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) AFMS Data Quality Program AFMSA/SGY

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 FY10 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 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…

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 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, 2a-b, 4b-d, 8a-d, 9 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

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

14. 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?

15. 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/

16. 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 #:

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 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

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 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

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 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!!!!!!

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 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 Provider File Report Card (SAR replacement) Establish CHCS DQ standards Process ownership of data elements Policies, business rules, and AFMS standardization (CHCS DQ Continuity Guide, AFMOA Resolution Guide)

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 AFMS –CHCS Provider File % of Total Error/Discrepancy By Error Type- Jul 2009 Error-Discrepancy TOTAL % NPI - NULL27696046% NPI - Duplicate30270% Generic Provider15430% Potential Duplicate33281% Naming Convention207493% DEA / License #37051% SSN00% Specialty Code (PSC)146472% HIPAA Taxonomy411437% Pclass MisMatch20130% Primary Hospital Location 5364 1% Signature Class36521% EDI-PN00% TOTAL37613162% TOTAL RECORDS REVIEWED 605809

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 New and Improved Process Provider File Detail Data Base Data Quality Contract Personnel developed the following approach Smartronix sub to PSI Central DSS Provider File pull from each MTF CHCS Automated query identified potential errors/improvement opportunities Results exported into an Access database Produces a “Detail Report” for each facility Actionable listing of MTF specific entries requiring attention Enables MTF to use limited resources on problem resolution Drillable to focus efforts on recent activity Generates a MTF “Provider File Report Card” Sample on next slide

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 Volume and error types will dictate cleanup strategies Peer Group Comparison

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 Provider Report Card (continued – page 2) Monthly error rates for the MTF

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 New and Improved Process MTF Provider File Report Cards MTF Report Cards Automatically generated from the MTF detail file Baseline MTF CHCS provider file metrics Shows types of errors/discrepancies Shows the primary effect/impact Focused two-page format More readable and actionable Includes performance measures (peer-group based) Error rates for each MTF/DMIS captured Monthly trend analysis of new provider entries Other statistical information captured for future comparison AFMOA DQ Follow-up ingrained in the process

26. 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 Provider File Roles and Responsibilities AFMOA SGAR/Data Quality Program Office MTF DQ Team Provide analysis for the MTF Guide MTF through data clean-up Action plan for clean-up Report data at DQMC Provide feedback to AFMOA/DQ Indentify training issues Facilitate training Conduct site visits as needed Share data with proper DQ teammates Provide performance measures Help MTFs focus efforts Provide MTFs recommended processes/ share best practices

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 27 Way Ahead 27 Way Ahead JULAUGSEPOCTNOVDECJANFEBMARAPRMAYJUN Baseline -All active providers Baseline (10Aug-Rpt Card) FY10- 2 nd Qtr (15 Oct-Rpt Card) FY 10 2 nd Qtr (15 Jan- Rpt Card) FY 10 3 rd Qtr (15 Apr- Rpt Card) Order Entry activity to focus on recent activity (conceptual report on next slide) Match w/OHI information Annual review

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 28 Conceptual report that will show MTFs potential $ lost Reflects providers with NULL provider NPIs, not the rest of the errors Reflects current primary insurance listed in CHCS Opportunity to show the MTFs “What’s in it for them” 28 Way Ahead - Conceptual Report “Potential” Impact to TPC

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 DQ Tool Kit Data Quality Statement Guide Reporting Consistency Training document for new personnel AFMOA Resolution Guide – How to guide produced to assist MTF’s in the provider data cleanup process CHCS DQ Continuity Guide, Version 2 CHCS Standardized Business Rules AFMS Workload Guidelines Version 2.0 (draft) Brings together DQ, MEPRS, Coding and Billing AF supplemental guidance to DOD coding guidelines

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 Guide 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: Darrell Dorrian, Interim 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

34. 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)) Question 1a is deleted for FY10.

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

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 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, has been coded within 3 business days of the encounter? Source is BDQAS b) What percentage of APVs have been coded within 15 days of the encounter? Source is BDQAS c) What percentage of Inpatient records have been coded within 30 days after discharge? Internal Process - CCE Report (Un-coded records report)

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 Question 3. Medical Expense and Performance Reporting System for Fixed Military Medical and Dental Treatment Facilities Manual (MEPRS Manual), DoD 6010.13-M, dated April 7, 2008, paragraph C3.3.4, requires report reconciliation. a) Was monthly MEPRS/EAS financial reconciliation process completed, validated and approved prior to monthly MEPRS transmission? Source is 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? Source is MEPRS Manager Data Quality Statement Validation and Reconciliation

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 Question 3. Continued…New Questions on Timecards submitted by Service determined date. c) For DMHRSi, what is the percentage of submitted timecards by the suspense date? Source is MEPRS Manager Number of Timecards Submitted On-time Total Number of Timecards for an MTF d) For DMHRSi, what is the percentage of approved timecards by the suspense date? Source is MEPRS Manager Number of Timecards Approved On-time Total Number of Timecards for an MTF Data Quality Statement Validation and Reconciliation

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 Compliance Question 4. Compliance with TMA or Service-Level guidance for timely submission of data (C.3.).* a) MEPRS/EAS (45 days) Source is MEPRS Manager/MEWACS b) SIDR/CHCS (5 th Duty of Day of the month) Source is BDQAS c) WWR/CHCS (10 th Calendar Day Following Month) Source is BDQAS d) SADR/ADM (Daily) Source is BDQAS

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 Data Quality Statement Rounds Compliance 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

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 Data Quality Statement Coding Accuracy Calculation Use the following 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

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. 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

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 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

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 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

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 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.) Source for a, b, c, d is Audit Tool 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 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

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 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

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 8. Comparison of reported workload data. a) # SADR Encounters (count only) / # WWR visits Source is BDQAS b) # SIDR Dispositions / # WWR Dispositions Source is BDQAS c) # EAS Visits / # WWR Visits Source is BDQAS d) # EAS Dispositions / # WWR Dispositions Source is BDQAS e) # of Inpatient Professional Services Rounds SADR encounters (FCC=A***)/#Sum WWR (Total Bed Days + Total Dispositions) Note: FY10 Goal is 80% (Will be graded red and green only) Source is Monthly Statistical Report (Internal Process) Data Quality Statement Completeness

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 9. System Design, Development, Operations, and Education/Training (E.4.a). a. # of AHLTA SADR encounters / # of Total SADR encounters (ALL SADR encounters including APV and ER) Source is 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

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 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? (NOTE: Only Host sites report up.) Source is Internal Process Run the CHCS standard report – “Potential Duplicate Patient Search”. Data Quality Statement AHLTA Penetration

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 Question 11. I am aware of data quality issues identified by the completed DQ Statement and DQMC 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

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 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

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 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

54. 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/management_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 DMHRSi - https://dmhrsi.satx.disa.mil https://kx.afms.mil/kxweb/dotmil/kj.do?functionalArea=DMHRS1 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/

55. 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?