“Test Drive and “Tune-Up” for Maximum PerformanceCharlene Colon, Clinical Data Analyst

Womack Army Medical Center, Fort Bragg, NCAugust 2005

3

ObjectivesObjectives Support improvements in ADM and MEPRS Data

Quality by understanding data capture and performance measures in DoD Healthcare:- Identify differences between Visits as defined by MEPRS and

Encounters processed by ADM and CHCS II - Outline “Downstream Impacts” of key data elements that drive

Relative Value Units (RVU):• Primary Care Provider RVU/FTE calculations

• Prospective Payment System RVU calculations

- Share related CHCS II experiences - Present approaches to utilize the data to “Drive” improved

capture processes

4

Why the Focus? Why the Focus?

ADM is the clinical application that captures patient level data that enables the Military Health System (MHS) to benchmark coding practices, productivity and resource utilization to deliver health care services

ADM has transitioned from capturing “Ambulatory” services to also include “Professional” services for Inpatient to:- Standardize data collection methods- Compare workload and productivity- Forecast demand for services- Establish performance benchmarks- Identify trends and utilization- Calculate costs of services- Assess quality of services

5

Today’s TopicsToday’s Topics

Part 1 – Meet the “Pit Crew” Part 2 – CHCS ADM/MEPRS Chassis Part 3 – ADM “Test Drive” Part 4 – Performance “Tune Up” Part 5 – “Best of the Web”

Class Notes:

- Hyperlinks can only be accessed from Slideshow Mode- Imbedded Icons can only be accessed from Normal View

6

Meet the “Pit Crew”Meet the “Pit Crew” Credits and Appreciation to:

- DQ Team and Committee- DBO Business Systems Branch:

• (EAS IV/MEPRS, UCAPERS & ADM)

- Uniform Business Office- Clinical Operations

• Credentials, MCP Network Mgr & Health Systems Specialists

- Patient Administration- Clinic Managers - Information Management Division

• SAIC CHCS Site Manager & Systems Support • CHCS/CHCS II Training Staff

- Staff at Womack Army Medical Center, Fort Bragg, NC for their “Commitment to Quality” and the patients they serve.

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Basic FeaturesBasic Features Medical coding is captured by CHCS ADM

CHCS II encounter coding is “Written-Back” to CHCS ADM

Diagnosis Codes indicate the “Why the patient was seen”?

Procedure Codes identify the procedures/services provided:

- Current Procedural Terminology (CPT-4) Codes are established by the American Medical Association (AMA) and are updated annually

- RVU Weighted Values are established by the Centers for Medicare and Medicaid Services (CMS) and are updated annually. MHS updates specific RVU weights not addressed by CMS

Each patient encounter must contain at least one CPT (Evaluation & Management – E&M) Code

- E&M Coding for Ambulatory Procedure Visits (APVs) is now optional

Each day, all completed MTF encounters are electronically transmitted in the Standard Ambulatory Data Record (SADR) Extract

See Notes View for additional information

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VA

/MEPRS “500” Data Track/MEPRS “500” Data Track

MDRMDR

M2M2

WWR(Count Visits)

EAS IVEAS IV Count Visits & Eligible Count Visits & Eligible

EncountersEncounters

WAMWAMCount Visits & Count Visits & Raw ServicesRaw Services

MEQS

SIDR(Admissions)

SADR(Encounters)

TPOCSTPOCSBillableBillable

EncountersEncounters

PDTSPDTS

Worldwide Workload Report

Standard Ambulatory & Inpatient Data Record

MEPRS Executive Query System

CHCSCHCSCHCSCHCS EAS IVExtract

MHS Data Repository

MHS Mart

FHPArmy

AFNavy

Service Repositories

Pharmacy Data Transaction System

See Notes View for additional information

RVU Calculations

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CHCS/MEPRS ChassisCHCS/MEPRS ChassisStandard Tables

DMIS IDMedical SpecialtyHIPAA Taxonomy

SADR Edits

CHCS Site Defined MEPRS

Table

IBWA RNDS*Encounters

CHCS Site Defined Hospital

Location

Inpatient/Outpatient Visit Disposition

Status

CHCS Site Defined Provider

Table

Standard CPT/HCPCS Code &

Modifier Tables

Inpatient/Outpatient& APV Indicator

CHCS II Write-Back

Standard ICD-9 Code Table

CHCS (PAS/MCP) Business Rules

HIPAA Mandated Data Elements

Billing & SADR Extracts

See Back-Up Slides for additional information

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Visits vs EncountersVisits vs Encounters A “COUNT” VISIT requires 3 Key Elements to = Workload:

1. Interaction between patient and healthcare provider2. Independent judgment/assessment of patients condition, to accomplish one

or more of the following:• Examination• Diagnosis• Counseling• Treatment

3. Documentation An “ENCOUNTER” = Clinical Performance/Patient Interaction:

- Document reason for seeking care- Capture medical services provided - Establish Level of professional service and decision making

A Count Visit is Always an Encounter, but not all Encounters meet the definition of a Count Visit for Workload Reporting in EAS IV and Worldwide Workload (WWR)

DQMC Statement 8. a) - # SADR encounters / # WWR visits

Focus Shifting from Counting “Visits” to Measuring Work/Services ProvidedFocus Shifting from Counting “Visits” to Measuring Work/Services Provided

See Notes View for additional information

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Workload, Billing & RVUWorkload, Billing & RVU All Visits that that have been processed as “Completed” Encounters

in ADM/CHCS II will contribute to RVU calculations (based on CPT Codes with associated RVU weights)- Simple RVU includes all RVU weights for an encounter- Primary Care Provider RVU/FTE includes only RVU for Provider Skill Type 1

and 2 (Excludes Resident FTEs) for Primary Care FCCs- Prospective Payment System RVU requires a Direct Care Medical Specialty for

the Primary Provider* All Encounters are billable in TPOCS and MSA if performed in a

“B***”, “C***” or FBI* FCC (if they contain CPT Codes with Outpatient Itemized Billing (OIB) CMAC Rates). FBN* is billable only in MSA

Non-count Visits are included in total completed Encounters on many productivity reports that have important implications to all providers and clinics - including financial and staffing

Nurse/Tech services should be part of the Provider Visit – Enter Nurse/Tech as a Secondary Provider in ADM

Nurse/Tech procedures entered within the Provider Encounter will increase Primary Care Provider RVU/FTE/Day RVU

Non-count Visits are included in total completed Encounters on many productivity reports that have important implications to all providers and clinics - including financial and staffing

Nurse/Tech services should be part of the Provider Visit – Enter Nurse/Tech as a Secondary Provider in ADM

Nurse/Tech procedures entered within the Provider Encounter will increase Primary Care Provider RVU/FTE/Day RVU

* See Back-Up Slides for additional information

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Encounter ProcessingEncounter Processing ADM Encounter record created when Visit Status entered in CHCS

PAS/MCP is updated to KEPT or WALK-IN

Encounter “Checked-In” in ADM or CHCS II will update Visit Status to support workload reporting

Updates to Visit data such as HCP Seen, MEPRS Code or Count/Non-Count must still be made in CHCS PAS/MCP using the End of Day processing option

- CHCS PAS Supervisor Security Key required to update Visits > 7days

- Visits marked as OCC-SVC in CHCS PAS/MCP are not included in the ADM Compliance Report

Encounter coding can be entered by Clinic Staff, Provider or Coding Professional, based on services provided within the Clinic and documented in the Medical Record, for services provided within the Clinic by Clinic Staff

Encounter coding, disposition and administrative elements may be updated and ADM for CHCS II completed encounters

Updated encounters will be re-set to “PENDING” to be included in the next daily SADR batch extract file

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Inpatient VisitsInpatient VisitsWALK-IN SEARCH CRITERIA

Patient: HEALTHE,YOU FMP/SSN: 30/800-11-2255Clinic: QQQCHCSIITESTBRAGG CLINIC/WAMC ATC Category: Clinic Phone: Appt Type: ACUTE APPTProvider: QQQCHCSIITEST,BRAGGDOCA Duration: Detail Codes: Srv Type: Time Range: 0950 to 0950 Days of Week: Dates: 14 Feb 2005 to 14 Feb 2005------------------------------------------------------------------------

------------------------------------------------------------------------This is an inpatient.Are you from the attending service? No//

WALK-IN SEARCH CRITERIAPatient: HEALTHE,YOU FMP/SSN: 30/800-11-2255Clinic: QQQCHCSIITESTBRAGG CLINIC/WAMC ATC Category: Clinic Phone: Appt Type: ACUTE APPTProvider: QQQCHCSIITEST,BRAGGDOCA Duration: Detail Codes: Srv Type: Time Range: 0950 to 0950 Days of Week: Dates: 14 Feb 2005 to 14 Feb 2005------------------------------------------------------------------------

------------------------------------------------------------------------This is an inpatient.Are you from the attending service? No//

If the user accepts the default No//, a "B" Level FCC is assigned to the Visit. The Visit is a Count and reported in the WWR and Total Visits Data Set.

If the user enters “Y” (Yes), the current Admitting Clinical Service "A" Level FCC is assigned to the Visit . The Visit is a Non-Count and only reported in the CHCS PAS/MCP Monthly Statistical Report and upon coding completion included in the SADR.

CHCS II supports Inpatient Visit processing, but User Training is needed!!!

IBWA RNDS* are automatically assigned an “A” Level FCC of the “Current” Inpatient Clinical Service

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ADM Patient Encounter

ALMOND,ALAN P 20/123-49-1111 AGE:37y ────────────────────────────────────────────────────────────────────────────────Appt Date/Time : 21 Jun 2001@0921 Type: ACUT$ Status: WALK-IN Clinic: ACUTE CR MTF MEPRS : BGAA In/Outpatient: Outpatient APV: No Injury Related: No Appt Provider: AUSTIN,GILBERT M Pregnancy Related: No Appt HCP Role: 1 ATTENDINGAdditional Providers: No Disposition: RELEASED W/O LIMITATIONS =============================================================================== ICD-9 Dx Description Priority -------------------------------------------------------------------------------

------------------------------------------------------------------------------- Chief Complaint:

Help = HELP Exit = F10 File/Exit = DO INSERT OFF

ADM Patient Encounter

ALMOND,ALAN P 20/123-49-1111 AGE:37y ────────────────────────────────────────────────────────────────────────────────Appt Date/Time : 21 Jun 2001@0921 Type: ACUT$ Status: WALK-IN Clinic: ACUTE CR MTF MEPRS : BGAA In/Outpatient: Outpatient APV: No Injury Related: No Appt Provider: AUSTIN,GILBERT M Pregnancy Related: No Appt HCP Role: 1 ATTENDINGAdditional Providers: No Disposition: RELEASED W/O LIMITATIONS =============================================================================== ICD-9 Dx Description Priority -------------------------------------------------------------------------------

------------------------------------------------------------------------------- Chief Complaint:

Help = HELP Exit = F10 File/Exit = DO INSERT OFF

ADM Patient EncounterADM Patient Encounter

Source: CHCS ADM Training Database – Training PatientSee Notes View for additional information

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ADM Patient Encounter ALMOND,ALAN P 20/123-49-1111 AGE:37y ────────────────────────────────────────────────────────────────────────────────┌──────────────────────────────────────────────────────────────────────────────┐+ V70.5 1 V70.5 1 AVIATION EXAMINATION V70.5 2 V70.5 2 PERIODIC PREVENT EXAMINATION V70.5 3 V70.5 3 OCCUPATIONAL EXAMINATION V70.5 4 V70.5 4 PRE-DEPLOYMENT EXAMINATION V70.5 5 V70.5 5 DURING DEPLOYMENT EXAMINATION V70.5 6 V70.5 6 POST-DEPLOYMENT EXAMINATION V70.5 7 V70.5 7 FITNESS FOR DUTY EXAMINATION+ V70.5 8 V70.5 8 ACCESSION EXAMINATION└─Make choice = SELECT──────────────────────Exit = F10─────────────────────────┘ V70

------------------------------------------------------------------------------- Chief Complaint:

ADM Patient Encounter ALMOND,ALAN P 20/123-49-1111 AGE:37y ────────────────────────────────────────────────────────────────────────────────┌──────────────────────────────────────────────────────────────────────────────┐+ V70.5 1 V70.5 1 AVIATION EXAMINATION V70.5 2 V70.5 2 PERIODIC PREVENT EXAMINATION V70.5 3 V70.5 3 OCCUPATIONAL EXAMINATION V70.5 4 V70.5 4 PRE-DEPLOYMENT EXAMINATION V70.5 5 V70.5 5 DURING DEPLOYMENT EXAMINATION V70.5 6 V70.5 6 POST-DEPLOYMENT EXAMINATION V70.5 7 V70.5 7 FITNESS FOR DUTY EXAMINATION+ V70.5 8 V70.5 8 ACCESSION EXAMINATION└─Make choice = SELECT──────────────────────Exit = F10─────────────────────────┘ V70

------------------------------------------------------------------------------- Chief Complaint:

Code SearchCode Search

• Entered as Primary Diagnosis for Deployment Related “Yes” or “Maybe”• Either based on Patient Stated or Provider Assessment

17

ADM Patient Encounter ALMOND,ALAN P 20/123-49-1111 AGE:37y ────────────────────────────────────────────────────────────────────────────────Appt Date/Time : 21 Jun 2001@0921 Type: ACUT$ Status: WALK-IN Clinic: ACUTE CR MTF MEPRS : BGAA In/Outpatient: Outpatient APV: No Injury Related: No Appt Provider: AUSTIN,GILBERT M Pregnancy Related: No Appt HCP Role: 1 ATTENDINGAdditional Providers: No Disposition: RELEASED W/O LIMITATIONS=============================================================================== ICD-9 Dx Description Priority ------------------------------------------------------------------------------- V70.5 6 POST-DEPLOYMENT EXAMINATION 1 309.81 PROLONG POSTTRAUM STRESS 2 244.9 HYPOTHYROIDISM NOS 3 401.9 HYPERTENSION NOS 4 ------------------------------------------------------------------------------- Chief Complaint: V70.5 6

ADM Patient Encounter ALMOND,ALAN P 20/123-49-1111 AGE:37y ────────────────────────────────────────────────────────────────────────────────Appt Date/Time : 21 Jun 2001@0921 Type: ACUT$ Status: WALK-IN Clinic: ACUTE CR MTF MEPRS : BGAA In/Outpatient: Outpatient APV: No Injury Related: No Appt Provider: AUSTIN,GILBERT M Pregnancy Related: No Appt HCP Role: 1 ATTENDINGAdditional Providers: No Disposition: RELEASED W/O LIMITATIONS=============================================================================== ICD-9 Dx Description Priority ------------------------------------------------------------------------------- V70.5 6 POST-DEPLOYMENT EXAMINATION 1 309.81 PROLONG POSTTRAUM STRESS 2 244.9 HYPOTHYROIDISM NOS 3 401.9 HYPERTENSION NOS 4 ------------------------------------------------------------------------------- Chief Complaint: V70.5 6

Diagnosis EntryDiagnosis Entry

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ADM Patient Encounter - E&M Code Enter/Edit ALMOND,ALAN P 20/123-49-1111 AGE:37y ────────────────────────────────────────────────────────────────────────────────Appt Date/Time : 21 Jun 2001@0921 Type: ACUT$ Status: WALK-IN Clinic: ACUTE CR MTF MEPRS : BGAA┌──────────────────────────────────────────────────────────────────────────────┐ Total Duration of Prolonged Services Code(s) Less than 30 minutes Not reported separately 30 minutes - 1 hr. 14 min. 99354 X 1 unit of service 1 hr. 15 min. - 1 hr. 44 min. 99354 X 1 and 99355 X 1 1 hr. 45 min. - 2 hr. 14 min. 99354 X 1 and 99355 X 2 2 hr. 15 min. - 2 hr. 44 min. 99354 X 1 and 99355 X 3 2 hr. 45 min. - 3 hr. 14 min 99354 X 1 and 99355 X 4

└──────────────────────────────────────────────────────────────────────────────┘ 99214 OFF/OPV; E&M EST PT, DETAIL HIST/EXAM MOD COM 1234 25 1

ADM Patient Encounter - E&M Code Enter/Edit ALMOND,ALAN P 20/123-49-1111 AGE:37y ────────────────────────────────────────────────────────────────────────────────Appt Date/Time : 21 Jun 2001@0921 Type: ACUT$ Status: WALK-IN Clinic: ACUTE CR MTF MEPRS : BGAA┌──────────────────────────────────────────────────────────────────────────────┐ Total Duration of Prolonged Services Code(s) Less than 30 minutes Not reported separately 30 minutes - 1 hr. 14 min. 99354 X 1 unit of service 1 hr. 15 min. - 1 hr. 44 min. 99354 X 1 and 99355 X 1 1 hr. 45 min. - 2 hr. 14 min. 99354 X 1 and 99355 X 2 2 hr. 15 min. - 2 hr. 44 min. 99354 X 1 and 99355 X 3 2 hr. 45 min. - 3 hr. 14 min 99354 X 1 and 99355 X 4

└──────────────────────────────────────────────────────────────────────────────┘ 99214 OFF/OPV; E&M EST PT, DETAIL HIST/EXAM MOD COM 1234 25 1

Additional E&M ServicesAdditional E&M Services

CPT Code Modifier indicates additional Evaluation & Management Services

19

ADM Patient Encounter - E&M Code Enter/Edit ALMOND,ALAN P 20/123-49-1111 AGE:37y ────────────────────────────────────────────────────────────────────────────────Appt Date/Time : 21 Jun 2001@0921 Type: ACUT$ Status: WALK-IN Clinic: ACUTE CR MTF MEPRS : BGAA================================================================================ ICD-9 Dx Description Priority -------------------------------------------------------------------------------- V70.5 6 POST-DEPLOYMENT EXAMINATION 1 309.81 PROLONG POSTTRAUM STRESS 2 244.9 HYPOTHYROIDISM NOS 3 401.9 HYPERTENSION NOS 4===================================================== Dx Lvl ===================E&M Code Description (Maximum of 3 codes) 1-4 Mod1 Mod2 Mod3 Units-------------------------------------------------------------------------------- 99214 OFF/OPV; E&M EST PT, DETAIL HIST/EXAM MOD COM 1234 25 1 99354 PROLONG PHY SERV,OFF/OUTPAT,DIR PAT CONT BEYO 1234 1

ADM Patient Encounter - E&M Code Enter/Edit ALMOND,ALAN P 20/123-49-1111 AGE:37y ────────────────────────────────────────────────────────────────────────────────Appt Date/Time : 21 Jun 2001@0921 Type: ACUT$ Status: WALK-IN Clinic: ACUTE CR MTF MEPRS : BGAA================================================================================ ICD-9 Dx Description Priority -------------------------------------------------------------------------------- V70.5 6 POST-DEPLOYMENT EXAMINATION 1 309.81 PROLONG POSTTRAUM STRESS 2 244.9 HYPOTHYROIDISM NOS 3 401.9 HYPERTENSION NOS 4===================================================== Dx Lvl ===================E&M Code Description (Maximum of 3 codes) 1-4 Mod1 Mod2 Mod3 Units-------------------------------------------------------------------------------- 99214 OFF/OPV; E&M EST PT, DETAIL HIST/EXAM MOD COM 1234 25 1 99354 PROLONG PHY SERV,OFF/OUTPAT,DIR PAT CONT BEYO 1234 1

Additional E&M ServicesAdditional E&M Services

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PENDING vs PENDINGPENDING vs PENDING

PENDING “Visit” Status:- Incomplete Workload

PENDING “SADR” Status:- Encounter Coding Complete or Updated and ready for

transmission in the daily batch SADR extract file- ADM Encounters must contain at least one Diagnosis Code and

one E&M Code to be flagged in ADM as “PENDING” SADR Transmission

• E&M Code in ADM is optional for APV encounters (June 2005)

CHCS (KG ADS SADR NIGHTLY TASK) processes all “PENDING” Encounters completed in ADM and CHCS II for inclusion into the daily SADR Extract, based on the Treating DMIS ID

See Notes View for additional information

21

Quality IndicatorsQuality Indicators Timeliness

- Daily transmission of completed encounters- Coding Complete within 3 Business Days (Excluding Holidays)- APV Coding Complete within 15 Business Days

Accuracy- Clinic Pick-Lists and CHCS II Favorites updated to accurately represent the standard

definition and use of the ICD-9 Diagnosis and CPT/HCPCS Codes- Sustainment Training for Documentation, Coding and Sequencing- Limitations of ADM (each CPT Code must be unique within the encounter record)

Completeness (1% Uncoded could mean $1M – PPS RVU)- Coding Backlog – Uncoded records – Resources vs Re-work???- Unresolved Interface Errors- Null Provider Medical Specialty not included in PPS RVU calculations- Secondary Encounter Providers (Second MD (Non-Intern/Resident) results

in additional CPT Procedure RVU for the Encounter Provider in PPS RVU calculations

22

Maximum PerformanceMaximum Performance

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Performance “Tune Up”Performance “Tune Up”

Pit Crew Diagnostics:- ADM Compliance Report- Provider/Staff Time Reporting (EAS Accumulator – By Name)- Count vs Non-Count T-CONS with E&M Codes- SADR Provider Medical Specialty (<=905 or Not Null)- Secondary Providers - Allied Health Locations (PT/OT, Audiology, Mental Health, etc. with

E&M Codes- E&M Codes for PharmD’s- E&M Codes for Nurses and Technicians (99499 or 99211)

• CHCS II will assign a 99212 based on Diagnosis that cannot be changed unless a different Diagnosis is selected

- IBWA encounters vs Inpatient Consults- E&M Distribution by FCC (Bell Curve)

• New vs Established Encounters - 20/80 • Sick vs Well Encounters - 80/20+

- Nurse T-CONS (Create Nurse T-CON Clinic Location)- Limit assignment of “Nurse Wellness” role in CHCS II

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Encounter Databook Encounter Databook

The DQMC Audit is not enough to assess performance and target areas for improvement

Import SADR extracts, M2 query results and CHCS Ad-Hoc Flat File into Access to prepare Databook using Excel (Pivot Tables)- Neither the SADR nor M2 contains all elements needed to conduct Clinic

Practice assessments

Excel format provides ability to “Drill Down”:- ClinOps/CHCS II Databook is updated twice each week and are posted to a

shared drive for access by Clinic Chiefs and Administrators

- Drill Down Databook is updated monthly or per user request

- RVU Databook is updated monthly (prior month – 1)

Specific encounters can be identified in CHCS, by using the (grave key) ` + Appointment IEN in the CHCS KG ADC DATA or Patient Appointment File- Use a CHCS Print File template to display elements of interest

Reconciliation Lists are provided to Clinic Chiefs and Managers to assist with coordinating updates

See Notes View for additional information

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Got Data! Now What?Got Data! Now What?

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• Assess the type of encounters or T-CONS being generated • Review Staff generating T-CONS• There will be an increase in T-CONS with CHCS II, for MTFs that have previously changed them to OCC-SVC. Alert you DQ Mgr as this will impact the WWR/SADR DQ Metric

Service TypeService Type

27

• Select Clinics of Interest to review their E&M Coding distribution• Note: Only display “R” Ready records to prevent duplicate reporting• Compare to Industry and Army Benchmarks • Identify Outliers – Coordinate Training and User Feedback

Distribution %Distribution %

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• Assess “U”pdated encounters• Lag time for updated transmissions could be impacting your UBO Staff• Additional Procedures entered, Upcodes or Downcodes• Identify trends requiring updates to the CHCS II encounter

Update TrendsUpdate Trends

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• Target Allied Health Locations where the only valid E&M Code is 99499 or T-CON• Supports verification of the PASBA Metric for Allied Health, likely to be impacted during initial CHCS II implementation• Capture Encounter IENs from the Drill Down for reconciliation

Invalid E&MInvalid E&M

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• The data view with the greatest “opportunity” for improvement• Drill Down to validate GME (Residents) are documenting 2nd Providers• Level 4 & 5 Resident Encounters documented per PASBA GME Policy• E&M Codes for Non-Privileged Staff encounters• PharmD Coding Guidelines• PPS requirement for the Provider Medical Specialty that must be <= 905. • Don’t wait till you see your PPS RVU impacted in M2. Run the new CHCS Utility 'Re-Order Provider Specialty Utility‘ at least weekly to re-align your Provider Medical Specialties and resolve exceptions.

Invalid E&MInvalid E&M

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Facility Distribution (Raw)Facility Distribution (Raw)

Total WAMC CHCS II Encounters Selected E&M Codes (1-11 Aug 2005)New Established Consults Preventive Care

83 159 149 77 30

1604

2678

4445

1713

483

65 23 28 39226 162 122 58

22266 11

6037

0

1000

2000

3000

4000

5000

6000

7000

9920

1

9920

2

9920

3

9920

4

9920

5

9921

1

9921

2

9921

3

9921

4

9921

5

9924

1

9924

2

9924

3

9924

4

9939

1

9939

2

9939

3

9939

4

9939

5

9939

6

9939

7

9949

9

E&M Distribution Table (Most Frequently Used)

CH

CS

II E

nco

un

ters

32

Value of Care ModelValue of Care Model

• Map M2 RVU query results to EAS Accumulator – By Name• Providers with NO Time Reported prevent accurate calculation of RVU/FE per Day• Shows “You Can Do More With Less”• Include ALL Clinics, Provider Specialties (Skill Types)• Avg RVU/Encounter enables Peer Comparisons

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Transitioning to CHCS IITransitioning to CHCS II Improved ability for 3 day completion compliance Coder workflow changes:

1) Code all handwritten documents done the day prior2) Audit all encounters with third-party insurance3) Audit and Re-Code as needed all APV clinic visits4) Audit ER or other designated high-cost clinics5) Audit CHCSII-coded notes with time remaining in day6) No audit work will be carried over to the next business day

Coders authorized to directly update ADM, based on encounter documentation and track trends to identify areas for improvement

Coders coordinate with Providers to update CHCS II when validity of coding impacts validity of Diagnosis or Procedures in the Patient Record

Regular detailed data assessment needed to identify training and transition impacts*Source: AMEDD Commander Guidance on CHCSII Utilization of 17 February 2005

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““Drivers” for Data QualityDrivers” for Data Quality

The Drivers for “Quality Data” are only going to increase with advances in technology, increasing needs to measure access, quality, performance, costs, implement regulatory standards for health care data and use the data to improve

the health of the patients we serve.

35

Questions?Questions?

“Pit Crew” Manual & ReferencesBack-Up Slides

38

Visit Quiz!Visit Quiz! Provider Interpreting EKGs in a “B” MEPRS Clinic?

A. CountB. Non-Count

Advice Nurse T-CON?A. CountB. Non-Count

Advice Nurse T-CON that results in the patient being seen by a Provider (Same Day)?

A. CountB. Non-CountC. Count Visit to the Provider

Each Visit that is part of a complete or flight physical examination, performed in a separately organized clinic or specialty service?

A. CountB. Non-Count

Ward Visits by a Provider from the Attending Service?A. CountB. Non-Count

39

• Group and Treating DMIS IDs

• CHCS MTF Divisions

• Site Defined 4th Level MEPRS based on Standard MEPRS Definition

• Hospital Locations/Places of Care

CHCS MTF Division(DMIS ID)

CHCS MTF Division(DMIS ID)

CHCS MTF Division(DMIS ID)

Hospital Locations

4th LevelMEPRS Code

DMIS Group Parent(DMIS ID)

4th LevelMEPRS Code

4th LevelMEPRS Code

4th LevelMEPRS Code

4th LevelMEPRS Code

4th LevelMEPRS Code

4th LevelMEPRS Code

4th LevelMEPRS Code

Hospital Locations

Hospital Locations

Hospital Locations

Hospital Locations

Hospital Locations

Hospital Locations

WAM Enhancements now allow same

MEPRS FCC Code in multiple Divisions

Within the same DMIS Group

Building BlocksBuilding Blocks

See Notes View for additional information

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Clinic Profile Clinic Profile Identifies Providers that can have appointments

schedules in the clinic Flags Clinic Visits as Count or Non-Count Links to the Appointment Types available in the Clinic

and whether they are Count or Non-Count, based on Workload Reporting Rules

Non-Count Clinics cannot have Count Visits such as: - Immunizations (FBI*)- Nurse T-CON Clinic- CHCS II Test Clinic (BTST) or other as designated by your MTF

Clinic Profile and Appointment Type used by CHCS II to set the Workload Count/Non-Count indicator. - CHCS II prevents an E&M Code of other than 99499 for Non-Count

Visits

41

Appt TypeProfile

Linking It All TogetherLinking It All Together

CHCS MTF Division(DMIS ID)

CHCS MTF Division(DMIS ID)

DMIS Group Parent(DMIS ID)

4th LevelMEPRS Code

4th LevelMEPRS Code

4th LevelMEPRS Code

4th LevelMEPRS Code

4th LevelMEPRS Code

4th LevelMEPRS Code

Hospital Locations

Hospital Locations

Hospital Locations

Hospital Locations

Hospital Locations

Clinic Profile Clinic ProfileClinic Profile Clinic Profile Clinic Profile

ProviderProfile

ProviderProfile

ProviderProfile

42

Provider Medical SpecialtyProvider Medical Specialty Provider Medical Specialty/HIPAA Taxonomy

- MTF Providers require a Provider Medical Specialty <=905 to support Prospective Payment System (PPS) RVU and Billing

- TRICARE Network Providers identified with >910 to support Health Care Finder Functions

- Establishes CHAMPUS Maximum Allowable Charge (CMAC) Provider Class for TPOCS and MSA Billing

- External Civilian Providers require either “000” or “001”, to support TPOCS and MSA Billing (External Civilian Ancillary Services

- Quick Fix released in Change Package 255 addresses SADR design issue resulting in “Null” Provider Medical Specialty and provide an update utility to maintain the Provider Taxonomy

- Secondary Supervising Providers now required for Non-Privileged Providers (NEW – June 2005)

View Informational “Provider Specialty Utility” (New CHCS Utility)

43

CHCS Menu Path--------- PAD System Menu (DG USER) Data Quality Reports Menu (DOD DQ REPORTS MENU) DQL DQ Hospital Location Report DQS Pharmacy Site DQ Report DQP DQ Provider Default Report->>DQR Re-Order Provider Specialty Utility

Select Data Quality Reports Menu Option:

DQM Re-Order Provider Specialties UtilityThis utility will ensure that the first Provider Specialty in the PROVIDER SPECIALTY multiple field is mapped to a taxonomy code. If not, the utility will find the first Provider Specialty entry in the multiple that is mapped to a taxonomy code and switch the two entries. Providers that do not have any specialties that map to a taxonomy code will be placed on the spooled exception report. DQM Re-Order Provider Specialties Utility History Num ProvidersSpool File Name User Name Convert Except================================================================================DQM_PROV_SPEC_CONV_RPT 22Jan2005-0343 HOPKINS,LINDA M 714 561DQM_PROV_SPEC_CONV_RPT 09Feb2005-2111 HOPKINS,LINDA M 5 560

CHCS Menu Path--------- PAD System Menu (DG USER) Data Quality Reports Menu (DOD DQ REPORTS MENU) DQL DQ Hospital Location Report DQS Pharmacy Site DQ Report DQP DQ Provider Default Report->>DQR Re-Order Provider Specialty Utility

Select Data Quality Reports Menu Option:

DQM Re-Order Provider Specialties UtilityThis utility will ensure that the first Provider Specialty in the PROVIDER SPECIALTY multiple field is mapped to a taxonomy code. If not, the utility will find the first Provider Specialty entry in the multiple that is mapped to a taxonomy code and switch the two entries. Providers that do not have any specialties that map to a taxonomy code will be placed on the spooled exception report. DQM Re-Order Provider Specialties Utility History Num ProvidersSpool File Name User Name Convert Except================================================================================DQM_PROV_SPEC_CONV_RPT 22Jan2005-0343 HOPKINS,LINDA M 714 561DQM_PROV_SPEC_CONV_RPT 09Feb2005-2111 HOPKINS,LINDA M 5 560

Provider Specialty UtilityProvider Specialty Utility

44"Test Drive and "Tune-Up" ADM and MEPRS

Application Architecture

Outpatient Appointment SchedulingManaged Care Program (PAS/MCP)

Inpatient Admissions andDispositions (PAD)

Ambulatory Data Module (ADM)

CHCS Patient Database

Standard Files and Tables (DMIS, ICD-9, CPT/HCPCS, DRG, National Drug Codes, Zip Code, Standard Insurance) Table)Site Defined Files and Tables (Locations, Providers, Users, Formulary, Tests/Procedures, ADM Coding Pick Lists)

Application Business Rules

Clinical Order Entry and Results Reporting

Laboratory(LAB)

Radiology(RAD)

Pharmacy (PHR)

ConsultsNursing Orders

Medical Services Accounting (MSA)

Workload Assignment Module

(WAM)

CHCS Generic Interface Specification (GIS) for (HL7) and Electronic Transfer Utility (ETU)

ADM Patient EncounterMSA,BILLABLE CIVILIAN 20/800-44-7976 AGE:53y

==============================================================================Appt Date/Time :05 Mar 2002@1800 Type: APV Status: WALK-IN

Clinic: GEN SURG APU GR MEPRS : BIAEIn/Outpatient: Outpatient APV: Yes Work Related: YesAppt Provider: CASEY,KATHLEEN MAURA MD Injury Date : 05 Mar 2002

2nd Provider #1: GLUCK,ERIC S MD Role: ASSISTING2nd Provider #2: SINCLAIR,YVONNE J DDS Role: ASSISTING

Disposition: ADMITTEDChief Complaint: 925.1 CRUSHING INJ OF FACE AND SCALP==============================================================================

ICD-9 Dx Description Priority------------------------------------------------------------------------------

925.1 CRUSHING INJ OF FACE AND SCALP 1802.29 MULT FX MANDIBLE-CLOSED 2E880.0 FALL ON/FRM STAIR/STEP, ESCLTR 3

==============================================================================CPT Cd Description Dx Lvl Mod1 Mod2 Mod3 Units------------------------------------------------------------------------------D7820 CLOSED TMP MANIPULATION 123 1D7610 MAXILLA OPEN REDUCT SIMPLE 123 113121 REPAIR OF WOUND OR LESION 123 80 51 300190 ANES,FACIAL BONE/SKULL;NOS 123 AA 121125 AUGMENTATION, LOWER JAW BONE 123 80 121275 REVISION, ORBITOFACIAL BONES 123 80 2

VT 400 Terminal Emulation CHCS II Graphic User Interface

PATIENT SURVEY SIDR SADR WWR MEPRS-EAS TPOCS

LAB INSTRUMENTS CO-PATH LAB-INTEROP DBSS HIV

DIN-PACS VOICE RAD

PDTS ATC BAKER CELL PYXIS VOICE REFILL

CHCS II ICDB/HEALTHeFORCES EI/DS DoD/VA SHARING CODING/COMPLIANCE CIS CIW

G-CPR TRANSPORTABLE CPR TRAC2ES CAC UCAPERS NMIS DRG ENCODER/GROUPER

ELIGIBILITY & ENROLLMENT

SAIC San Diego, CA and Falls Church, VA February 2005

HL7, M/OBJECTS, ESI-OBJECTS OR CUSTOM NTERFACES FTP DATA TRANSFERS

CDRCDR

CLINICAL DATA REPOSITORY

CDWCDW

WAREHOUSE

45

CPT Code Billing ModifiersCPT Code Billing Modifiers

CPT Range Modifiers Descriptor Rate Calculation

E&M Codes99201-99499

-25SIGNIFICANT, SEPARATE E&M SVC BY SAME PHYS/DAY/OTH SVC

Required Modifier when more than one E&M Code is entered for an Encounter

-27MULTIPLE OUTPATIENT E&M ENCOUNTERS ON SAME DATE

Two Encounters with same Date of Service

-57 DECISION FOR SURGERY Informational Modifier

CPT/HCPCS Procedures

-26 PROFESSIONAL COMPONENTCalculated Charges for Professional Services, when there is a Component Rate.

-TC TECHNICAL COMPONENTCalculated Charges for Technical Services, when there is a Component Rate.

-50 BILATERAL PROCEDURE Charges are calculated at 2*CMAC Rate.

-51 MULTIPLE PROCEDURES Charges are calculated at CMAC Rate & Units of Service.

-62 TWO SURGEONS Services for each Surgeon are billable.

-80 ASSISTANT SURGEON Services for each Surgeon are billable.

-81MINIMUM ASSISTANT SURGEONASSIST

Services for each Surgeon are billable.

-82SURGEON/QUALIFIED RESIDENT SURGEON NOT AVAIL

Services for each Surgeon are billable.

46

ADM Information SourcesADM Information Sources

WEB SITE LINK

ADM 3.0 Users Manual Business Rules Application Capabilities

http://www-nmcp.med.navy.mil/EduRes/CompMedia/chcs/nuggets/kgads.asp

DoD Coding Guidelines (Apr 05) Business Rules Coding Scenarios

http://www.tricare.osd.mil/org/pae/ubu/default.htm

ADM Compliance Report “How To”

* Copy Link into Browser

http://www.pasba.amedd.army.mil/Quality/Resources/ADMComplianceReportInstr031215.pdf

ADM Encounter Specific Code Report By Clinic/Provider “How To” Clinic Provider

Coding Report

47

Best of the WebBest of the Web

WEB SITE LINK

American Academy of Family Practitioners Practice Management Measures

http://www.aafp.org/x5981.xml

TRICARE Access Imperatives Kaiser Clinic Template Model

http://www.tricare.osd.mil/tai/Clinic_Templating.htm

Medical Group Mgmt Benchmarks Staffing Models Relative Value Units

http://www.managedcaredigest.com/edigests/mg2000/mg2000c01.html

E&M Coding Benchmark Analyzer* CMS Benchmarks by Specialty Analyze your E&M Distribution

http://www.physicianspractice.com/tools/em_calc.html

Pediatric Practice Benchmarks Benchmarks RVU Calculator

http://www.pcc.com/pub/pm/curve-calc.html

* Requests Zip Code to Access

48

Tri-Service Web SitesTri-Service Web Sites

WEB SITE LINK

CHCS/CHCS II Training Courses & Downloads

http://www.distributivelearning.net

CHCS Data Management* User Guides, User Update Guides

http://www.chcs-dm.com/DM4CHCS/default.html

TMA Data Quality Management Control Program

http://tricare.osd.mil/rm/fa_dq.cfm

Post Deployment Health Toolbox Algorithms & Coding Guides

http://www.pdhealth.mil/guidelines/toolbox.asp

TRICARE Operations Center Access to Care Template Analysis Tool (TAT)

http://www.tricare.osd.mil/tools/

MEPRS Early Warning and Control System (MEWACS)

http://www.tricare.osd.mil/ebc/rm_home/meprs/mewacsxls.cfm

* See your CHCS Administrator for Access

49

Service Web SitesService Web Sites

WEB SITE LINK

Army Knowledge On-Line*: CHCS II Updates CHCS II Template Team

Log On to AKO & Follow Link:https://www.us.army.mil/suite/page/406

Also Links to AF CHCS II Site

OTSG Decision Support*: Portal to All AMEDD Metrics/Data

https://ke2.army.mil/otsg/main.php?cid=57

Army PASBA (.mil Access Only) DQ Metrics & Coding Support

http://www.pasba.amedd.army.mil/

Army MEPRS Program Office All things Army MEPRS

http://ampo.amedd.army.mil/

NMC Portsmouth CHCS “Nuggets” & SOPs

http://www-nmcp.med.navy.mil/EduRes/CompMedia/chcs/nuggets.asp

Air Force P2R2 MTF Performance Analyzer

https://p2r2.hq.af.mil/

* Password Required

50

Womack Army Medical Center Fort Bragg, NC

Charlene Colon, Clinical Data Analyst Information Management Division, Clinical Data Branch Charlene.Colon@na.amedd.army.mil

Womack Army Medical Center Fort Bragg, NC

Charlene Colon, Clinical Data Analyst Information Management Division, Clinical Data Branch Charlene.Colon@na.amedd.army.mil