2010 ubo/ubu conference health budgets & financial policy 1 briefing: using the m2 to identify...

2010 UBO/UBU Conference

Health Budgets & Financial Policy

1

Briefing: Using the M2 to Identify & Manage MTF Data Quality — Trends and Impacts of Changes in Coding and Grouping

Date: 23 March 2010

Time: 1010–1200

2010 UBO/UBU ConferenceTurning Knowledge Into Action Objectives

The attendee will be able to:– Describe changes in coding for FY10– Characterize changes in RVU scales for CY10– Explain the importance of practice expense in the use

of RVUs– Describe the impact of the change from simple RVU

to enhanced simple RVU– Describe the change from DRGs to MS-DRGs– Characterize the change in RWP weight scales for

FY10– Identify key coding impacts on RVUs and RWPs

2

2010 UBO/UBU ConferenceTurning Knowledge Into Action FY10 Encounter Coding

Minimal changes in coding for FY10 published to date Some items being discussed:

– Consult coding changes driven by Medicare– TBI coding– Case Management Coding (new code for case

management assessment)

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2010 UBO/UBU ConferenceTurning Knowledge Into Action CY10 Relative Value Units

Annual weight table updates Generally based on Medicare weights, with some

modifications

4

Medicare weights

+

Commercial weights for some non-

Medicare services

+

Modifications for MHS

4


Medicare weights include only those services covered by CMS Commercial weights start with Medicare’s

– But add values for some services not covered by Medicare MHS Changes

– Add values for items that are not covered commercially, but MHS wants to pay for (i.e., telephone consults, LASIK)

– Reduction of weights for global procedures

Code Description DC Work RVU

PC Work RVU

66984 Cataract Surgery 7.25 10.36

In purchased care, pre- and post-op care not recorded, included in global code, not so with direct care

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2010 UBO/UBU ConferenceTurning Knowledge Into Action

The 10 RVUs from Medicare or commercial data are earned on one claim, but in direct care, earned on separate encounter records

6


Impacts of update in RVUs for CY09 to CY10– CPT Codes: 2.3% increase in weights– HCPCS Codes: 2.1% decrease in weights

Some common codes and their work RVU changes

Code Description 2009 2010 % Chg

99211 Off Visit; Minimal 0.17 0.18 6%

99212 Off Visit; Straightforward 0.45 0.48 7%

99213 Off Visit; Low Complexity 0.92 0.97 5%

99214 Off Visit; Moderate Complexity 1.42 1.50 6%

99215 Off Visit; High Complexity 2.00 2.11 5%

99217 Observation 1.28 1.28 0%

7

2010 UBO/UBU ConferenceTurning Knowledge Into Action Use of Relative Value Units

Units of Service– Reported by MTFs since 2003– Meaning depends on associated procedure code– Can indicate:

Number of times a procedure was performedNumber of time increments of a serviceNumber of visitsEtc…Depends on reported code

8

2010 UBO/UBU ConferenceTurning Knowledge Into Action Example CPTs and Units of Measure

Code Description Unit of Measure

99213 Office/Outpatient Visit of Low to Moderate Complexity

Visit

97761 Prosthetic Training; Upper and/or Lower Extremity; each 15 min

15 min of a visit

A0021 Ambulance, out of state, per mile Mile

73020 Radiology exam, shoulder; 1 view Picture

23600 Tx of proximal humeral fracture Setting + Follow Up Care

59400 Vaginal delivery, pre and post partum care Delivery, Pre and Post Partum Care

33510 Coronary Artery Bypass, Vein only, single graft Procedure + pre and post op

9

2010 UBO/UBU ConferenceTurning Knowledge Into Action Use of Relative Value Units

Historical emphasis on M2 “Simple RVU”– Work component only

Units of service not considered in Simple RVU Led to 5% understatement of provider workload Particularly a problem with codes that are commonly

used with multiple units– Time increments, for example

“Enhanced Simple RVU” includes units of service

10


Simple RVU = 0.85

Enhanced Simple = 10.20

3 hours of prosthetic training

3 hours of gait training

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2010 UBO/UBU ConferenceTurning Knowledge Into Action Impacts of Incorporating Units of Service

MEPRS Code Description Simple RVU

Enhanced Simple RVU % Increase

BA Medicine 778,092 842,486 8%

BB Surgery 507,050 530,070 5%

BC OB/GYN 450,694 456,872 1%

BD Pediatrics 441,470 451,992 2%

BE Orthopedics 333,720 337,330 1%

BF Mental Health 826,722 890,153 8%

BG Family Practice 1,313,652 1,322,818 1%

BH Primary Care 1,605,355 1,643,718 2%

BI Emergency Med 461,173 464,635 1%

BJ Flight Medicine 151,313 151,703 0%

BK Underseas Med 3,785 3,788 0%

BL PT/OT 460,798 578,545 26%

Total 7,333,826 7,674,109 5%

FY10, to date12

2010 UBO/UBU ConferenceTurning Knowledge Into Action Impacts of Incorporating Units of Service

Tmt DMIS ID Tmt DMIS ID Name

Enhanced Simple

RVUSimple

RVU % Chg

0052 TRIPLER AMC-FT SHAFTER 833,663 792,398 5%

0280 NHC PEARL HARBOR 156,407 151,442 3%

0284 NBHC NAVCAMS EASTPAC 4,023 4,015 0%

0285 BMC MCAS KANEOHE BAY 67,845 62,679 8%

0287 15TH MED GRP-HICKAM 63,434 61,471 3%

0437 SCHOFIELD BARRACKS AHC 244,251 238,100 3%

0524 BMA BARKING SANDS 26 26 0%

0534 TMC-1-SCHOF 25TH-SCHOFIELD BKS 32,595 32,537 0%

1987 NBHC MCB CAMP HM SMITH 4,025 3,996 1%

5442 ARMY-SURGICARE OF HAWAII (CIV) 931 931 0%

7043 USCG CLINIC HONOLULU 4,128 4,095 1%

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2010 UBO/UBU ConferenceTurning Knowledge Into Action Practice Expense RVUs

Work RVUs incorporate provider effort Simple and Enhanced Simple RVU are types of work

RVUs Practice Expense incorporates all other expenses

incurred by the provider in order to deliver care

Work RVU

Practitioner

PE RVU

Nurse(s)

Technicians

Supplies

Billing

Rent/Lights,

etc…..

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2010 UBO/UBU ConferenceTurning Knowledge Into Action Example CPTs and RVUs

Code Description Work RVU Practice Expense

80051 Electrolyte Panel 0.00 0.54

S0800 LASIK 7.17 18.63

99211 Office Visit; Low to Moderate 0.17 0.34

99281 ER E&M 0.45 0.09

PE intended to cover “all else”

billed by practitioner

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2010 UBO/UBU ConferenceTurning Knowledge Into Action Incorporation of Practice Expense

PE RVU is usually more than half of the total RVU. Especially true for:

– Technician dominated product lines, or

– Care where expensive equipment is required

ER PE RVU is low because a facility bill is expected

MEPRS2 Code

Enhanced Simple RVU

Enhanced Practice Expense

RVU PE as a % of Total

BA 842,486 1,240,547 60%

BB 530,070 698,787 57%

BC 456,872 501,732 52%

BD 451,992 544,300 55%

BE 337,330 395,909 54%

BF 890,153 479,606 35%

BG 1,322,818 1,282,304 49%

BH 1,643,718 2,230,775 58%

BI 464,635 275,957 37%

BJ 151,703 154,556 50%

BK 3,788 3,677 49%

BL 578,545 436,254 43%

Total 7,674,109 8,244,402 52%

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2010 UBO/UBU ConferenceTurning Knowledge Into Action Incorporation of Practice Expense

Two types of practice expense used in private sector:– Facility PE– Non-Facility PE– Provider will receive reimbursement for care based on location

of care

Code Description Work Fac Non-Fac

99211 Off Visit; Minimal 0.18 0.06 0.34

99213 Off Visit; Low Complexity 0.97 0.32 0.80

99282 Emergency Room E&M 0.88 0.19 0.19

Facility PE is low because a bill is expected from the facility where provider delivers care, to cover nurses, supplies, etc.

Out ofOffice

In office

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2010 UBO/UBU ConferenceTurning Knowledge Into Action APCs and RVUs – Provider Delivery Model

Care provided in own office

Care provided in a facility

Work + In Office PE

Work + Out of Office PE

AND

APC or APG (or other)

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Bill #1: Rx

Bill #2: Doctor, payment for seeing patient at ER

Bill #3: ER bill, from hospital

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Bill #1: Rx

Bill #2: Doctor, payment for seeing patient at ER (RVU)

Bill #3: ER bill, from hospital (APC)

17% of the bill is paid via RVU

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2010 UBO/UBU ConferenceTurning Knowledge Into Action Use of RVUs in MHS PPS

Historical PPS:– Ambulatory Earnings based on MEPRS Code and

Simple RVU– Simple RVU: Sum of work RVU weights associated

with reported CPTs– Earnings Rates * Simple RVU = PPS Earnings– Rates based on private sector cost / work RVU– “Count” does not matter– No credit for multiple providers– No credit for unlisted provider specialty codes– MEPRS “B” Codes only

2121

2010 UBO/UBU ConferenceTurning Knowledge Into Action Use of RVUs in MHS PPS

Limitations of Historical PPS:– Work RVU represents provider effort only– Allowed & Work RVU doesn’t necessarily go together– Units of service not incorporated into work RVU– Not terribly consistent with payment methodologies (important

because rates are private sector based)– MEPRS B Only encourages coding practice changes – Do More == More Money

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Immunization Encounters (MEPRS Code FBI)

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

Oct

-07

Nov

-07

Dec

-07

Jan-

08

Feb

-08

Mar

-08

Apr

-08

May

-08

Jun-

08

Jul-0

8

Aug

-08

Sep

-08

Oct

-08

Nov

-08

Dec

-08

Jan-

09

Feb

-09

Mar

-09

Apr

-09

May

-09

Jun-

09

Jul-0

9

Aug

-09

Sep

-09

Oct

-09

Nov

-09

Dec

-09

Jan-

10

A

F

N

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2010 UBO/UBU ConferenceTurning Knowledge Into Action PPS in FY10

Many limitations have been addressed by new rules in PPS Switch from simple RVU => enhanced simple RVU

– Big impacts on PT/OT, mental health, nutrition– Addresses the units of service issue

Inclusion of practice expense as a basis for earnings– Allows product lines that are technician dominated or use

expensive equipment to be properly resourced– More closely aligns with payment methodology– Big impacts in optometry and mental health– Results in exclusion of earnings for nurse-only care (covered

under PE RVU) Implementation of units of service limits to correct coding errors

23

2010 UBO/UBU ConferenceTurning Knowledge Into Action PPS in FY10

Separation of earnings into “institutional” and “non-institutional” for APV and ER

– Institutional component earnings via APC weight– Non-institutional component earnings based on Enhanced

Simple RVU + Out of Office Practice Expense– Better aligned with payment methodologies– Results in a lower ER earnings rate than previously.

Still not perfectly consistent with purchased care payment rules

– But much closer than before– Discounting is applied in private sector for some codes– Treatment of multiple providers– Use of modifiers in RVU assignment (i.e., 55)

24


Inpatient Relative Weighted Product Changes

25

2010 UBO/UBU ConferenceTurning Knowledge Into Action FY10 Coding Changes

New ICD-9 Code sets published in October 2009 Minimal changes other than introduction of new codes Major change in requirement to code “present on

admission” indicator (POA) Indicates whether the patient:

– Presented with the problem represented by the diagnosis code, or

– If the problem was acquired while patient in the hospital

A POA is required for every reported diagnosis code Plays a key role in billing

2626

2010 UBO/UBU ConferenceTurning Knowledge Into Action DRG Grouping

Diagnosis Related Groups (DRG):– Coding system used to categorize similar stays into groups– Intent is to assign cases to the same group if clinically

similar, and similar in terms of resource intensity.– Used to pay most acute care hospitals for inpatient care

DRG Grouping Software– Hospitals code records with ICD-9 CM diagnosis and

procedure codes and other data (age, LOS, etc.)– Based on this, DRG software is run to add a DRG to the

hospital record– Many different versions of DRG software – depends on the

payor– CPT codes are not used in DRG assignment

27

2010 UBO/UBU ConferenceTurning Knowledge Into Action DRG Examples

DRG Groupers assemble records based on the combination of reported diagnosis and procedure codes– Expert panels determine the groups– Improperly coded records get a DRG of “ungroupable”

The same diagnosis code can group to a number of different DRGs; – Depending on what comes along with the diagnosis

code– Co-morbidities and complications are particularly

important

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2010 UBO/UBU ConferenceTurning Knowledge Into Action Records with the Same Primary Diagnosis

Primary Diagnosis: Diabetes with Renal Manifestations (250.4)

DRG Description Sec Dx 1 Sec Dx 2 Proc 1 Proc 2

302 Kidney TransplantChronic Kidney Disease Postop Infection

Kidney Transplant

Ureteral Catheter

331Kidney/UT Diagnosis w cc

Cocaine Dependence

Pathological Kidney Lesion

332Oth Kidney/UT Diagnosis w/o cc Edema

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2010 UBO/UBU ConferenceTurning Knowledge Into Action Records with the Same Primary Diagnosis

Primary Diagnosis: Diabetes with Renal Manifestations

DRG Description Sec Dx 1 Sec Dx 2 Proc 1 Proc 2

302 Kidney TransplantChronic Kidney Disease Postop Infection

Kidney Transplant

Ureteral Catheter

331Kidney/UT Diagnosis w cc

Cocaine Dependence

Pathological Kidney Lesion

332Oth Kidney/UT Diagnosis w/ cc Edema

• All 3 cases had diabetes as the primary DX

• None grouped to the two Diabetes DRGs!

• The “w renal manifestations” led the grouper to a DRG related specifically to the kidneys!

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Major change in the DRG system for TRICARE has just occurred– TRICARE must follow Medicare payment policy, per law– From “DRGs” to Medicare Severity DRGs (MS-DRG)– Reclassification of complications and co-morbidities– Definitions of ‘what is a complication or co-morbidity’ changed– From two levels of complication / co-morbidity to three in some

cases– Introduction of payment reductions for hospital acquired

conditions TRICARE uses a modified version of CMS grouper (newborns,

mental health)– But TRICARE specific relative weights are used, instead of

Medicare’s

Medicare-Severity DRGs

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2010 UBO/UBU ConferenceTurning Knowledge Into Action Example Changes in DRGs

DRG Description

085 Pleural Effusion w CC

086 Pleural Effusion w/o CC

MS DRG Description

186 Pleural Effusion w MCC

187 Pleural Effusion w CC

188 Pleural Effusion w/o CC/MCC

Names the same but not necessarily the content!

Separate category for “major complications and co-morbidities!

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Illustration of Change in “What is a Complication?”

DRG Description Disp RWP CMI

358 UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC 67 79.13 1.1810

359UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O

CC 242 239.05 0.9878

Total 309 318.18 1.0297

MS DRG

DRG Description CC No CC Total

358UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W

CC 48 19 67

359UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O

CC 6 236 242

Total 54 255 309

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2010 UBO/UBU ConferenceTurning Knowledge Into Action FY10 Relative Weight Changes

Annual weight table update in October 2009 Each MS-DRG gets:

– Relative Weight– Average Length of Stay– Short and Long Stay Outlier Thresholds

Weights are based on average TRICARE billed amounts on acute care hospital claims received the prior year (July to July)

3434

2010 UBO/UBU ConferenceTurning Knowledge Into Action Relative Weights

Based on hospital costliness only (private sector) Practitioners paid via RVU Relative weights incorporate only those expenses

incurred by the hospital in order to deliver care

Work RVU + Out of Office PE

Practitioner

Billing

Other minor $

Relative Weight

Nurse(s)

Technicians

Supplies

ICU / OR

Rent/Lights

etc…..

35

2010 UBO/UBU ConferenceTurning Knowledge Into Action Example DRG Weights and Thresholds

DRG DRG Description RW ALOS SST LST

294 DIABETES AGE >35 0.74 3.4 1 19

295 DIABETES AGE 0-35 0.49 2.5 1 11

302 KIDNEY TRANSPLANT 2.87 6.2 2 22

331OTHER KIDNEY & UT DX AGE >17 W CC 1.19 4.9 1 27

332 OTHER KIDNEY & UT DX AGE >17 W/O CC 0.65 2.5 1 14

Selected DRGs that relate to diabetes

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2010 UBO/UBU ConferenceTurning Knowledge Into Action Relative Weighted Products

Weighted workload measure intended to represent hospital costliness:– Conceptually similar to payment rules

“Normal cases” receive the same RWP credit in the same DRG– RWP = Relative Weight– Normal Case is one with LOS between long and short

stay thresholds. Most cases are “normal” or short stay outliers

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2010 UBO/UBU ConferenceTurning Knowledge Into Action Relative Weighted Products

Outlier RWPs: – Relies on the concept of a daily weight – Per diem weight is RW / GLOS – (GLOS= Geometric Mean LOS; because LOS is not

normally distributed)– Short Stay: RWP never higher than relative weight– Long Stay: More credit than a routine stay, but not so

much to encourage excessive LOS.

38

2010 UBO/UBU ConferenceTurning Knowledge Into Action RWP

Short Stay Outlier Rule:– Twice the per diem for first day– Per diem for each additional day– Capped at relative weight– Same as payment rule

1st day gets two times the RWP as the other days

Daily RWP for Short Stay Outlier (with per diem weight ~.12 )

0

0.05

0.1

0.15

0.2

0.25

0.3

1 2 3 4 5 6 7 8 9 10 11 12

39


Long Stay Outlier Rule:– Relative weight for entire ‘normal stay”– A third of the per diem weight for each extra day– Discourages excessive lengths of stay

DRG Weight

Cumulative RWPs by Length of Stay

0

0.5

1

1.5

2

2.5

3

3.5

4

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45

Slight growth in RWP once Long Stay Threshold is crossed

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Total RWPs for a Low BirthweightNewborn DRG

Cumulative RWPs by Length of Stay

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45

Weight = 3.05; Per Diem = .1271

Short Stay Threshold is 12 days; Long Stay Threshold is 36 days

41


Long Stay Outliers:– TRICARE and Medicare do not pay more for long stay

outliers – Discourages excessive lengths of stays– Cost outliers do receive additional payments, though

RWPs do give the extra long stay credit– Since “cost outlier” status is difficult to determine in

direct care– Done in both direct and purchased care data for

consistency

42

2010 UBO/UBU ConferenceTurning Knowledge Into Action Changes in Weights and RWPs for FY10

MS DRG Description 2009 2010 % Chg

635 NEONATE, BIRTHWT 1000-1499G, DIED 2.166 10.545 387%

108EXTRAOCULAR PROCEDURES EXCEPT

ORBIT AGE 0-17 0.795 2.042 157%

915 ALLERGIC REACTIONS AGE >17 W MCC 0.838 1.920 129%

111 SINUS & MASTOID PROCEDURES AGE 0-17 1.066 2.25 111%

595 MAJOR SKIN DISORDERS W MCC 1.605 3.206 100%

Overall change in MS-DRG Weights of 1% (decline)

Tripler change was -1%

Selected DRGs with significant increases in weights

43

2010 UBO/UBU ConferenceTurning Knowledge Into Action Changes in RWPs for 2010

Selected DRGs with significant decrease in DRG weights

MS DRG Desc 2009 2010 % Chg

422HEPATOBILIARY DIAGNOSTIC PROCEDURES

W/O CC/MCC 1.967 1.084 -45%

949 AFTERCARE W CC/MCC 1.871 1.013 -46%

836ACUTE LEUKEMIA W/O MAJOR O.R.

PROCEDURE AGE >17 W/O CC/MCC 3.369 1.739 -48%

553 BONE DISEASES & ARTHROPATHIES W MCC 1.511 0.767 -49%

610 NEONATE, DIED W/IN ONE DAY OF BIRTH 0.362 0.155 -57%

794 NEONATAL DIAGNOSIS, AGE > 28 DAYS 5.337 2.042 -62%

729OTHER MALE REPRODUCTIVE SYSTEM

DIAGNOSES W CC/MCC 2.273 0.86 -62%

44

2010 UBO/UBU ConferenceTurning Knowledge Into Action MS DRGs

MS-DRGs include a mechanism to reduce payments for certain hospital acquired conditions (HAC)– Conditions identified are deemed high cost or high

volume by CMS– Based on reported “present on admission” indicators– Required on primary and secondary diagnosis codes– “Pay for performance”: Concept is that hospitals don’t

get paid for problems they cause

45

2010 UBO/UBU ConferenceTurning Knowledge Into Action Hospital Acquired Conditions

Conditions for which Medicare and TRICARE no longer pay if not present on admission:

– Foreign object retained after surgery– Air embolism– Blood incompatibility– Stage III and IV pressure ulcers– Falls and trauma– Manifestations of poor glycemic control– Catheter associated UTI– Vascular catheter associated infection– Surgical site infections after some surgeries– Deep vein thrombosis / pulmonary embolism after knee / hip

replacement

46

2010 UBO/UBU ConferenceTurning Knowledge Into Action MS DRG

Medicare example, primary diagnosis is stroke

DRG Description Sec DxSec DX

POAAvg Pmt

066Stroke w/o

cc/mcc N/A N/A 5,348

065 Stroke with ccDislocation of patella, due to fall Y 6,177

065 Stroke with ccDislocation of patella, due to fall N 5,348

47

2010 UBO/UBU ConferenceTurning Knowledge Into Action MS DRGs

From ~ 500 DRGs to more than 800 DRGs DRGs also have been renumbered!

– 001 used to be a craniotomy; now it’s a heart DRG!– Likely a good thing, since definitions have

fundamentally changed. Some MHS information systems (i.e., CHCS) will only

show one DRG data element, though– Will cause misunderstanding among users as the

same code value will have different meanings depending on date of service.

48

2010 UBO/UBU ConferenceTurning Knowledge Into Action Use of RWPs in MHS PPS

Inpatient Earnings Mental Health vs. Other Mental Health and Substance Abuse:

– # of Bed Days * Local Market Rate– Major Diagnostic Category 19 & 20

All other services based on “relative weighted product” or RWP

– # RWPs * Local Market Rate

49

Type of Care PPS Earnings

Mental Health 54,449,229

Non-Mental Health 1,829,617,221

Total Inpatient 1,884,066,450

49

2010 UBO/UBU ConferenceTurning Knowledge Into Action Use of RWPs in MHS PPS

Historically, PPS used the “old” DRG system FY10 switch to MS-DRGs

– Necessary because old groupers no longer being maintained

Limitations in MHS Inpatient PPS– Earnings rates incorporate hospital + provider– But the RWP only reflects hospital expenses– Some care is expensive for the hospital and not the

doctor– And vice versa

50


Examples of High Institutional Payment and Low Non-Institutional Payment

DRG DRG Description Institutional Payment

Non-Institutional Payment

Total Payment

% Hospital

481 BONE MARROW TRANSPLANT $ 1,743,798 $ 10,476 $ 1,754,274 99%

606NEONATE, BW 1000-1499G, W SIGNIF OR PROC, DISCHARGED ALIVE $ 1,543,888 $ 54,835 $ 1,598,722 97%

622NEONATE, BW >2499G, W SIGNIF OR PROC, W MULT MAJOR PROB $ 1,256,092 $ 66,102 $ 1,322,194 95%

542TRACH W MV 96+HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R. $ 1,203,798 $ 53,042 $ 1,256,840 96%

For these cases, RWP would do a nice job of explaining

costliness since most of the cost is hospital

51


Examples of High Non-Institutionaland Low Institutional Payment

DRG DRG Description Institutional Payment

Non-Institutional Payment

Total Payment

% Hospital

601NEONATE, TRANSFERRED <5 DAYS OLD $ 1,321 $ 115,185 $ 116,506 1%

217

WND DEBRID & SKN GRFT EXCEPT HAND,FOR MUSCSKELET & CONN TISS DIS $ 14,941 $ 47,094 $ 62,035 24%

257TOTAL MASTECTOMY FOR MALIGNANCY W CC $ 5,988 $ 45,115 $ 51,103 12%

544

MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY $ 9,971 $ 44,351 $ 54,322 18%

For these cases, RWP would do a terrible job of explaining costliness since a small % of

the cost is hospital.

52

2010 UBO/UBU ConferenceTurning Knowledge Into Action Use of RWPs and PPS

Obvious solution is to use RWP for hospital component and RVU for provider component

– But inpatient professional services not fully captured in MHS

Rounds visits are required to be reported by providers– But inpatient procedures are not– (Information about what procedures are done is on the SIDR, but

in ICD-9 terminology– Means that no RVUs can be assigned. RVUs only work with

CPT/HCPCS

53

2010 UBO/UBU ConferenceTurning Knowledge Into Action Example of Rhinoplasty Direct Care Coding

Direct Care Coding

SIDR Value

Admission Date 5/23/2009

Discharge Date 5/24/2009

DRG 056

Procedure 2188

Days 1

SADR SADR #1 SADR #2 SADR #3 SADR #4

Service Date 5/22/2009 5/22/2009 5/23/2009 5/24/2009

MEPRS Code B D A B

Procedure Code NONE NONE NONE 99024

E&M Code 99499 NONE 99499 99499

RVU 0 1.22 0 0.76

• No procedure coded on SADR

• Separate pre-op and follow up visit coded

Roughly 2 RVUs

54


Example of Rhinoplasty Private Sector Coding

Private Sector CodingTED-I Value

Admission Date 5/14/2009

Discharge Date 5/16/2009

DRG 056

Procedure 2172

Days 2

TED-N TED #1 TED #2 TED #3 TED #4 TED #5

Service Date 5/14/2009 5/15/2008 5/15/2008 5/16/2008 5/16/2008

Procedure Code 99291 99232 99255 99238 21335

RVU 2.27 4.50 1.39 1.28 8.91

• Procedure is coded in both records

• No pre-op or follow up visit (bundling)

Roughly 18 RVUs – almost 10 times as many as direct care

55

2010 UBO/UBU ConferenceTurning Knowledge Into Action Other PPS Changes (Potential)

BRAC has caused a complication in PPS (impacts both inpatient and outpatient)

– Currently, all care is funded based on place of service– Need to separate facility vs. provider, to accommodate providers

of one service treating patients at an MTF of another service– Complicated issue

Poor quality CHCS provider data Not all MTFs are on DMHRS yet Lack of reporting of CPT codes for inpatient surgeries

56

2010 UBO/UBU ConferenceTurning Knowledge Into Action Coding and RWPs and RVUs

Take care to properly document and code all diagnoses and procedures according to UBU guidelines

Units of service– Multiplier for RVU credit. Take caution in coding!

Some ridiculous values appear in the data at times Present on admission indicators

57

2010 UBO/UBU Conference

Health Budgets & Financial Policy

58

Briefing: Using the M2 to Identify & Manage MTF Data Quality — Playing the Game to Win

Date: 23 March 2010

Time: 1010–1200

58


59

Objectives

Briefly describe how the incentives inherent to Resource Allocation Systems (like PPS) create incongruent goals, depending on the roles of different organizations.

Describe instances that illustrate data error (1) caused accidentally, (2) that maximizes revenue, (3) where policy directs miscoding that maximizes revenue, (4) where data suggest missed opportunities, (5) where events and resulting revenues are duplicated, and (6) where data problems obscure understanding the real world.

Describe goal-maximizing strategies available to (1) payors, (2) revenue receivers, and (3) for jointly held goals.

59

2010 UBO/UBU ConferenceTurning Knowledge Into Action Overview

Effects of Resource Allocation Systems Illustrations of Data Error Defensive Strategies

6060

2010 UBO/UBU ConferenceTurning Knowledge Into Action Effects of Resource Allocation Systems

Payment Systems– Generally characterized by goal– Medicare (like PPS) seeks cost containment– Pure resource allocation systems must add up to the

available funds (equitable sharing goal)– Systems may also want to encourage/discourage

numbers in the system, such as numbers of: Given types of providers Use of preferred settings Frequency of services Prevention of unwanted services

6161


The MHS Prospective Payment System (PPS)– Discourages use of clerks or non-medical personnel– Discourages direct care pharmacy– Discourages case management– Encourages use of emergency rooms– Discourages furnishing of non-doctor care, such as

prosthetics (HCPCs) “Encourages” means pays more when it is true;

“Discourages means pays nothing when it is true.

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All payment systems involve payers and receivers of funds. Most of the time, the patient is neither.

Payers (TMA for PPS) generally prefer lower payments to higher, and equity among fund distribution.

Receivers (SGs, and potentially major commands and MTFs) prefer higher payments to lower, and to maximize their share of resourcing.

Productivity is a different issue, but can influence payment systems when the incentives for scoring high on productivity involve data elements that affect PPS earnings.

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Illustration:– A patient presents with an ear ache, an itchy patch of

skin on the elbow, and a sore knee.– Lowest earnings and worst productivity:

The PCM diagnoses and treat the three conditions.

– Almost triple the earnings and productivity: The PCM diagnoses and treats one of the conditions and

books two more appointments for the remaining conditions.

– More than triple the earnings and productivity: The PCM refers to ENT the sore throat; in a second

appointment the PCM refers to dermatology the elbow, and in a third appointment, the PCM refers to Ortho the knee.

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The inevitable consequence is that receivers investigate, discover, and implement opportunities that will add revenue (or productivity) with minimal consumption of additional resources.

Another consequence is usually that the payer instigates strong controls (audits of records, data mining for gaming, harsh penalties for violators of good coding) to offset the incentives created by a PPS system.

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Illustrations– The following sections look at data error that:

Appears to be accidental.May be accidental, but was very advantageous to

receivers.Is policy driven, and very advantageous to

receivers.May not be gaming, but which can harm revenues

or healthcare by the “Fog of War”.

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2010 UBO/UBU ConferenceTurning Knowledge Into Action Accidental Data Error

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The following slides are all real data from M2 and clearly show data that cannot be right, but mostly unrelated to coding.

Accidental Data Error

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Just Missed the Centennial Celebration, but his service continues!


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24 Years Older thanthe World Record Holder


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What difference does it make?

1. Affects eligibility for benefits

2. Affects validity of coding (maximum and minimum ages)

3. Affects TPC and OHI

4. Affects equivalent lives

5. Affects screening for prophylaxis

6. Affects normal values


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Accidental: Phantom Encounters

Phantom encounters can’t be found in central data, or have only their skeletons without their flesh! Typical causes are:

1. Submitted completed records are sometimes “cached” and not processed into the central data bases.

Missing Data

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Cached


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NOTE: This is countingthose we know did not

come, but does nottell us of those wenever heard about!

Nor can we tell where coding waschanged, or changed back!


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2. Disconnects between the capture system (AHLTA) and the transmitting system (CHCS) prevent the encounters’ transmission.

Missing Data


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AHLTA?


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2. Disconnects between the capture system (AHLTA) and the transmitting system (CHCS) prevent the encounters’ transmission.

3. CCE Edits (CHCS) are sometimes “undone” by a retransmission of the AHLTA record.

Missing Data

Accidental: Corrupt Encounters

Not Discernable from Central Data

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2010 UBO/UBU ConferenceTurning Knowledge Into Action Advantageous Data Errors

Several common types of data error, which can be advantageous, are:– Incorrect pharmacy pricing– Date errors gaining outlier per diem rates– Recording duplicates– Coding Creep

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Prime Vendor priceused by other MTFs

Local CHCS pharmacypricing table

$9.7 Milliontoo high

Advantageous Data Errors: Pricing

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This is a storedcorporate document

in M2

1. Bad pricing can be caused by either or both of local CHCS prices, or using the wrong “unit” for counting quantities.

2. In this case, the second MTF has CHCS loaded with the “box” price, but is using the correct “inner package” quantities.

3. This overstates the pharmacy cost (and OHI bill) by 60 times.


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1. The low end is often as destructive as the high end.

2. Captopril (an ACE inhibitor for hearts) costs 19¢ each.

3. Coumadin (a blood thinner) costs 6¢ each.

4. This understates the pharmacy cost (and OHI bill) by dividing a unit or box cost by the case quantity!

This is a storedcorporate document

in M2


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Advantageous Data Errors: Outliers

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Mirrored encounters have a single event represented in multiple records, as though it occurred many times. Typical causes are:

1. MTF’s changed their identifier (“DMIS ID”) between reports of the event.

Advantageous Data Errors: Duplicates

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Mirrored encounters have a single event represented in multiple records, as though it occurred many times. Typical causes are:

1. MTF’s changed their identifier (“DMIS ID”) between reports of the event.

2. Persons create a new record, possibly because they are unaware a record already exists.


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2 records for each

twins sharingone ID, or

duplicates?

Same day readmission and

redischargeor duplicates?

Has to beduplicates!


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• Normal and predictable

• Created by financial or other reward incentives

• Moderated by penalties, audits, or other controls

• Confounded by “optimization” vs. “gaming”

Advantageous Data Errors: Coding Creep

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AmbulatoryFlavor

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AmbulatoryFlavor

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SETTINGS, SKILLS, AND PROCEDURES

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In aggregate, MHS isdoing as well as

purchased care inavoiding “mismatches”

A “match” is when the E&M is for highlevel treatment, by

an appropriate provider specialty,

in an ER.


AmbulatoryFlavor

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These E&M CodesMUST

be in an ER!

MHS-WIDE


AmbulatoryFlavor

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Just 2 MTFswith DentalClinic ERs

Just 2 MTFswith ERs in1 other OPD

Where are they from?


AmbulatoryFlavor

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QUANTITIES AND MODIFIERS BY SETTINGS

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Occupational Medicine Physician$24K in

PPS


AmbulatoryFlavor

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Good Coding, Bad Results


AmbulatoryFlavor

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Bad Coding, Bad Results

15 hours of continuous therapy

10.2 days of continuous therapy



AmbulatoryFlavor

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2010 UBO/UBU ConferenceTurning Knowledge Into Action Policy-driven Adv. Data Errors

Formal Policy is sometimes given requiring advantageous data errors:– Mandated coding creep– Mandated inappropriate admissions– Mandated unbundling

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Policy-driven Coding Creep

DIRECTED ????

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Policy-driven Coding Creep

DIRECTED ????

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Myringotomies – Inpatient or Same Day Surgery?Which MTF is Different?

Policy-driven Admissions

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Over 150 Admissions/Year


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Potential Impacts (FY08)

150 x 0.7 = 105 RWPs x $9,300 = $1 million

150 x 1.4 = 210 RVUs x $72 = $16 thousand

PPSEarnings

But also…

Quality of Care?

• Nosocomial Infection

• Psychological Impact

• Safety Risks

Patient Admin Burden?

OHI Billing Appropriateness?


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Unbundling of Electrolyte Panels, by Service

BILLING MUST RE-ASSEMBLE

THE PANELS

October 2005 – December 2009

Policy-driven Unbundling

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Bad Data Obscures Mgt– Missed Opportunities– Lumpy Pictures Abound

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Data “Fog of War”

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Worth a Try?

Data “Fog of War”: Missed Opportunities

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People Thought to Have No OHI in October

People Known to Have OHI in November

Peoplefor whom

the MTFran

ancillarytests

inOctober

$$$


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How M2 Solves this Kind of Question

But TRICK: Never more than 500,000 allowed!

1. Create a list of those with Medical OHI in November (the smallest list of the three).

2. Create a subset of the list with just those eligible but with no Medical OHI in October

3. And for just those, retrieve their October ancillary data and costs.

Main Query 1

Sub-Query 1.1

Sub-Query 1.1.1

And then build it backwards from your logic


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• Cyclical lumpy data

• Perverse lumpy data

• Invalid lumpy data

Data “Fog of War”: Lumpy Pictures

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CYCLICAL LUMPY DATA

MHS WORLDWIDE BED DAYS (FY09)

Bad Months!

Most productive months?


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MHS WORLDWIDE BED DAYS (FY09)

CYCLICAL LUMPY DATA

LUMPINESSCAUSED BY

UNEVENINTERVALS


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LUMPINESSCAUSED BYSEASONALEFFECTS

TFL


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LUMPINESSCAUSED BY

EVENTEFFECTS

9/11

Iraq

TAMP Extension

Surge


TRS Change

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CYCLICAL LUMPY DATA

LUMPINESSCAUSED BYARTIFICIALPARTITIONS


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CYCLICAL LUMPY DATA



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CYCLICAL LUMPY DATA

The “Drag Forward” RuleReplacing Interim Bills



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INVALID LUMPY DATA


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INVALID LUMPY DATA

$0

$500,000

$1,000,000

$1,500,000

$2,000,000

$2,500,000

$3,000,000

$3,500,000

$4,000,000

$4,500,000

$5,000,0001 2 3 4 5 6 7 8 9

10 11 12

1 2 3 4 5 6 7 8 9

10 11 12

1

2007

2008

2009

ONE MEDICAL CENTEREXPENSES IN

MEPRS


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0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

1 2 3 4 5 6 7 8 9

10 11 12

1 2 3 4 5 6 7 8 9

10 11 12

1

2007

2008

2009

WTD SCRIPTS IN MEPRS

INVALID LUMPY DATA


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10,000

100,000

1 2 3 4 5 6 7 8 9

10

11 12 1 2 3 4 5 6 7 8 9

10

11 12 1 2 3 4

2007

2008

2009

INVALID LUMPY DATA

ONE MEDICAL CENTERPTDTS ISSUE

COST


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INVALID LUMPY DATA

One MTF

One MTF


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INVALID LUMPY DATA, One MTF

New CY07RVU table


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Data Types Prone to Lumpiness:

– Institutional Purchased Care

– Non-Institutional Purchased Care for OB and Surgeries

– Direct Care Inpatient (SIDRs)

– MEPRS (EAS)

– Enrollment, especially newborns

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2010 UBO/UBU ConferenceTurning Knowledge Into Action Data “Fog of War”: Lumpy Pictures

Data Types Prone to Lumpiness:

– Institutional Purchased Care

– Non-Institutional Purchased Care for OB and Surgeries

– Direct Care Inpatient (SIDRs)

– MEPRS (EAS)

– Enrollment, especially newborns

Precautions on perceptions with Lumpy Data:

– Redistribute when feasible to “unlump”

– Avoid “answers” from lumpy systems (i.e., MEPRS cost/RVU)

– “TLAR” anomalies based on knowledge

– Caveat

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2010 UBO/UBU ConferenceTurning Knowledge Into Action Defensive Strategies

Payor Strategies Receiver Strategies Joint Strategies

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2010 UBO/UBU ConferenceTurning Knowledge Into Action Defensive Strategies: Payors

Penalize Creeping (and enforce!) Penalize (Inapp) Admissions (and enforce!) Penalize setting mismatches (and enforce!) Limit units of service Pay least of Rx “should” or “did” cost Test duplicate records (and penalize when appropriate)

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2010 UBO/UBU ConferenceTurning Knowledge Into Action Defensive Strategies: Receivers

Rebundle mandated unbundling before billing Check for low-price outliers (esp. Rx) Demand release of cached records Check peers for gamesmanship and request payor rules to

prevent; OR Adopt peer gamesmanship

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2010 UBO/UBU ConferenceTurning Knowledge Into Action Defensive Strategies: Joint

Analyze and dissect lumpy data for hidden management needs.

Audit records for balance of full disclosure (Pxs and Dxs) and relevance.

Fix or replace automation that does not work.

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Summary

If resource allocation follows arbitrary rules. . .– Know the causes and symptoms of data error– Take steps to maintain equity against

advantageous or disadvantageous error– Avoid policy-driven data error– See through the data “fog of war”– Adopt defensive strategies to protect resources

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2010 ubo/ubu conference health budgets & financial policy 1 briefing: using the m2 to identify...

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