13 september 2012 data quality management control program service-level breakout session...
TRANSCRIPT
13 September 2012
Data Quality Management Control Program
Service-Level Breakout Session
UNCLASSIFIED
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Overview
• Regulatory Guidance• Program Management• Organizational Factors• System Inputs, Processes, and Outputs
– CHCS– ADM– MEPRS/EAS– TPOCS– MEWACS
• Patient Records Accountability
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13 Sept 2012Unclassified
Overview
• Coding Audits– Sampling Size and Techniques– Inpatient Records– Outpatient Records
• Workload Comparison Regulatory Guidance• System Security• System Design, Development, Operations, and Education and
Training
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13 Sept 2012Unclassified
Regulatory Guidance
DODI 6040.40Military Health System Data Quality Management Control Procedures
Department of Defense
INSTRUCTION
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13 Sept 2012Unclassified
Regulatory Guidance
DODD 6040.41Medical Records Retention and Coding at Military Treatment Facilities
Department of Defense
DIRECTIVE
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13 Sept 2012Unclassified
Regulatory Guidance
DODD 6040.42Medical Encounter and Coding at Military Treatment Facilities
Department of Defense
DIRECTIVE
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13 Sept 2012Unclassified
Regulatory Guidance
DODD 6040.43Custody and Control of Outpatient Medical Records
Department of Defense
DIRECTIVE
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13 Sept 2012Unclassified
• Data Quality Manager• Data Quality Assurance Team• Intermediate Command DQ Manager• Service Data Quality Manager• DQMC Review List• Commanders Monthly Data Quality Statement (internet
based)
Program Management
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• Composite Health Care System (CHCS)• Armed Forces Health Longitudinal Technology Application
(AHLTA)• Ambulatory Data Module (ADM)• Medical Expense and Performance Reporting System
(MEPRS) / Expense Assignment System (EAS)• MEPRS Early Warning and Control System (MEWACS)• Defense Medical Human Resources System –Internet
(DMHRS-i)• Third Party Outpatient Collection System (TPOCS)
System Inputs, Processes, and Outputs
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• Written Procedures• Current Versions• Upgrades & Updates• Rejected Records• End of Day Processing
– Percentage of Clinics– Percentage of Appointments
• Timely Coding Completion
Data InputMEPRS/EAS, ADM, CHCS, TPOCS
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13 Sept 2012Unclassified
• Q. 1. What percentage of appointments was closed in meeting your “End of Day” processing requirements, “Every appointment – Every day?” (B.5.a)
Commander’sData Quality Statement
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13 Sept 2012Unclassified
• Q. 2. In accordance with legal and medical coding practices, have all of the following occurred:
– a) What percentage of Outpatient Encounters, other than APVs, have been coded within 3 business days of the encounter? (B.6.a)
– b) What percentage of APVs have been coded within 15 calendar days of the encounter? (B.6.b)
– c) What percentage of Inpatient records have been coded within 30 calendar days after discharge? (B.6.c)
Commander’sData Quality Statement
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13 Sept 2012Unclassified
• EAS– Financial Reconciliation – Inpatient and Outpatient Workload Reconciliations– MEWACS Review– Timely Data Transmittal– Workload Comparison
Data OutputMEPRS/EAS, ADM, CHCS, TPOCS
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13 Sept 2012Unclassified
• Q. 3. Medical Expense and Performance Reporting System for Fixed Military Medical and Dental Treatment Facilities Manual (MEPRS Manual) DoD6010-13-M, dated April 7, 2008, paragraph C3.3.4, requires report reconciliation (C.1.a,c,e,f)
– a) Was the monthly MEPRS/EAS financial reconciliation completed, validated and approved by the MTF Resource Manager (i.e. Navy/Army Comptroller or Air Force Budget Officer/Analysts) prior to MEPRS monthly transmission?
Commander’sData Quality Statement
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13 Sept 2012Unclassified
• Q. 3. Medical Expense and Performance Reporting System for Fixed Military Medical and Dental Treatment Facilities Manual (MEPRS Manual) DoD6010-13-M, dated April 7, 2008, paragraph C3.3.4, requires report reconciliation (C.1.)
– b) Were the data load status, outlier and allocation tabs in the MEWACS document reviewed and explanations provided in the comments section for flagged data anomalies?
Commander’sData Quality Statement
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13 Sept 2012Unclassified
• Q. 3. Medical Expense and Performance Reporting System for Fixed Military Medical and Dental Treatment Facilities Manual (MEPRS Manual) DoD6010-13-M, dated April 7, 2008, paragraph C3.3.4, requires report reconciliation (C.1.)
– c) For DMHRS-i, what is the percentage of submitted timecards by the suspense date?
– d) For DMHRS-I, what is the percentage of approved timecards by the suspense date?
Commander’sData Quality Statement
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• CHCS– Duplicate Registration– Timely Data Transmittal
• Standard Inpatient Data Record (SIDR) • Worldwide Workload Report
– Inpatient Records• Accountability• Documentation• Coding• SIDRs completed (in a “D” status)
– Workload Comparison
Data OutputMEPRS/EAS, ADM, CHCS, TPOCS
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• Q. 4. Compliance with TMA or Service-Level guidance for timely submission of data (C.3.a,b,c,d).
– a) MEPRS/EAS (45 calendar days)
Commander’sData Quality Statement
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13 Sept 2012Unclassified
• Q. 4. Compliance with TMA or Service-Level guidance for timely submission of data (C.3.).
– b) SIDR/CHCS (5th and 20th calendar day of the following month)
Commander’sData Quality Statement
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• Q. 4. Compliance with TMA or Service-Level guidance for timely submission of data (C.3).
– c) CAPER (ADM) - daily
Number of successful daily transmissions /
Number of days in the month.
Commander’sData Quality Statement
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Commander’sData Quality Statement
• Q. 4. Compliance with TMA or Service-Level guidance for timely submission of data (C.3).
– d) Daily Outpatient Workload Detail Report (DOWDR) or Daily Patient Appointment Files – daily transmissions.
Number of successful daily transmissions /Number of days in the month.
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13 Sept 2012Unclassified
Data Output
• A minimum of 30 records/encounters should be pulled randomly from the entire population of MTF for data month.
• A random audit of 30 records per MTF will provide a statistical confidence level of 90%, with a confidence interval/sampling error range of plus or minus 15%.
• The PASBA is considering the development of pull-list for auditing purposes, for inpatients and APVs. (The PASBA already creates a monthly pull-list for auditing of DD Form 2569s for inpatients, outpatients and APVs).
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• Coding– DRG Codes – Related Data Elements (C.5)
• All Diagnoses• Any Procedures• Sex• Age• Discharge/Disposition
• Percentage of SIDRs Completed (D-Status)
Data OutputInpatient Coding
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13 Sept 2012Unclassified
• Q. 5. Outcome of quarterly *(monthly) inpatient coding audit: (C.5.c.f.g,h,).
– a) Percentage of inpatient medical records whose assigned
DRG Codes were correct?– Formula: Number of correct MS-DRG codes / total number of
MS-DRGs.
* Army will continue to require monthly inpatient coding audits.
Commander’sData Quality Statement
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13 Sept 2012Unclassified
• Q. 5. Outcome of quarterly * (monthly) inpatient coding audit: (C.5.c.f.g,h)
– b) Percentage of Inpatient Professional Services Rounds encounters E & M codes audited and deemed correct?
– Formula: Number of correct E&M codes / total number of E&M Codes.
* Army will continue to require monthly inpatient coding audits.
Commander’sData Quality Statement
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13 Sept 2012Unclassified
• Q. 5. Outcome of quarterly * (monthly) inpatient coding audit: (C.5.c.f.g,h,)
– c) Percentage of Inpatient Professional Services Rounds encounters ICD-9 codes audited and deemed correct?
– Formula: Number of correct ICD-9 codes / total number of ICD-9 codes.
* Army will continue to require monthly inpatient coding audits.
Commander’sData Quality Statement
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• Q. 5. Outcome of quarterly * (monthly) inpatient coding audit: (C.5.c.f.g,h,)
– d) Percentage of Inpatient Professional Services Rounds encounters CPT codes audited and deemed correct?
– Formula: Number of correct CPT codes / total number of CPT codes.
* Army will continue to require monthly inpatient coding audits.
Commander’sData Quality Statement
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13 Sept 2012Unclassified
• Q.6. Outcome of quarterly * (monthly) Outpatient Record audits. (c.6.a,b,c,d)
– a) Is adequate documentation of the encounter selected to be audited available? Documentation includes documentation in medical record, loose (hard copy) documentation or an electronic record of the encounter in AHLTA? (Denominator equals sample size.)
– Formula: Number of adequately documented encounters available / number of requested encounters.
* Army will continue to require monthly outpatient coding audits.
Commander’sData Quality Statement
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13 Sept 2012Unclassified
• Q. 6. Outcome of quarterly * (monthly) Outpatient Record audits.
– 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.) – Formula: Number of correct ___ codes / total number of ___
codes.
* Army will continue to require monthly outpatient coding audits.
Commander’sData Quality Statement
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13 Sept 2012Unclassified
• Question 7 Outcome of quarterly * (monthly) Ambulatory Procedure Visits (C.7.a,b,c)
– 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.) – Formula: Number of correct ___ codes / total number of ___
codes.
* Army will continue to require monthly APV coding audits.
Commander’sData Quality Statement
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Commander’sData Quality Statement
• Question 8. DD-2569 forms. (C.8.a,b,c,d,e,f)
• Inpatient dispositions:– a) What percentage of completed and current (signed within the past 12 months) DD Form 2569s (TPC Insurance Info) is available for review?– Formula: Number of complete and current DD 2569s / number of non-active duty records audited.
–b) What percentage of available, current and completed DD Form 2569s is verified to be correct in the Patient Insurance Information (PII) module in CHCS?– Formula: Number of correct entries in PII module / number of available, current and complete DD Form 2569s.
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Commander’sData Quality Statement
• Question 8. DD-2569 forms. (C.8.a,b,c,d,e,f)
• Outpatient encounters:– c) What percentage of completed and current (signed within the past 12 months) DD Form 2569s (TPC Insurance Info) is available for review?– Formula: Number of complete and current DD 2569s / number of non-active duty records audited.
– d) What percentage of available, current and complete DD form 2569s is verified to be correct in the Patient Insurance Information (PII) Module in CHCS?– Formula: Number of correct entries in PII module / number of available, current and complete DD Form 2569s.
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Commander’sData Quality Statement
• Question 8. DD-2569 forms. (C.8.a,b,c,d,e,f)
• APVs:– e) What percentage of completed and current (signed within the past 12 months) DD Form 2569s (TPC Insurance Info) is available for review?– Formula: Number of complete and current DD 2569s / number of non-active duty records audited.
– f) What percentage of available, current and complete DD form 2569s is verified to be correct in the Patient Insurance Information (PII) Module in CHCS?– Formula: Number of correct entries in PII module / number of available, current and complete DD Form 2569s.
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13 Sept 2012Unclassified
• Q. 9. Comparison of reported workload data (C.9).– a) # of CAPER Encounters / number of kept appointments.– b) # of MEPRS Dispositions / # of SIDR “D” and “E” status.– c) # of MEPRS Visits / # of Kept Appointments (count only) – d) # of Inpatient Professional Services Rounds CAPER
encounters (A*** CAPERs) / # of Total Bed Days + Dispositions (from EAS)
Commander’sData Quality Statement
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• Q.9a CAPER Visits / Number of Kept Appointments (DOWDR)
– Should have an equal number of visits.– Encounters – Omit Appt. Status of “No-Shows,” “Canceled,” and
Disposition Code “Left Without Being Seen”.– Encounters – Include Appt. Status “TelCon” and “Occ-Svc”– Only CAPER records marked with an Appt. Status of “C”
(complete) are to be included.
Data OutputWorkload Comparison
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13 Sept 2012Unclassified
• Q.9b MEPRS Dispositions / Number of SIDR “D” and “E” status dispositions
– Should have an equal number.– MEPRS Dispositions will come from EAS.– Only SIDRs With a Disposition of Status of “D” (Completed)
and “E” (Disposition) are to be included– SIDRs – Exclude Carded for Record Only (CRO) and Absent
Sick Records.
Data OutputWorkload Comparison
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13 Sept 2012Unclassified
• Q. 9c MEPRS Visits / Number of Kept Appointments (count).
– Should have an equal number.– Include MEPRS Functional Cost Code B** (Outpatient) and
FBN (Hearing Conservation)– Include APVs.– Kept appointments are count only and come from DOWDR.
Data OutputWorkload Comparison
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13 Sept 2012Unclassified
• Q. 9d Inpatient Professional Services Rounds CAPER encounters (A*** CAPERs) / # Total Bed Days + Dispositions from EAS.
– Should have an equal number.– IPSRs can be identified in CAPER files with a Functional Cost
Code of A***.
Note: FY13 Goal is 95%.
Data OutputWorkload Comparison
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13 Sept 2012Unclassified
• Q.10. Use CHCS during the data month to identify potential duplicate patient registration (C.2a)
– For CHCS/AHLTA hosts only, what was the number of potential duplicate patient registration in the data month for all MTFs under the host? List the DMIS IDs of the MTFs included in the comments section.
Commander’sData Quality Statement
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• Q.11. Provide the number of incomplete and
non-transmitted SIDRs for the month. (F.1)
Note: This question on the DQ Statement is only a requirement for Army sites and will not be reported to TMA.
Commander’sData Quality Statement
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13 Sept 2012Unclassified
• Q.12.a. Provide the number of loose forms/documents/papers that are currently waiting to be filed, either electronically or in the hard-copy medical record.
Note: This question on the DQ Statement is only a requirement for Army sites and will not be reported to TMA.
Commander’sData Quality Statement
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13 Sept 2012Unclassified
• Q.12.b. Provide the number of loose forms/documents/papers that are currently waiting to be filed, either electronically or in the hard-copy medical record, 30 days after an active duty soldier has retired or separated from the service.
Note: This question on the DQ Statement is only a requirement for Army sites and will not be reported to TMA.
Commander’sData Quality Statement
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13 Sept 2012Unclassified
• Q. 13. I am aware of data quality issues identified by the completed Data Quality Statement and the Data Quality Review List and when needed, have incorporated monitoring mechanisms and have taken corrective actions to improve the data from my facility.
Commander’sData Quality Statement
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13 Sept 2012Unclassified
• Are there internal controls and procedures in place to approve and manage assignment of security key privileges?
• Have all security key holders been identified and their need for security key privileges validated by the CIO or designee?
Security
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• System Administrator Appointed In Writing for Each System• Training and Education Procedures and Documentation• System Change Request Process• System Incident Report• Routine Maintenance• Points of Contact for Equipment Failure Issues• Contingency Plans• Incident tickets
45
System Design, Operations, and Education/Training
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Data Quality Measures
Timely completion of outpatient workload
• Approximately 60-65% completed on same day as encounter
• Use ADM Compliance report to track completion of workload
• Timely completion is not dependent on coder staffing
• Develop AIMS forms to assist provider with frequently used codes
• Monitor clinics and/or providers which are least compliant
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Data Quality Measures
Admin Closed appointments
• When to use:• Training and testing purposes• Duplicate encounters• Appointment created in error• No actual interaction with patient
• When not to use:• Incomplete documentation• No-Show or cancelled appointment• Passage of time
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Data Quality Measures
Collection of Other Health Insurance
• Consistent and on-going training of staff• SOPs• Uniform Business Office to conduct training
• Educate patients• Posters within clinics and MTF• News articles • Pamphlets addressing most common questions
• Identification of patients• Insurance cards issued by MTF• Electronic DD Form 2569• OHI Discovery contracts
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Provider Aggregate (PA) RVU
• Both PPS and PBAM will use Provider Aggregate (PA) RVU for FY12
– Nurses and Techs (Skill Types 3 and 4) will receive credit only for specific CPT/HCPCS codes
– Multiple Provider Discounting– Multiple Procedure Discounting– Modifier Impact– Procedure Clean-up– No credit for J, K, L HCPCS codes
• Targets adjusted for both PPS and PBAM to account for differences
• Enhanced RVU still appropriate for cost comparisons to purchased care
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Outpatients, within 3 Business Days
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APVs, within 15 Calendar Days
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Inpatients, within 30 Days of Discharge
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Outpatients, E&M Coding
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Outpatients, ICD-9 Coding
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Outpatients, CPT Coding
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Outpatients, DD Form 2569 (OHI)
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Inpatients, DD Form 2569 (OHI)
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APVs, DD Form 2569 (OHI)
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Mission
To deliver actionable analytics, applications and coding services in order to optimize clinical outcomes, data quality and business operations. We provide customer-focused products and expertise to strengthen decision-making at all levels of the MHS.
Vision
The MHS leader in the transformation of clinical and business operations through optimization of decision making tools and processes
Mission and Vision
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• The collection of health statistics began during the Revolutionary War.
• The first Surgeon General’s Report was printed in 1822 and was published annually until 1942.
• In 1942 the Medical Statistics Agency was created to maintain statistics relating to all theaters of war, and continued for the next 30 years.
• In 1970 the agency was renamed the Patient Administration and Biostatistics Section, under Plans, Supply and Operations Directorate, OTSG.
• In 1973 the AMEDD was reorganized to create the U.S. Army Health Services Data System Agency, and the PA&B Section was placed under this agency.
• In 1974 there was another reorganization within the Health Services Command (HSC), which later became the U.S. Army Medical Command (MEDCOM) at Ft. Sam Houston, Texas.
• In 1977, another reorganization took place and the Patient Administration Systems and Biostatics Activity (PAS&BA) was created.
• In 1989 the PAS&BA acronym was changed to PASBA.
• Since 1989 the PASBA has been re-aligned under several different activities and in
2009 was aligned under the Program Analysis and Evaluation Directorate, Office of the Surgeon General.
PASBA
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To deliver actionable analytics, applications and coding services in order to optimize
clinical outcomes, data quality and business operations.
We provide customer-focused products and expertise to strengthen decision-making
at all levels of the MHS.
Data Quality
HIM/Coding
Data Analysis
Data Management
Patient Administration Policy
Ana
lysi
s, R
epor
ting
& C
onsu
lting
PASBA Mission
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Data Quality Impact
Impacts:
• Patient Care
• Budgeting & Resources
• Planning & Forecasting
• Decision Support
• Research
MEPRS, etc, etc.
DHMRSi
Documentation & Coding
• What does your data say about you, your patient, your clinic,…?
• Accurate, timely, consistent, & complete
• DQMCP– TMA directed– Commander’s program– 33 measures– Central systems:
• ADM, AHLTA, CCE, CHCS, DHMRSi, Essentris, MEPRS
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PASBA Toolkit
Behavioral Health (BH) Enhanced Access to Care (EATC)
E&M / TCU Code Utilization
Code Auditing and Reporting Application (CARA)
- Non-Face-to-Face Service Code Utilization (TCU)
Coder Manager- Established Patient E&M Code Utilization (EMCU)
Coding Help Desk (CHD)Outpatient Record Transmission Tracking Tool (ORT3) metric
Clinical Operations metrics (ClinOps) Provider Productivity Application (PPA)
- Allied Health metric Warrior Transition Unit (WTU) metrics
- Body Mass Index (BMI) metric - WTU Access and Utilization Metric
- End of Day (EOD) Compliance metric
- WTU Enhanced Access to Care metric
- Inpatient Professional Service Rounds (IPSR) metric
- WTU Trending metric
- Inpatient Record Transmission Tracking Tool (IRT3) metric
Web Interface for Scanned Patient Records
- MAPR Data Quality Measures metricData Quality Management Control Program (DQMCP
- Provider Specialty metric Sexual Assault Response and Prevention Tracking Application (SARPTA)DART
- PDHA / PDHRA Chronic Pain, High Utilizer, Polypharmacy (CHUP)
• PABSA tools and metrics• 38+ metrics &
reports• Drillable• Exportable• PASBA data
warehouse • <=24 hrs old
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PASBA Homepage
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Coding Section
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Coding Section
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Online Applications
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CARA
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CARA
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Clinical Operations Metrics
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IRT3
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IRT3
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IRT3
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IRT3
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EOD
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EOD
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PASBA METRIC POCs:
E-Mail: [email protected]
METHODOLOGY
The End of Day (EOD) Processing Compliance Metric is intended to assist MTFs identify systematic problems and need for training of EOD standards. The data source for this metric is the PASBA Daily Outpatient Workload Detail Report (DOWDR) file, which is the appointment file transmitted daily by the CHCS Hosts. The emphasis of this metric is on EOD completed TIMELY (by end of business day) and CORRECTLY. The last updated record is assumed to reflect the most current information, therefore the correct one. This is important to mention as MTFs do not have the capability to check both conditions in their EOD compliance report. If an appointment was closed on time, but the information gathered from most current records indicates it was done incorrectly, it will be reported as noncompliant. The underlying assumption of this metric is that the DOWDR is transmitted daily and that the appointments closed out at EOD are extracted in the DOWDR no later than the day following the appointment. An exception is givento the Emergency Room which should have until 7 AM the next day to complete the EOD. All appointments with statuses other than "A" (Admin) or "O" (Occ-Svc) in "B***" and "FBN*" clinics are monitoredfor compliance with the "Every Appointment - Every Day" requirement. In addition "B***" and "FBN*" clinics are monitored for compliance with the "Every Clinic - Every Day" requirement. Records with appointment statuses of "T" (T-con) that are not countable are excluded.
During the PASBA DOWDR processing, the following key elements are captured, and enable us to monitor compliance:
a) the date when the record was first extracted by the CHCS host.b) the date when the record was first extracted with a populated provider ID and an appointment status other than "P" (Pending) or "B" (Booked - non MTF).c) appointment statuses on the initial record and the most current record.d) date when the appointment was made and the date of the appointment.
A record is flagged as NONCOMPLIANT if any of the following is true: a) it was first transmitted more than one day after the appointment date, or more than two days later for ER. Exception is given to "T-cons" for which a record is considered late only if it was transmitted for the first time more than one day after the appointment date or the date it was entered in the system, whichever is later. (an extra day is given to ER). b) it was extracted with a filled provider ID and an appointment status other than "Pending" or "Booked" more than one day after the appointment, or more than two days later for after hours services.
EOD Methodology
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EOD Methodology (Cont)
Exception is given to "T-cons" for which a record is considered late only if it was transmitted with an other than pending stauts more than one day after the appointment date or date it was entered in the system, whichever is later. (an extra day is given to ER). c) the most current record has a missing provider ID or an appointment status of "Pending" or "Booked". d) the appointment record was received with an appointment status of "Kept", "Walk-in", "Sick-call " before the appointment date. e) the date when the appointment was made indicates it was booked after the appointment date, except ER , "T-cons" and records with inpatient status. f) the most recent appointment status contradicts the initial appointment status. Exception is given to "T-cons" and to "Kept", "Sick-call" and "Walk-in" appointment statuses which may be interchanged in AHLTA or CHCS. The compliance with "Every Appointment - Every Day" is reported at the RMC, Parent, Child and Clinic level. The compliance with "Every Clinic - Every Day" is reported at the RMC and Parent MTF level. If a clinic didn't report any appointments for a particular day, it was considered closed for that particular day. OPEN CLINIC DAYS is the sum across all clinics of the number of days for which an appointment was found in the DOWDR. COMPLIANT CLINIC DAYS is the sum across all clinics of all dates with 100% EOD compliance. The reasons for noncompliance are summarized at the RMC, Parent, Child and Clinic level. The tables list the inverse orderin which each criteria is checked. Appointments that fail multiple criteria are reported under the last criteriathat would fail them. For example, if an appointment was closed late with an appointment status of "Kept", but the last record received indicates a status of "Cancelled", it will be reported as "Closed Late", not "Incorrect Initial Status", as that would be the last criteria that was checked. Aditional links include summaries of noncompliance reasons by last appointment status and of records which indicatethat the appointment statuses were changed; each at the respective levels mentioned above. In addition, for each day, a report by clinic and appointment date is provided with counts of compliant andnoncompliant appointments. Scale used: Green : >= 95% Amber: 90% - 94.99% Red : < 90% Because of the large file size, individual noncompliant records are provided in a separate workbook by Parent MTF.Users interested in those records should return to the PASBA website and open the accompanying workbook. Limitations: The methodology relies on the timely and correct transmission of the DOWDR file.
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EOD
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New vs Established Patient
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New vs Established Patient
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New vs Established Patient
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New vs Established Patient Methodology
Established Patient E&M Code (99211 -99215) Utilization Metric
PASBA METRIC POCs:Francie McQueeney: (210) 295-8922, DSN: 421
E-Mail: [email protected]
METHODOLOGY
This metric tracks the utilization of E&M codes 99211 -99215 for count visits of privileged providers in ‘B***’ or ‘FBN’ clinics. It is intended to assist MTFs in training and identifying potential workload loss due to the misuse ofthese codes. In particular it monitors 'new patient' vs. 'established patient' code usage. Definitions: NEW CODED AS ESTABLISHED is the number of codes in records of patients who were found to be new patients using the algorithm described below. ESTABLISHED CODED AS ESTABLISHED is the number of codes in records of patients who were found to be established patients using the algorithm described below. TOTAL RECORDS is the number of records with E&M of 99211-99215. Using the Standard Ambulatory Data Record (SADR) and the Daily Outpatient Workload Detail Report (DOWDR) the following steps were taken: a) Step 1. Extracted records with “Kept”, “Walk-in”, and “Sick-call” (except LWBS) appointment statuses in“B***”, “A***” or “FBN*” clinics of privileged providers. Excluded encounters with E&M code indicating the encounter was a “Non-Face-To-Face” service (E&M 99441-99444), IPSR (rounds) with an E&M of 99499 and no CPT. Additionaly 'BIA* ' and ‘BFF*’ clinics were excluded. MEPRS authorized substance abuse (BFF*) clinics are included.
b) Step 2. Obtained the count visit flag from the DOWDR and kept only the countable visit records and Inpatient Professional Services Rounds (IPSR). IPSRS were considered ‘countable visits’.
c) Step 3. Created an established patient flag by looking at all encounters and IPSR records within the previous 3 years (3 x 365 days) of each encounter. In creating this flag, all “A***” clinics were converted to “B***”.
The encounter was flagged as “Established” if, for the same patient, a previous encounter was found in the sameDMISID and MEPRS, and by a privileged provider (skill type 1 & 2) regardless of specialty OR in any DMISIDs belonging to the same PARENT by the same PROVIDER ID. Otherwise, the encounter was flagged as “New.” This is the interpretation of the coding guidelines for classifying new and established patients. “A new patient is one who has not received any professional services from the privileged provider or another privileged provider of the Slide 84 of 95
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New vs Established Patient Methodology
same specialty who belongs to the same group practice in the previous three years”.
(MHS Professional Services and Specialty Coding Guidelines, June 2010).
A patient will also be considered established also if he or she was seen by the same provider in the last 3 years.
We can only capture this looking at records by PROVIDER ID, which is unique only within a PARENT.
d) Step 4. Kept records with E&M 99211 – 99215. If a patient was found to be "New", the record
was flagged as "New Coded as Established".
e) Step 5. Calculated RVU LOSS by adding the Enhanced RVU difference between the value of the Established
Patient E&M code and the value of the New Patient E&M code. The assumption was that the correct E&M code
would be of the same level as the E&M code on the record (i.e. 99211 supposed to be 99201).
The dollar amounts loss was calculated by multiplying the number of RVUs by current amount amount used for PPS.
f) Step 6. Summarized records in the following monthly and rolling 12 months tables:
RMC
Parent MTF
Child MTF
Clinic
Provider ID* (for each MTF)
Miscoded records* (for each RMC)
Note*: monthly tables only.
The monthly tables include only the records of the report month, while rolling 12 months tables include records of
previous 12 months, including the month of the report. (i.e. Aug 2009 to July 2010 for July 2010 metric.)
Scale used:
Green : >= 95%
Amber: 90% - 94.99%
Red : < 90%
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New vs Established Patient
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ORT3
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ORT3
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ORT3
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ORT3 Methodology
Outpatient Record Transmission (ORT) Summary Report
PASBA METRIC POCs:
Vicki Vestal: (210) 295-8931, DSN: 421E-Mail: [email protected]
The ORT Summary is a monthly report of the outpatient records transmission. Methodology is the same as ORT3: only outpatient clinics ('B***' clinics, with the exception of 'B**0') and Hearing Conservation Clinics (FBN*) are included in this metric.
The data sources used to capture total records are the PASBA Standard Ambulatory Data Record (SADR) and the Daily Outpatient Workload Detail Report (DOWDR).
Appointments with statuses of 'kept', 'sick-call', 'walk-in' and 'pending' in the DOWDR are matched with SADR records regardless of appointment status by DMISID and appointment identification number (APPTIEN).Radiology records outside Interventional Radiology Clinics and telephone consults are excluded from the DOWDR. Each record is verified if it is in compliance with the PBAM transmission timeliness of 30 calendar days.
The report contains summaries at RMC, PARENT MTF, CHILD MTF, CLINIC and PROVIDER level for both report month, and rolling 12 months. The rolling 12 months reports include 12 month restrospectively starting with the month of the report. For each MTF a table at the provider level is provided separately.
The RVU loss is calculated using the Enhanced Total RVU extracted from M2 SADRs. The average RVU per encounter at the MEPRS level is imputed to the missing SADRs. The amount lost is calculated by multiplying the RVU loss with the amount as used by PPS. Each summary reports the number of completed SADRs, number of PBAM timely records, number of Data Quality Management Program Control Program (DQMCP) timely records, and the total number of DOWDR records that were tracked. For each category a percentage is calculated.
PBAM has a 30 days timeliness criteria, while DQMCP uses a 3 business days / 15 calendar days for non APV/APV records. Please consider that PBAM and DQMCP have different completion targets. PBAM = 99%. DQMCP = 95%.
The conditional formatting for SADR completion is done using the following scale: 0%-99.59% RED, 99.6% -99.99% AMBER, and 100% GREEN. This was based on the AMEDD completion rate at the time of the development of the report. RED = under AMEDD completion rate, AMBER = above, but not 100% complete. The conditional formatting for PBAM timeliness was done using the 99% PBAM target. RED = not met, GREEN = met.For DQMCP is done using the following scale: 0%-98.99% RED, 99.00% -94.99% AMBER, and 95.00% - 100% GREEN.
Limitations: The DOWDR captures the provider and/or clinic for which the appointment was booked, and may not always be the provider who saw the patient. This metric reports encounters under the provider and/or clinic captured in the DOWDR at the last transmission to PASBA. This should not be an issue if EOD is done correctly.
The numbers reported under DQMCP timeliness may not match those under the DQMCP program run by the DQ section because of the difference in filtering criteria applied to the SADR records before matching them to the DOWDR and/or new records being transmitted
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ORT3
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Data Quality Section, PASBA
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QUESTIONS?
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- Promote, Sustain and Enhance Soldier Health - Train, Develop and Equip a Medical Force that Supports Full Spectrum Operations - Deliver Leading Edge Health Services to Our Warriors and Military Family to Optimize Outcomes
For more information go to: https://ke2.army.mil/bscThis has been a dynamic, living document since 2001
America’s Premier Medical Team Saving Lives, Fostering Healthy and Resilient People, and Inspiring TrustArmy Medicine…Army Strong!
Maximize Value in Health Services
Effectively and efficiently provide the right care at the
right time to promote a healthy population and ready force.
Provide Global Operational Forces
Agile and adaptive medical teams ready to execute relevant,
responsive Health Services in any operational environment and in combination with any partnered
team.
Build the Team
A compelling place to serve and a preferred partner in leading joint interagency
health services.
Balance Innovation with Standardization
A culture of innovation which provides standardized solutions to support best practices and optimal
outcomes.
Optimize Communication and Knowledge Management
Leverage Communication to impart knowledge and build meaningful,
positive relationships.
Pat
ien
t/C
ust
om
er/
Sta
keh
old
er
CS 6.0 Inspire Trust in Army
Medicine
CS 4.0 Responsive Battlefield
Medical Force
CS 1.0 Improved Healthy and
Protected Families, Beneficiaries and
Army Civilians
CS 3.0 Improved
Healthy and Protected Warriors
CS 5.0 Improved
Patient and Customer
Satisfaction
IP 10.0 Optimize Medical
Readiness
IP 13.0 Build Relationships and Enhance Partnerships
LG 18.0 Improve
Training and Development
IP 11.0 Improve
Information Systems
CS 2.0 Optimized Care and
Transition of Wounded, Ill, and Injured Warriors
IP 12.0 Implement
Best Practices
IP 14.0 Improve
Internal and External
Communication
LG 20.0 Improve
Knowledge Management
LG 17.0 Improve
Recruiting and Retention of
AMEDD Personnel
Inte
rnal
Pro
cess
Lea
rnin
g
and
Gro
wth
LG 19.0 Promote and
Foster a Culture of Innovation
IP 8.0 Improve Quality,
Outcome-Focused Care and Services
IP 7.0 Maximize Physical and
Psychological Health Promotion
and Prevention
IP 9.0 Improve
Access and Continuity of
Care
IP 16.0 Synchronize
Army Medicine to Support
Army Stationing &
BRAC
R 21.0 Optimize
Resources and Value
R 22.0 Optimize Lifecycle
Management of Facilities and IT Infrastructure
R 23.0 Maximize Human Capital
EN
DS
ME
AN
SW
AY
S
Res
ou
rce
IP 15.0 Leverage Research,
Development and Acquisition
Fe
ed
ba
ck
Ad
jus
ts
Re
so
urc
ing
De
cis
ion
s
To deliver the Strategic
Processes...
That achieve our Strategic
Ends
We marshal our
Resources…
And enable
our People…
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