analysis Report to MAJCOM DQ Manager Began Phase II analysis Complete CHCS DQ Toolkit Guidance Oct – Dec 06 Nov 06 Dec 06 Jan 07 Mid Jan 07 FY08 Mar 07-Sep 07 Forwarded Data Packages to MAJCOM Feb 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 FY07 Updates  Changes to FY07 DQ Statement  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?  Questions 7b Removed - What percentage of E&M codes deemed correct?  Question 9 - # of AHLTA SADR encounters / # of Total SADR encounters Note: FY07 not scored (AHLTA Utilization)  Changed IBWA to “Inpatient Profession Services”  Approve digital signature for command statement DQ Toolkit Guidance

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 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 FY07 Workload Guidelines  Released Apr 07  Brings together DQ, MEPRS, Coding and Billing  AF supplemental guidance to DOD coding guidelines

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 and complete.  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 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 Useful Web Sites  Data Quality -  BDQAS –  P2R2 -  UBU -  UBO -  MEPRS –  MEWACS -  AF/SGY- 99BB60E38F3A36D5?functionalArea=ResourceMgmt  DFAS -  Pop Health -  HIPAA -  SAIC -

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 QUESTIONS?