1. 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 1 Data Quality Management Control Program (DQMC) Air Force Data Quality Program Manager

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 Overview Data Quality (DQ) Program Systems DQ Composite Health Care System (CHCS) Initiatives FY09 Updates Take Away Questions

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

4. 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 Team Key Players DQ Manager Resource Management Office (RMO) Group Practice Manager (GPM) Medical Expense and Performance Reporting System (MEPRS) Credentials Manager Budget Analyst/Uniform Business Office (UBO) Coding/Billing Supervisor Clinical Systems Administrator(s) It is great to look – But are you working toward improvement?

5. 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 DQ team meets monthly Review Metrics/Compliance Issues Provide deficiency correction plan and estimated completion date (if applicable) Report monthly to Executive Committee Keep meeting minutes for at least two years Keep Review Lists for five years It is great to look – But are you working toward improvement?

6. 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 Maintained locally Tool to assist Military Treatment Facilities (MTFs) in identifying and correcting financial and clinical workload data problems monthly Data Quality Statement Facility Report Card Specific information from the DQMC Review List Commander signs/approves monthly Forwarded through the regional office to AF DQ Manager AF summary submitted to DQMC

7. 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

8. 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 and Performance Reporting System “MEPRS” -- Valuation Defense Health Program Cost Accounting OUTPUTOUTPUT Total Cost RVUs RWPs ICD/E&M/CPT DRGs SIDR SADR CHCS

9. 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 MHS Management Analysis and Reporting Tool (M2) Used to extract data for PPS and AF Business Plan Need to identify the M2 user and alternate 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 DQ Monitoring Tools

10. 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 Sample use of M2 M2 Query:

11. 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 MEPRS Early Warning and Control System (MEWACS) Trend analysis tool Usage monitored by DQMC Outlier indications Review and correct data accordingly Outliers are not always incorrect data DQ Monitoring Tools Cont…

12. 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 Ambulatory and Inpatient Metrics FY “Point-in-time" Comparison Reports Updated on the 20th of the month Display by MTF or MAJCOM MTF Rankings, Transmission Reports (daily/summary), Top DRG, "Principal" Diagnosis and Procedure Reports, E&M by Provider Specialty Data Quality Statement Reports Compare and report values on DQ statement Consistent reporting for questions: 1a-b, 2a-b, 4b-d, 8a-d, 9 DQ Monitoring Tools Cont…

13. 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

14. 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

16. 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?

17. 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 are required to add the Civilian Provider to CHCS. Is there a local policy? Create a local policy/standard operating procedure Educate and train the ancillary staff Use correct PSC linked to HIPAA Taxonomy Provider naming convention, NPI, and DEA/License number should be strictly enforced and monitored Last Name/First Name, Middle Name or Initial (if available) Example: Smith / Johnson,S / Provider / Outside Provider Recommend subscribing to HCIdea to research NPI/DEA/License # ; http://www.hcidea.org/

18. 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) Incorrect fields in red: PROVIDER: SMITH, JOHN R Name: SMITH, JOHN R Provider Flag: PROVIDER Provider ID: Provider1234 NPI Type/ID: Provider Class: Doc Person Identifier: 123-45-6789 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: 123-45-6789 DEA#: 99999999 License #: Corrected fields in red: PROVIDER: SMITH,JOHN R Name: SMITH,JOHN R Provider Flag: PROVIDER Provider ID: SMITHJR NPI Type/ID: 01/0125899 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: 123-45-6789 (Not Mandatory) DEA#: BM1212127 License #:

19. 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 facilities collections Average # Claims for Outside Provider Scripts per month Large Facility 1,500-3,000 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, NPI (new requirement mid FY08), 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

20. 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 Independent Duty Medical Technician – Provider Specialty Code 521 Lost revenue for codes 500 – 518 and 910 – 999 Zero workload RVU Prevent Encounter from flowing to TPOCS Impact on PPS Provider Specialties 910 and above are Clinical Services Provider Specialty Codes

21. 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 112.89 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 = $130.73 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 112.89 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 ZERO!!!!!! PPS Workload = ZERO!!!!!!

22. 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 CHCS Provider File Training More accountability needed Potential for fraudulent billing Inaccurate Data Missing Critical Data Elements Incorrect Critical Data Elements Loss of workload and revenue opportunities

23. 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 AF CHCS DQ Initiative Contract awarded Sept 06 Hired 2 contractors Review and analyze CHCS File and Table Build Provider File Provide functional and technical guidance Site Analysis Report (SAR) Establish CHCS DQ standards Process ownership of data elements Policies, business rules, and AFMS standardization (CHCS DQ Continuity Handbook)

24. 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 AF CHCS DQ Initiative Cont… MTF Reporting Requirements Monthly Data Quality Statement SADR/CAPER Write Back Error Report Data due Monthly on the 5 th to Air Staff All Provider Report Data due Quarterly on the 15 th to Air Staff Workbook is prepared Site Analysis Report (SAR) provided back to MTF MTF corrects errors Performance Metrics

25. 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

26. AFMS –CHCS Provider File % of Total Data Element Errors By Error Type Cycle Error Type1st2nd3rd4th SSN or Pseudo SSN18,6355,4433,82747,833 Generic Provider2,4662,9182,20011,292 Improper Signature Class21,07423,71118,84415,962 No DEA #41,61653,55536,06125,081 Provider Duplicate8,47910,5996,5656,487 Improper Naming Convention46,25753,09929,45820,019 # Provider Signature Classes Used2,6852,7622,2942,032 # Hospital Locations used for Providers2,9023,1332,9162,607 Total Errors144,114155,220102,165131,313 Total Elements Reviewed2,800,6163,060,6563,087,0722,774,672 % of Total Errors5.15%5.07%3.31%4.73%

27. 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 Sample of a SAR 1.High-level Discoveries 2.Key Activities Review and Assessment Results 3.Icons  Downward trend  No change  Upward trend ActivitiesDescriptionPotential ImpactsDQ Finding Rating Provider Specialty Code  Validate all Provider Codes are mapped specific to provider’s area of expertise  Validate all PA’s – Provider Specialty 901  Validate all Nurses (RNs) – Provider Specialty Code 600  Validate Technicians – Provider Specialty Code 900  Certify no providers are mapped in the code ranges 910-999 and 500-518 - PPS -TPOCS claims -MTFs Business Plan 1445  Name Field  Validate the proper naming convention structure  Validate duplicate provider names  Review generic provider names -TPOCS claims 1001  Social Security Number (SSN)  Validate required 9-digit field for internal providers  Review pseudo SSN -TPOCS claims 130 

28. 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 Data Quality Statement Guide Reporting Consistency Training document for new personnel CHCS DQ Continuity Handbook, Version 2 CHCS Standardized Business Rules FY08 Workload Guidelines Version 2.0 in final draft Brings together DQ, MEPRS, Coding and Billing AF supplemental guidance to DOD coding guidelines

29. 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 29 CHCS DQ Initiative Roadmap 1 st Quarter Provider File Submission 2 nd Quarter Provider File Submission 3 rd Quarter Provider File Submission Oct-Nov 08 Nov-Dec 08 Dec- Jan 09 Jan – Feb 09 Feb–Mar 09 Mar- Apr 09 Apr-Jun 09 June-Aug 09 We are here: Site Analysis of 63 sites completed 2 nd Quarter Aug- Sep 09 4 th Quarter Provider File Submission Sep-Oct 08 CHCS DQ 1 st Quarter Site Analysis Report Update Continuity Book CHCS DQ 2 nd Quarter Site Analysis Report Complete FY08 Performance Metrics

30. 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 Sample of Continuity Handbook Data ElementDescription AF DQ Standards National Provider Identifier (NPI) 10-Digit number for electronic billing For any provider flagged as “Provider” these files require an NPI number. If services are rendered by a provider containing no NPI, it will prevent claims to be paid for patients with Third Party Insurance Provider File Standards and Business Rules

31. 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 Sample of Workload Guidelines Encounter Activity Provider Type Provider Specialty Code MEPRS Code for Time Capture MEPRS Code for Workload Count/Non- Count indicator Patient Encounter Business Rules Coding Required Billing Required Nutritionist/ Dietitian Privileged Provider 704 - Dietician/ Nutritionist B*** CountRegistered dieticians or licensed nutrition Professionals are responsible for providing medical nutrition therapy (MNT). Yes

32. 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 Web Page Contact: Ms. Michele Gowen, RHIA, CCS Air Force Data Quality Program Manager Tel (703) 681-6504 DSN 761 Fax (703) 681-6011 DSN 761 https://kx.afms.mil/kxweb/dotmil/kj.do?functionalArea=DataQuality Documents, briefings, policies/directives, training and links

33. 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 Data Quality Statement Completeness Question 1. In the reporting month (include only B*** and FBN* accounts): a) What percentage of clinics have complied with “End of Day” processing requirements, “Every clinic – Every day?” (B.5.(a)) Number of clinics with 100% EOD completed Total number of open clinic days for the month BDQAS

34. 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 Data Quality Statement Completeness Cont… Question 1. In the reporting month (include only B*** and FBN* accounts): b) What percentage of appointments were closed in meeting your “End of Day” processing requirements, “Every appointment – Every day?” (B.5.(b)) Number of closed appointments Total appointments for the month BDQAS

35. 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 Data Quality 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)

36. 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 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 Data Quality Statement Validation and Reconciliation

37. 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 Data Quality 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 Calendar Day Following Month) BDQAS d) SADR/ADM (Daily) BDQAS

38. 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 Data Quality Statement Rounds Compliance (New) One calendar day of the attending professional services during each audited hospitalization will be audited from the randomly selected sample. For one day hospitalizations, that calendar day will be audited. For all other hospitalizations, the registration number will determine which calendar day will be audited. Odd numbers will use the first day Even numbers will use the second day

39. 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 Data Quality Statement Coding Accuracy Calculation Use the following new formulas for Q5b-d (Internal Process), 6b-d (Audit Tool), 7b-c (Audit Tool): ICD-9: Number of correct ICD-9 codes Total number of ICD-9 codes E&M: Number of correct E&M codes Total number of E&M codes CPT: Number of correct CPT codes Total number of CPT codes

40. 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? Data Quality Statement Compliance

41. 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. Inpatient Records. CONT… e) What percentage of completed and current (signed within the past 12 months) DD Forms 2569 (TPC Insurance Info) are available for audit? (How the patient answered is only relevant to answering “Question 6f”) The DD Forms 2569 need to be available and current at the time of the audit to be in compliance with the UBO program. Options for filing DD Form 2569: Maintain hardcopy DD Form 2569 in medical record Scan DD Form 2569 and store electronically Hardcopy DD Form 2569 stored in the MTF RMO/Business/TPC Office Data Quality Statement Availability/Accuracy

42. 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. Inpatient Records. CONT… f) What percentage of available, current and complete DD Forms 2569s are verified to be correct in the Patient Insurance Information (PII) module in CHCS? Internal Process based on Question 6e. Does not apply to OCONUS bases. Data Quality Statement Availability/Accuracy

43. 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 Data Quality Statement Availability/Accuracy

44. 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 Forms 2569s (TPC Insurance Info) are available for audit? Audit Tool Generated/Internal Process (This metric only measures whether or not a DD Form 2569 was collected/current in the record at the time of the encounter). The DD Forms 2569 need to be available and current at the time of the audit to be in compliance with the UBO program. f) What percentage of available, current and complete DD Forms 2569s are verified to be correct in the Patient Insurance Information (PII) module in CHCS? Internal Process based on Question 6e. Does not apply to OCONUS bases. Data Quality Statement Availability/Accuracy

45. 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) Questions 7.a,b,c,d,e Are the same as Questions 6.a,c,d,e,f Data Quality Statement Availability/Accuracy

46. 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 (count + non-count) / # 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: FY09 Goal 80% (Will be graded red and green only) Internal Process (Monthly Statistical Report) Data Quality Statement Completeness

47. 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.a). a. # of AHLTA SADR encounters / # of Total SADR encounters Note: ALL SADR encounters including APV and ER BDQAS Note: This question is to gauge the penetration of AHLTA at our MTFs. It is understood that not all clinical modules are deployed in the current version of AHLTA. Data Quality Statement AHLTA Penetration

48. 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 10. CHCS software used during the reporting month to identify duplicate patient registration records. (C.2a) a) What was the number of potential duplicate records in the reporting month? Internal Process Run the CHCS standard report – “Potential Duplicate Patient Search”. (For current advice about how to identify duplicate records, please see TRICARE Data Quality Web page: http://www.tricare.osd.mil/ocfo/mcfs/dqmcp/refs_reg s.cfm Data Quality Statement AHLTA Penetration

49. 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 11. I am aware of data quality issues identified by the completed Commander’s Statement and Review List and when needed, have incorporated monitoring mechanisms and have taken corrective actions to improve the data from my facility. (Electronic Signature Authorized) Data Quality Statement Awareness

50. 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, complete and timely. Front-end processes are CRITICAL to back-end success

51. 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 6015.1-M, DOD Glossary DODI 6010.13M, MEPRS Program for Fixed MTFs and DTFs DODI 6010.15M, Uniform Business Office DODI 6040.40, Data Quality Program DODI 6040.41, Medical Records Retention and Coding at MTF DODI, 6040.42, Medical Encounter and Coding at MTF DODI, 6040.43, Custody and Control of Medical Records AFI 41-102, AF MEPRS Program for Fixed MTFs and DTFs AFI 41-120, Resource Management Operations AFI 41-210, Patient Administration Functions DoD Professional Coding Guidelines AF Workload Standardization Guidelines EASIV Reference Guide

52. 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 - http://www.tricare.mil/ocfo/mcfs/dqmcp/manageme nt_control.cfm BDQAS - https://bdqas.brooks.af.mil/index2.htm UBU - http://www.tricare.mil//ocfo/bea/ubu/index.cfm UBO - http://www.tricare.mil/ocfo/mcfs/ubo/about.cfm MEPRS – http://meprs.info MEWACS - http://www.meprs.info/mol3/mol3.cfm DFAS - https://mypay.dfas.mil/mypay.aspx HIPAA - http://tricare.osd.mil/ocfo/mcfs/ubo/hipaa.cfm SAIC - http://www.chcs-dm.com/

53. 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?