data quality tips and tricks wendy funk kennell and associates [email protected]

Data Quality

Tips and Tricks

Wendy FunkKennell and [email protected]

Objectives1. List several important MHS initiatives that

rely upon good MTF data

2. Identify the major MTF-level data products

3. Identify common MHS Data Problems

4. Utilize M2 Standard Reports to analyze DQ issues

Transformation of the MHS into a data-driven

enterprise!Then:

Rudimentary funding

Closed organization

Production-focused

Now:

Productivity

Population Health

PPS & Business Plans

Balanced Scorecard

MCS Contracts / TFL

Data-Based Clinical Initiatives


• Disease Management Initiatives– Asthma and Congestive Heart Failure– Identification of high-risk patients using SIDR,

SADR and Claims data

• Pop-Health Portal– Preparation of action lists for providers or

primary care managers– Uses SIDR, SADR, Lab, Rad, PDTS and Claims– HEDIS measurement, other clinical work


• Pharmacy Utilization Review– Pharmacy Data Transaction Service

(PDTS) does real-time UR for MHS eligibles

– Online since 2001– (MTF Rx, Retail, TMOP, Paper Claims)– Significant achievement for the MHS!

Good coding & person identification

Data-Based Funding Initiatives

Data-Based Funding

• Prospective Payment System– O&M budgets; service level– Built-up from Business Plans; with

adjustments later…… (HA later in course!)

– Based on “workload” from SIDR and SADR

– Uses private sector pricing - does not rely on MTF costs

Coding on SIDR & SADR are important!

Data-Based Funding

• Prospective Payment System– Inpatient Earning are based on days

for mental health, and “RWPs” for all other care

– Ambulatory earnings are based on RVUs and provider specialty code

– Pay attention to procedure and diagnosis codes, provider specialty

– PPS Policy continues to evolve.

MTF XXXX Workload Rate EarningsBed Days for Mental Health 565 500$ 282,500$ RWPs for all-other stays 9,877 6,500$ 64,197,575$

Inpatient Earnings 64,480,075$

Inpatient PPS Earnings Example:

MTFs code the SIDR &

SADR

HA Applies PPS Rates

MDR adds RVUs and

RWPs

Data-Based Funding

• GWOT Funding– Additional funding on top of DHP to cover

new benefits for guard/reserve– NDAA 2004 extended period of coverage

for GWOT-activated members & families– Early eligibility, screening period and

extended transitional assistance– Significant increase in eligible population

November 2004 +New Way

Early Elg

60 days

Screen Mobilization Period

Routine TAMP

Extra TAMP 2-4 months

Mobilization Period

Routine TAMP

Old Way

Lengthened period of eligibility!!!

Growth in Guard and Reserve Population

Beneficiaries with Guard/Reserve Sponsors (incl sponsors)

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

1,000,000

Watch it Grow!

% Guard/Reserve of Total MHS EligiblesFY01 FM 12

96%

4%

% Guard/Reserve of Total MHS EligiblesFY05 FM 12

90%

10%• Includes all eligibles sponsored by guard/reserve; including sponsors

Data-Based Funding

• GWOT Guard/Reserve– The DHP earns money from the GWOT

fund based on SIDR, SADR, PDTS, and claims data

– Direct care costs are measured using “Patient Level Cost Allocation” (PLCA) costing methodology

– GWOT Guard/Reserve data in M2

Data-Based Funding

• TRICARE Reserve Select– Allows GWOT activated guard/reserve to

purchase eligiblity after completion of TAMP.

– Same access priority as ADFM, but no Prime.

– Must agree to continued service and must pay premiums

– Funding using same basic process as NDAA 2004 benefits

TRS Enrollment

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

May-05

Jun-05

Jul-05

Aug-05

Sep-05

Oct-05

Nov-05

Dec-05

Jan-06

Feb-06

Mar-06

Apr-06

May-06

Jun-06

Jul-06

Data-Based Funding

• TRICARE for Life– Separate fund provides for $$$ to care

for Non-AD / ADFM Medicare eligibles– Medicare Eligible Retiree Health Care

Fund (MERHCF)– MTF $$$ (earnings) based on SIDR,

SADR, PDTS.– Medicare Eligibility from DEERS (from

CMS)– More from Mr. Moss later in course

Costs of Caring for Medicare Eligibles in the Direct Care SystemInpatient and Outpatient Care Only

0

5000000

10000000

15000000

20000000

25000000

Army

Air Force

Navy

SIDR and SADR Full Costs for Medicare Eligibles

Other Funding• Third Party Collections

– CMAC for outpatient and ancillaries– DRG based billing for inpatient– Billing based on CHCS or AHLTA coding

• Venture Capital & MISSY– Extra funding available through TMA for

CHAMPUS Recapture– Models require MTF SIDR, SADR and

EASIV.

External Business & Data

Data-Based Contracts

• T-Next TRICARE Managed Care Support Contracts– 3 U.S. “At-Risk” contracts– Enrollment Processing and PCM

Assignment– Claims Payment– Managed Care & Much More!– Ongoing provision by TMA of SIDR,

SADR, PDTS, Claims and DEERS data


• TRICARE Global Remote, TRICARE Overseas Prime, TRICARE for Life– Claims

• TRICARE Retail Pharmacy– Claims & PDTS

• TRICARE Mail Order Pharmacy– Claims & PDTS


• TRICARE Dual Eligible Fiscal Intermediary Contract (MERHCF)– Claims

• Designated Provider– Managed Care (Health Care)– Enrollment– Capitated with Risk Adjustment

Focus on Data Quality

Data Quality and the MHS

• TRICARE Senior Prime– Very poor audits

• DoD Financial Statement Problems– Poor data quality cited

• Data problems cited repeatedly with MCS Contract ‘disputes’

Significant focus on DQ at TMA and Services.


• Data Quality Management Control• Data Quality Managers• Data Quality Course• Data Quality IPT (Functional)• Commander’s statements and review

lists• Data Quality Standard Reports for

M2


• Redesign of IM/IT Process– Functional responsibility for business rules– Requirements vetted through IM (Services,

HA/TMA, DEERS, Others)– Requirements documented

• Significant re-engineering of data feeds– Reduce burden on the source systems– Process it once, ship it out where needed!

Inpatient Data Record Flow

10/98

MTF

CHCS

AIR Force(uses

AFVAL edits)

Army(uses PASBA

edits)

Navy(none, may use PASBA edits)

DataMart

DMIS Processor

RCMASV1

RCMASV2

DMIS-SS

CEIS IDB(edit checks

include parser & logical edits)

LegacySAS

Inpatient Data Record Flow4/99

MTF

CHCS

AIR Force(uses

AFVAL edits)

Army(uses PASBA

edits)

Navy(none, may use PASBA edits)

DataMart

DMIS Processor

DMIS-SS

CEIS IDB(edit checks

include parser & logical edits)

RCMASV1

RCMASV2

FeedNode

IDBR(min edits) RPU

(min edits)

RLP(min edits)

RLPSAS

EDWETL

EDW Stars(data transformed

to FAM-D standard)

LegacySAS

Until 6/30/99

ARSPASBA

Inpatient Data Record Flow

Today

MTF

CHCS

MDR

Simplicity……….

Data Mart

Data Mart

Basic Information Systems

Types of Systems

• MHS is a complex business– Deliver healthcare – Process Claims– Managed Care

• Complex data needs; multiple ways to view the business

• More than 9 million eligibles; terrabytes of data

Types of Systems

Type PurposePeriodicity Quality

Example

Transactional

Run the business

Real-Time

No time to "clean" CHCS

Data Warehouse

Store, process Batch

Fix and standardize MDR

Data MartUse the data Batch

Receives data from warehouse M2

Types of Systems

Transactional Warehouse Data Mart

Real-Time Periodic Updates

Types of Systems

• Quality– Real time systems are harder to fix– Must often stop the real-time mission to

correct known errors– Usually too big a price to pay for a

business

Cleaning is usually designed into warehouse functions

Types of Systems

• Using the data– Transactional systems are not generally

designed for analysis purposes– Data Warehouses are generally used by

skilled programmers with significant data expertise

– Data Marts are designed for analytical purposes generally, intended to be easy to use

Types of Systems

• MHS operates a complex set of systems to meet different business requirements

• New systems are generally built with routine systems models (transactional, warehouse, mart)

• Older systems aren’t that way!

Types of Systems

• MHS Data Repository– MHS Business Data Warehouse– Receives data from transactional systems

and other data marts– Processes, cleans, archives– Limited access

• MDR provides data to most other corporate business systems– Services and External Entities as well

Types of Systems

• The “M2”:– Data Mart– Contains a subset of MDR data– Contains many data files from MTFs– Significant functional involvement in

development and maintenance– 1100+ users at all levels in the MHS– Ad-hoc querying or “Corporate Reports”

Types of Systems

• The “M2”:– M2 contains a family of corporate reports

designed for data quality enhancements– Reports are written to resemble DQ metrics

wherever possible– Additional reports about important data

problems are also included– Report documentation is provided in your

handouts

Types of Systems

• The “M2”:– Most DQ reports contain data for all MTFs– Some have prompted filters (you tell M2 your

DMIS ID and hit run)– Reports will be updated as data files are updated– Can also be modified and/or updated by the M2

user– Examples use the reports!– Help Desk info provided in previous presentation

Remainder of Presentation

• Description of systems• Output data files• DQ Issues or Considerations• Use of M2 Corporate Reports to aid

in DQ Management at the MTF

The MTF Data Environment

MTF Data Environment

• Many systems at each MTF– Service specific systems– TMA Systems

• Service Systems provide data to some TMA Systems– Personnel– Financial

MTF Data World!• Composite Health Care System (CHCS)

- Primary operational system supporting MTFs

- Hospital Management / Administration

- Clinical Coding

- Communicates with DEERS, other MTF-level systems

- 100+ separate systems with no common database

- Extremely important to MTF operations…

CHCSData captured as a part of doing

businessAppointing

Registration

Admitting

Billing (Inpat)

Ordering Ancillaries

Utilization Review

Workload Capture

Etc……

Real time data store about health care delivery, revenues, providers, patients, clinics and wards, etc……

LOCAL DATA ONLY!

MTF Data World!• Composite Health Care System (CHCS)

- Legacy Status

- Much of the functionality of CHCS is being built in other systems

- Enrollment Processing, Primary Care Manager Assignments now done with DEERS Online Enrollment System (DOES)

- Deployment of AHLTA is underway to replace the ambulatory data module and enhance clinical data

- Referral, Appointing underway

% of Encounters Recorded Using AHLTA

0%

10%

20%

30%

40%

50%

60%

70%

80%

A

F

N

CHCS is the local “Hub”

CHCSDEERS

Financial

AHLTA

Pharmacy

Billing

CHCS Files and Tables•CHCS contains many tables and files (i.e. patient, appointment, enrollment, etc…)

– Users can query CHCS, but it isn’t easy!

– CHCS is not generally available centrally

– CHCS databases only contain records for the local area.

– CHCS provides many standardized extracts to external systems

CHCS Data Quality

• Several CHCS extracts are important to the DQ program

• Important to care for data in CHCS

– MTF will run smoother!

– All other systems that receive CHCS data will benefit

• CHCS and Data Quality

CHCS Configuration Management

• Configuration Management– Version control– Applies to software and code sets– Avoid problems by ensuring that you

are running the correct versions– If not, problems can occur!

CHCS and Data Quality

• Software Maintenance Updates– Changes in CHCS can affect all

systems that receive data from it– Software testing assumes users

have most recent versions operating– Sites with older software can get

“surprised” with interface problems

Symptoms of CM Problems

• Whole “types” of information missing from a record

–Enrollment data

–Provider data

–Patient data

• May suggest an interface problem

• Check with affected systems administrators

Symptoms of CM Problems

•Large numbers of “rejections” of data being sent from one system to another

- If one systems receives a code from another that it isn’t expecting, it may reject records

- Some systems allow “hand-jamming” of data when this happens!

- Check with S.A.

Avoiding CM Problems

•Follow Service guidance for updates to software and tables

•Plan for releases of new software; coordinate among all systems affected

•Document procedures

•Monitor implementation

•Use available resources (Help Desk, Service POCs, Peers, Interface Control Documents)


• Provider Tables– Pseudo provider IDs (anyprov, pttech,

erdoc, etc)– Duplicate providers– 910+ series providers (identify a

clinic, but not the provider

• PCM Tables


• Duplicate Records in Patient Registry– Records will be very similar, but not

exactly the same– Will cause improper exchange of data

between systems, etc..– CHCS has utilities to clean up duplicate

records– Plan to run routinely. Monitor. Record.

CHCS Data Products in the MDR

Name Description Acronym

Standard Inpatient Data Record

Inpatient Hospital Records

SIDR

Standard Ambulatory Data Records

Outpatient visit, t-con or inpatient rounds records

SADR

Appointment Appointment records for outpatient visits

None!

Ancillary Lab and Rad and Rx

Procedure records None!

Worldwide Workload Report

Summary workload data

WWRHL-7 also provided to EI/DS, but not in MDR due to quality concerns


• Records about hospital stays– MTF care (generally)– Created from data collected during the stay,

and from existing files/tables in CHCS– Forwarded by MTFs to Service and TMA– Processed in MHS Data Repository and sent to

M2 for use.– Very important data file. Focus of several DQ

Checklist Items


• Information on the SIDR– Patient Identifier and Demographics– Sponsor Information– Diagnosis and Procedure Codes– Admission & Disposition Dates, LOS– Encoder/Grouper DRG– Enrollment Information from DEERS check at

time of admission– Administrative data, etc…


• MDR Processing of SIDR – Person identification standardization– Application of DEERS attributes (including

application of retroactive changes) & GWOT data– DRG Grouping– Weighting and Costing– Encoder/Grouper DRG– Additional field derivations– Application of update records– Preparation of data for M2


Important Uses – Disease Management, Case Management– Prospective Payment System and Business

Plans– Balanced Scorecard– Medicare Eligible Retiree Healthcare Fund– Guard/Reserve GWOT Funding– Venture Capital, Resource Sharing– Etc…..

Important Data

Key Data Elements Why

Patient ID DEERS App, Disease & Case Mgmt, MERHCF, GWOT, PPS, Balanced Score Card, Billing

Patient Category Code

Assignment of Beneficiary Category, Billing

Diagnosis Codes & Procedure Codes

DRG assignment, RWPs, identification of records for certain conditions or procedures, billing

Admission and Discharge Dates

Length of stay, RWPs, billing

Work Centers Application of Costs, MERHCF, GWOT


Data Issues• Completeness or Timeliness: completed

records due 30 days after disposition– IMC Checklist Item– Standard Report available comparing SIDRs

reported for each MTF to Worldwide Workload Dispositions

– Should be 100% except for most recent months– Check M2 data status table for timing to interpret

properly

Compliance and Timeliness Report

tma.rm.dq.fyxx.dcip.rept.comp: – Updated once per month– Within a few days of M2 update– Can be updated by users also

MTF & Attributes

FY & FM

SIDR Dispositions

WWR Dispositions

% Complete

Inpatient Reporting Compliance

30 Day StandardSIDR Completeness by Branch of Service

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

A

F

N

Use Report to Identify Holes

MTF X -- Number of Dispositions by Month

0

20

40

60

80

100

120

140

160

180

Oct-04 Nov-04 Dec-04 Jan-05 Feb-05 Mar-05 Apr-05 May-05 Jun-05 Jul-05 Aug-05 Sep-05

30 Day Reporting Compliance?MTF X -- Number of SIDRs Completed by Month

0

20

40

60

80

100

120

140

160

180


These probably should

look like the

others!

Clinical Coding

• Records in M2 are available at detailed level– One record per stay

• Record identifiers are shared with CHCS– Tmt DMISID + Patient Register Number– PRN is called Record ID in M2– Allows MTF staff to find records that

need fixing!

Ungroupable DRG Report & Examples

• One sign of a poorly coded record (usually) is an ungroupable DRG! (469 & 470)

• Ungroupable DRGs are significant because they are not counted for most purposes!

MTF & Attributes

FY & FM

Patient Register Number

Bed Days

Estimated Full Cost

After logging into M2

Users go to the path

File

Retrieve from

Corporate Documents

Box pops up with all reports.

Move cursor to report of interest and click retrieve

Select:

tma.rm.dq.fy05.dcip.ungroupable.drg

Includes all MTFs. To limit to your MTF, use “SLICE AND DICE

The “L” taking a nap!

Slice and Dice Panel

Rearrange

Sort

Filter

Totals

Etc…

Etc..

Rearrange Data to summarize by fiscal year, limit to one DMISID

After selecting one DMISID you see a filter on the data element.

Note the calculator which will give a grand total.

This MTF had an estimated 116K in ungroupable DRGs.

This care earns nothing under PPS, TRICARE for Life or GWOT Funds

(This is one record where the coder didn’t list the weight of the baby!)

Drill down to find the bad cases!

Back to slice and dice

Add “record ID” into the report

This is one case!

•The record ID is the CHCS Patient Registry Number.

•Can be used to pull up THIS case in CHCS.

•If you fix and resubmit, it will show up in the data!


Looking at Length of Stay– Query your MTF– Admission and Disposition Date– DRG– Not a standard report, but not hard

If you limit to long lengths of stay, you can easily find errors……

Probably mistyped either the admission or the disposition date.

This is a delivery with a length of stay greater than one year.

Record ID is the PRN


• What’s the RWP Impact on coding like that?• First, what’s an RWP?

– Basis of earnings for PPS, GWOT, TFL, etc…– Very important

• Depends on DRG and Length of Stay– Primarily!– DRG Weight: Relative hospital costliness of that

DRG compared with all others


• RWP = DRG Weight; if length of stay is “normal”– Otherwise: +/- credit depending on length of

stay

• In this case:– RWP should likely have been: 0.55– RWP was: 98.38

Standard Ambulatory Data Record

• Not really an ambulatory record!– Ambulatory Care (Office, ER, Same Day Surgery)– Inpatient Rounds– Telephone Consults

– MHS does not generally capture inpatient procedure provider records, unlike private sector

– (Hospital record is captured, but not a separate provider piece; causes problems with studying productivity and billing)

• Very important data file. Focus of several DQ Checklist Items


• Information on the SADR– Patient Identifier and Demographics– Sponsor Information– Diagnosis and CPT Procedure Codes, Clinic– Service Date– Type of Appt – Enrollment Information from DEERS check at

time of admission– Administrative data, etc…– Provider Specialty Code


• Major Pieces of Information not on the SADR– Units of Service and Modifiers associated with each

procedure code

– Collected in ADM or AHLTA– Not yet forwarded in the SADR– Leads to a system-wide understatement of

workload– Change request underway– All SADRs since OIB began will be reharvested


• MDR Processing of SADR – Due to lack of completeness of SADRs,

appointment records are used to enhance the SADR data file.

– For each kept appointment, if a SADR exists, it is used.

– If a SADR is not collected, then the appointment record is used to create an “inferred SADR”.

– When/if a SADR finally shows up, the inferred SADR is removed and the real SADR kept.


• MDR Processing of SADR

– Match to appointment records, include SADRs and kept appointments w/o a SADR

– Application of DEERS attributes (including application of retroactive changes) & GWOT data

– Weighting and Costing; including estimation on “inferred” records.

– Person identification standardization– Additional field derivations– Application of update records– Preparation of data for M2


Important Uses – Disease Management, Case Management– Prospective Payment System and Business

Plans– Balanced Scorecard– Medicare Eligible Retiree Healthcare Fund– Guard/Reserve GWOT Funding– Venture Capital, Resource Sharing– Etc…..

Important Data

Key Data Elements Why

Patient ID DEERS App, Disease & Case Mgmt, MERHCF, GWOT, PPS, Balanced Score Card, Billing

Patient Category Code

Assignment of Beneficiary Category, Billing

Diagnosis Codes & Procedure Codes

APG/APC assignment, RVUs, identification of records for certain conditions or procedures, billing

Provider ID & Specialty

RVU assignment, provider productivity, practice patterns, etc…

Work Centers Application of Costs, MERHCF, GWOT


Data Issues• Completeness or Timeliness: completed

records w/in 3 days for non APV, 15 for APV– IMC Checklist Item– Significant issue with SADR– Very large numbers of historical SADRs are

missing– Compliance has improved but is still an issue– New appointment records offer excellent

opportunities for managing compliance!


• Compliance– IMC Checklist Item– Two methods for monitoring compliance– Two Corporate Reports available for measuring

compliance– SADR:WWR Comparison– SADR:Appointment Comparison


tma.rm.dq.fy05.dcop.rep.comp.wwr: – Updated once per month– Within a few days of M2 WWR update– Can be updated by users also

MTF & Attributes

FY & FM

SADR Encounters

WWR Count Visits

Ratio of SADR: WWR


• Compliance– Imprecise match– WWR visits are a subset of SADR encounters– WWR includes only those visits that the local

MTF determines “count”– SADR includes all encounters– Metric should be “greater than 100%”

All Encounters:

N= 31 Million“Count Only

N= 29 Million

2 Million Non-Count Ambulatory

Visits!

MHS-wide SADR to WWR Ambulatory Reporting Compliance

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%


Greater than 100% complete --- Is this good or bad?

Built from corporate report in M2


tma.rm.dq.fy05.dcop.rep.comp.appt: – Updated once per month– Within a few days of M2 Appointment update– Can be updated by users also

MTF & Attributes

FY & FM

Captured SADRs

Inferred SADRs

% of SADRs captured


• Compliance– Record level match– Report is limited to ambulatory records, t-cons

and hearing conservation clinic.– More precise methodology– “Action report” for drill to appointment ID,

provider or clinic level– Be cautious with very recent data; check data

status table in M2 for timing info

Slice and Dice

Include year, month and percent complete to chart out compliance metric

MHS-wide SADR to Appointment Ambulatory Reporting Compliance

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

Oct-04

Nov-04

Dec-04

Jan-05

Feb-05

Mar-05

Apr-05

May-05

Jun-05

Jul-05 Aug-05

Sep-05

Less than 100% when compared with appointments

Swap out percent complete with number of encounters, to see how many are missing

Missing SADRs from FY05

0

20,000

40,000

60,000

80,000

100,000

120,000


Number of incomplete SADRS from FY05

Back to slice and dice to see which clinics are missing the most SADRs

ClinicMissing

SADRs% of Total

Missing

Primary Care 248,664 24%

Family Practice 232,662 23%

Pediatrics 66,930 6%

All Other Clinics 484,458 47%

Total Missing (05) 1,032,714 100%

Clinics with the most missing SADRS

Two MEPRS Codes make up ~ half of what’s missing!

Compliance Action Report

tma.rm.dq.fy05.dcop.rep.comp.actionrep: – Updated once per month– Within a few days of M2 Appointment update– Can be updated by users also

MTF

FY & FM

Provider ID & Clinic

Appointment ID

Missing Encounters

Lost PPS Earnings


• Action Report -- Compliance– “Record ID” is appointment ID; same as in CHCS,

ADM, AHLTA, etc..– Provider ID & MEPRS Code are from appointment

record– Number of encounter is “actual missing records”– PPS Earnings estimated by applying PPS rates to

estimated RVUs for the case (based on avg. RVUs in that clinic, SDS or not, and type of provider)

Will result in a list of missing records.

“Record ID” is the Appointment IEN. Can be used to retrieve records in the source system.

Sorted by descending PPS earnings – low hanging fruit….

Use provider ID to determine impact of lost earnings under PPS.

Sorted list of estimated financial impact of missing SADRs.

By provider ID

Include “Record ID” to assist in locating record that needs completing.

List of providers and their missing appointment IDs.


Clinical Coding – Very important; poor coding can have serious

consequences– Coding problems have been cited repeatedly

by auditors– Check for ungroupables– Evaluate coding with SADR in M2; can see

diagnosis and procedure codes.

Ungroupable APG Report

tma.rm.dq.fy05.dcop.ungroupable.apg : – Prompted report– You enter your DMISID and hit run!

MTF

FY & FM

Appointment ID

Number of Encounters

Full Cost

Review of coding practice using M2

• Record level data allows for detailed analysis of coding practice

• UBU Coding Guidelines published in TRICARE website

• Clinical coding is what drives RVU assignment– Policy changes– Staffing changes– Impacts of missing records -- no count really

does count. But not coded doesn’t count at all!

How are RVUs assigned?

• Done in the MDR• Match SADR to MHS Weight table

– Will soon be in M2• For each procedure, assign work RVU

from weight table; unless:– E&M code on the same record as a

significant procedure– Unspecified provider specialty (depends on

the RVU field)• Some RVU fields use slight

modifications to these rules.

Proc Code Description RVU

E&M 99203 Office Visit 1.34

1 92225 Ophthalmoscopy 0.38

2 92015 Determination of

Refraction 0.38

3 76519 Ultrasound 0.54

4

Simple RVUs for this record : 2.64

How are RVUs assigned?

• MHS Weight Table– Mostly contains CMS weights– Modified for unique MHS reporting of pre and

post operative visits– Some additions for things CMS doesn’t cover

• Units of Service is a critical missing data elements in RVU assignment.– Serves as a “multiplier” in RVU assignment

logic.– PT, Mental Health, Dermatology, others

•Separate records for pre-op, post-op and surg

– Private sector RVUs include the pre and post op work!

– MHS weight table modified so that the procedure record only gets the weight for the procedure; pre and post ops earn weight separately.

Typical MHS-coded same day surgery


Provider Information – Provider identifiers are only unique to each

CHCS Host– Provider Table in CHCS– Name, specialty, HIPAA taxonomy, etc.– Some historic problems with names &

specialties– Important for productivity analysis, billing,

provider profiling, etc.– 2 corporate reports in M2

Unspecified Provider Specialty

tma.rm.dq.fy05.dcop.unspecified.provspec – Updated once per month– Within a few days of M2 Appointment update– Can be updated by users also

MTF & Attributes

FY & FM

MEPRS Code

# w/ unspecified specialty

# w/o unspecified specialty

% unspecified specialty

Encounters with Unspecified Provider Specialty Code

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

Oct-04

Nov-04

Dec-04

Jan-05

Feb-05

Mar-05

Apr-05

May-05

Jun-05

Jul-05

Aug-05

Sep-05

A

F

N

•PPS announces future plans to discontinue crediting SADRs with unspecified provider specialties (910-999)

•SAIC patch written for CHCS

•Significant Improvements made in FY05


Invalid Provider IDs– “Catch-all” identifiers used in some clinics– ER Doc, PT tech, Card clinic, any provider, etc.– Usually not too difficult to find because these

IDs generally hold a large amount of workload

M2 report sorts RVUs by provider. Can review the list to see if any obvious problems appear.

Invalid Provider IDs

tma.rm.dq.fy05.dcop.invalid.provid – Updated once per month– Within a few days of M2 Appointment update– Can be updated by users also

MTF & Attributes

FY & FM

Provider ID

RVUs

Invalid Provider IDs

• Report is a list of workload by provider and MTF• Sort by descending workload• Are the most productive providers reasonable?

– Are they real people?– You CANNOT bill for “ER DOC”……… Lost TPOCS

billings.

• Clean out provider table to remove these IDs as options. – Discuss with clinic/appointing staff to ensure access is

not harmed, though.

•Provider ID “NUROBS”

•Almost 3 times the RVUs of any other provider at that MTF

•Is this a real provider? Or perhaps an observation unit?

Other Important MTF Data

MEPRSPharmacy

Lab and Rad


• MEPRS: – Financial & FTE Reporting– Covered later in the course

• Lab and Rad Data:– One record per outpatient procedure– FY2005+– New data source. Only recently

available.– More to come as data matures…


• Pharmacy Data Transaction Service (PDTS): – Drug Utilization Review system– Real-time communications between

PDTS and CHCS– CHCS sends prescription info & PDTS

responds with DUR advice– Data files from PDTS contain data

that originates in CHCS

•Rx ordered at MTF in CHCS

•Information stored in Rx file locally

•Real time DUR Check

•PDTS receives DUR requests from MTFs (and TMOP and Trrx)

•Checks against rx history files to determine whether it’s okay to dispense

•Responds back to Pharmacies with “go” or “no go”

Source for MEPRS

Source for MDR/M2 PDTS Data Table

Pharmacy and the MHS

• Growing Demand– New expensive drugs– Aging population– Influx of new beneficiaries

• Startling inflation in pharmaceutical industry

• #2 product line in MHS……– Extremely important management issue

Pharmacy Data Transaction Service

• MTF Pharmacy data from PDTS is used for many important purposes– Medicare Accrual Fund, GWOT

funding– PPS does not use pharmacy currently.

• Very significant issues in cost data from CHCS on individual dispensing records.


• Pre-defined Units and Drug Codes don’t always go together.– Ex. Birth control pills dispensed in a

pack of 28. Is this a unit of “1” or “28”?– Rounding issues and bulk issues

• Local pricing is not reliable– PDTS re-prices everything unless the

MTF has set the “local pricing flag” to yes.

Most Expensive Drug Report

tma.rm.dq.fy05.rx.mostexp.drugs – Updated once per month– Toward the end of the month– Can be updated by users also

MTF & Attributes

NDC & Name

Cost

Days Supply

Cost per Day

This MTF has it’s local pricing flag on.

These prices came from MTF

Asthma medication is not that expensive!

Problems with pre-defined units and NDC.


• Pre-defined Units and Drug Codes don’t always go together.– Ex. Birth control pills dispensed in a

pack of 28. Is this a unit of “1” or “28”?– Rounding issues and bulk issues

• Local pricing is not reliable– PDTS re-prices everything unless the

MTF has set the “local pricing flag” to yes.

Wrap Up

• M2 is a useful part of a data quality manager’s tool-kit– Provides a good source for record level data– Uses the same record identifiers as the source

systems, to allow things to get fixed faster– Contains lots of different data files from the MTF– Corporate Reports are easy to use.

• Real time tools are still helpful and needed

Wrap Up

• WISDOM Course for training– Need more than software training– Most important to understand the underlying

data

• For M2 accounts:– 1-800-600-9332

• Be sure to inquire about other standardized reports and such when other speakers present!

data quality tips and tricks wendy funk kennell and associates [email protected]

Documents

databased funding initiatives

rwps slide

m2 slide

good mtf data

clinical work slide

data quality tips

datadriven enterprise

common mhs data problems