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Data Quality Management Program

Data Quality Management Program. TSgt Jody Callender Air Force Data Quality Manager AFMOA/SGYR. Overview. Team Composition and Responsibilities Commander’s Statement Provider Files Data Quality Issue Examples FY07 Initiatives References Useful Links Questions. Data Quality Team.

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Data Quality Management Program

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  1. Data Quality Management Program TSgt Jody Callender Air Force Data Quality Manager AFMOA/SGYR

  2. Overview • Team Composition and Responsibilities • Commander’s Statement • Provider Files • Data Quality Issue Examples • FY07 Initiatives • References • Useful Links • Questions

  3. Data Quality Team • Data Quality Manager • Clinic Managers • Credentials Manager • Budget Analyst • MEPRS Program Manager • Coding Supervisor • Billing Supervisor • IM/IT Department • Including system administrators • Others as needed • Executive Committee – monthly oversight

  4. Data Quality Team Approach • Multi-specialty DQ team established and meet monthly • Keep meeting minutes for at least two years – so you can track progress • Report monthly to Executive Committee • Ensure the minutes reflect your efforts to improve Data Quality • Review Metrics together to work toward solutions • It is great to look – But are you working toward improvement? • Monthly Statement is signed and forwarded to Service DQ Manager monthly • Ensure your commander knows what they are signing

  5. What is your data used for? • Population-based Healthcare Delivery • Forecast demand and track delivery of preventive services • Manage chronic disease/conditions • Monitor efficiency of the healthcare system • Provider/Clinic Productivity • Medicare Accrual Fund • Performance Based Budgeting – PPS • Reimbursements: Third Party Collections, Inpatient, CG/NOAA/PH Collections, Pay Patients, Foreign Patients • Reduce claims denial • Document Level of Effort by all clinic staff • Enable the Leadership to make informed decisions

  6. Data Quality Management Control Program • Regulatory Guidance DODI 6040.40, Data Quality Management Control Procedures • DQMC Review List • Internal tool to assists MTFs monthly/quarterly to identify and correct financial and clinical workload data • Commander’s Monthly Data Quality Statement • Facility Report Card • Specific information from the DQMC Review List • Commander signs/approves • Sent to MAJCOM/DQ Managers, Service DQ managers and the TMA Management Control Program Manager

  7. Commander’s DQ StatementCompleteness • Question 1. In the reporting month: • a) What percentage of clinics have complied with “End of Day” processing requirements, “Every clinic – Every day? Sum of Daily Totals of Open Clinics Successfully Completing EOD Processing 10 Sum of All Daily Totals of Open Clinics 200 10 Clinics with 20 of open clinic • b) What percentage of appointments were closed in meeting your “End of Day” processing requirements, “Every appointment – Every day?” (B.5.(b)) Sum of Daily Totals of Successfully Closed Appointments 70 =97% Total Appointments 2000 100 appointments a day with 20 days of open clinic = 95% Compliant Compliant

  8. Commander’s DQ StatementTimeliness • Question 2. In accordance with legal and medical coding practices, have all of the following occurred: • a) What percentage of Outpatient Encounters, other than APVs, have been coded within 3 business days of the encounter? BDQAS • b) What percentage of APVs have been coded within 15 days of the encounter? BDQAS • c) What percentage of Inpatient records have been coded within 30 days after discharge? Internal Process CCE Report or Encoder Group Report (open register numbers) Un-coded records report

  9. Commander’s DQ StatementValidation and Reconciliation • Question 3. In accordance with TMA policy, “Implementation of EAS/MEPRS Data Validation and Reconciliation,” dated 21 Dec 99 and “MEPRS Early Warning and Control System,” dated 28 May 02, along with the most current Service-Level Guidance • a) Was monthly MEPRS/EAS financial reconciliation process completed? MEPRS Manager and RMO Office • b) Were monthly Inpatient and Outpatient workload reconciliation processes completed? MEPRS Manager • c) Were the data load status, outlier/variance, WWR-EAS IV, and allocations tabs in the current MEWACS document reviewed and explanations provided for flagged data anomalies? MEPRS Manager

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

  11. Commander’s DQ StatementCompliance • Question 5 Outcome of monthly inpatient coding audit: • a) Inpatient Records (DRG) # Records Reviewed:_________ % Correct _______ Internal Process • b) IBWA Rounds encounters audited and deemed correct? Internal Process (Inpatient coder) at least 30 Records

  12. Commander’s DQ StatementAvailability/Accuracy • Question 6 Outpatient Records • a) Percentage of outpatient medical records on-hand containing the documentation and/or the loose documentation of the encounter selected to be audited or documented as checked out? Audit Tool/Internal Process • b) What was the percentage of E & M codes deemed correct? (E & M code must comply with current DoD guidance.) • c) What was the percentage of ICD-9 codes deemed correct? • d) What was the percentage of CPT codes deemed correct? (CPT code must comply with current DoD guidance.) b,c,d-Audit Tool Generated

  13. Commander’s DQ StatementAvailability/Accuracy • Question 6. Outpatient Records. CONT… • e) What percentage of completed & current DD Form 2569s are maintained in the record (non-active duty)? Audit Tool Generated/Internal Process (This metric only measure whether or not a DD2569 was collected/current in the record at the time of the encounter. How the patient answered on the form is only relevant to answering “Question 6f”) f) What percentage of completed & current DD Form 2569s in the medical record were verified to be correct in the Patient Insurance file in CHCS? Internal Process based on Question 6e (Only current and signed DD2569 whether there yes or no are checked)

  14. Commander’s DQ StatementAvailability/Accuracy • Question 7 Ambulatory Procedure Visits (C.7.a,b,c,d,e,f) • Questions 7.a,b,c,d,e,f Are the same as Questions 6.a,b,c,d,e,f

  15. Commander’s DQ StatementCompleteness • Question 8. Comparison of reported workload data. • a) # SADR Encounters / # WWR visits BDQAS • b) # SIDR Dispositions / # WWR Dispositions BDQAS • c) # EAS Visits / # WWR Visits BDQAS • d) # EAS Dispositions / # WWR Dispositions BDQAS • e) # of IBWA SADR encounters (FCC=A***)/#Sum WWR (Total Bed Days + Total Dispositions) Internal Process (Month Statistical Report)

  16. Commander’s DQ StatementAwareness • Q. 9. – I am aware of data quality issues identified by the DQMC Review List and when needed, have taken action to improve the data from my facility. Internal Process

  17. Provider Profiles • Civilian (Outside) Provider File • Pharmacy adds the most Civilian Provider to CHCS • Is there a local policy? • Educate your pharmacy staff on how to input the provider files • Default Provider Specialty Code for Civilian Providers is 000 General Medical Officer or 001 Family Practice Physician • 000/001 gets the claim to TPOCS • 000 is the minimum provider who can write scripts • Provider naming convention and DEA/License number needs to be strictly enforced and monitored, serious loss of revenue due to billing rejects • Smith / Johnson,S / Provider / Outside Provider • DEA/License # can be research on the web, if not provided • Do not use SSN (internal Providers only) • HIPAA Taxonomy number needs to be correct to prevent fraudulent billing or inability to bill

  18. Provider Profiles (con’t) • Enter Provider Specialty Code (Be specific – not general) • All PA’s – Provider Specialty Code 901 • All Nurses (RNs) – Provider Specialty Code 600 • All Technicians – Provider Specialty Code 900 • Potential lost revenue for codes 500 series, 910 & above • Zero out RVU in FY07 • Prevent Encounter from flowing to TPOCS • Fraudulent billing can occur with incorrect provider specialty codes • Non-credentialed provider (Tech) 900 • Credentialed Providers for example (PA) 901 • Provider Specialties Above 905 represent Clinical Services • 923-Family Practice Clinic/001-Family Practice Physician • 949-Pediatric Clinic/040-Peditrician

  19. Provider Profiles (con’t) PROVIDER: SMITH,JOHN R Name: SMITH,JOHN R Provider Flag: PROVIDER Provider ID: SMITHJR Provider Class: OUTSIDEPROVIDER Person Identifier: Person ID Type Code: Select PROVIDER SPECIALTY: 001 (FAMILY PRACTICE PHYSICIAN) Primary Provider Taxonomy: 207Q00000X CMAC Provider Class: - Select PROVIDER TAXONOMY: HCP SIDR-ID: Location: CHAMPUS SUPPORT Class: OUTSIDE PROVIDER Initials: JRS SSN: DEA#: BM1212127 License #: PROVIDER:SMITH, JOHN R Name:SMITH, JOHN R Provider Flag: PROVIDER Provider ID:Provider1234 Provider Class:Doc Person Identifier:123-45-6789 Person ID Type Code: Select PROVIDER SPECIALTY: 517 (DENTAL CONSULTANT) Primary Provider Taxonomy: CMAC Provider Class: - Select PROVIDER TAXONOMY: HCP SIDR-ID: Location: CHAMPUS SUPPORT Class: OUTSIDE PROVIDER Initials: JRS SSN:123-45-6789 DEA#:99999999 License #: *Handouts will be provided for this slide (this statement will be removed before brief)

  20. PEDIATRICS – BDA Provider Specialty Code = 040 Pediatrician Diagnosis Codes 204 Lymphoid Leukemia 112.89 Candidial Endocarditis Procedure Code 90780 Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour 90781 – Each additional hour E&M Code 99214 – Level 4 Established Patient OHI – Yes CMAC Value = $130.73 Class 1 Provider Will you bill for this patient? Yes Reimbursement - $130.73 PPS RVU = 1.44 Reimbursement = $106.56 PEDIATRICS – BDA Provider Specialty Code = 949 Pediatrics Diagnosis Codes 204 Lymphoid Leukemia 112.89 Candidial Endocarditis Procedure Code 90780 Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour 90781 – Each additional hour E&M Code 99214 – Level 4 Established Patient OHI – Yes CMAC Value = UNKNOWN Will you bill for this patient? NO Reimbursement $0 PPS RVU/Reimbursement = ZERO!!!!!! Value of Care *Handouts will be provided for this slide (this statement will be removed before brief)

  21. Potential Revenue Impact • Average # Claims for Outside Provider Scripts • Large Facility 1500-3000 • Medium Facility 700 • Small Facility 300 • Average Amount Billed $50 per claim • If your provider file has 100 outside providers that issued at least one script per month with a blank or incorrect provider specialty code • Potential Loss is $5,000 in billable claims per month • Potential Loss is $60,000 in billable claims per year

  22. FY07 Updates • Review List • Add new systems (AHLTA, CCE and DMHRSi) • IBWA (Inpatient Professional Services) • Commander’s Statement • Question 6a - Is documentation of the encounter selected to be audited available? Documentation includes the medical record, loose (hard copy) documentation or an electronic record of the encounter in AHLTA • Question 6e - What is the percentage of non-active duty encounters for which complete and current (signed within the past 12 months) DD Form 2569s (TPC Insurance Info) are available for audit. Note: Availability may be electronic, loose, or signed form maintained in other locations • Question 6f - What percentage of available, current and complete DD Form 2569s which are correct in the the Patient Insurance Information (PII) module in CHCS? Note: If no DD Form 2569s are available for audit, the answer to this question is not applicable (N/A)

  23. FY07 Updates • New Proposed Questions • Question 5c - Inpatient Professional Services Rounds encounters ICD-9 codes audited and deemed correct? • Question 5d - Inpatient Professional Services Rounds encounters CPT codes codes audited and deemed correct? • Question 8f - # of AHLTA SADR encounters / # of Total SADR encounters Note: FY07 not scored, FY08 Goal 90% (AHLTA Utilization) • Remove Questions 7b - What percentage of E&M codes deemed correct? • Change IBWA to “Inpatient Profession Services” • Approve digital signature for command statement • DQ Statement Guide • DQ CHCS Guide

  24. FY07 Updates • New Proposed Questions • Question 5c - Inpatient Professional Services Rounds encounters ICD-9 codes audited and deemed correct? • Question 5d - Inpatient Professional Services Rounds encounters CPT codes codes audited and deemed correct? • Question 8f - # of AHLTA SADR encounters / # of Total SADR encounters Note: FY07 not scored, FY08 Goal 90% (AHLTA Utilization) • Remove Questions 7b - What percentage of E&M codes deemed correct? • Change IBWA to “Inpatient Profession Services” • Approve digital signature for command statement • DQ Statement Guide • DQ CHCS Guide

  25. Summary • Team Composition and Responsibilities • Commander’s Statement • Provider Files • Data Quality Issue Examples • FY07 Initiatives • References • Useful Links

  26. Important References • DODI 6015.1-M, DOD Glossary • DODI 6010.13M, MEPRS Program for Fixed MTFs and DTFs • DODI 6010.15M, Uniform Business Office • DODI 6040.40, Data Quality Program • DODI 6040.41, Medical Records Retention and Coding at MTF • DODI, 6040.42, Medical Encounter and Coding at MTF • DODI, 6040.43, Custody and Control of Medical Records • AFI 41-102, AF MEPRS Program for Fixed MTFs and DTFs • AFI 41-120, Resource Management Operations • AFI 41-210, Patient Administration Functions • DoD Professional Coding Guidelines • AF Workload Standardization Guidelines • EASIV Reference Guide

  27. Useful Web Sites • Data Quality -  http://www.tricare.osd.mil/dataquality/mgt_control.htm • BDQAS – http://bdqas.afms.mil/ •  P2R2 -  https://p2r2.hq.af.mil/ •  Virtual Analyst -  https://p2r2va.hq.af.mil/ •  Resource Management -  http://www.tricare.osd.mil/ebc/rm_home/rm_home.cfm •  Fin Management -  https://www.afms.mil/sgmc/ •  Tricare (CMAC Rates) -  http://www.tricare.osd.mil/ • Quarterly UBO Reports - http://web1.skyline.stic2.com/UBO/Login.htm •  Sales Codes - https://dfas4dod.dfas.mil/library/account-proc/sales_code.pdf •  Reimbursements -  http://www.dtic.mil/comptroller/rates/ •  DFAS -  http://www.dash.mil/money/milpay/ •  Pop Health -  https://phsd.afms.mil/phso/ •  AFCHIPS -  https://afchips.brooks.af.mil/ •  UBU - http://www.tricare.osd.mil/org/pae/ubu/default.htm •  3M -  http://www.3m.com/us/healthcare/his/ •  Medicare -  http://cms.hhs.gov/ •  AHIMA -  http://www.ahima.org/careers.colleges/ •  American Family Physicians -  http://www.aafp.org/ •  HIPAA -  http://www.hipaacomply.com/ •  SAIC -  http://www.chcs-dm.com/ •  EAS -  https://www.ssg.gunter.af.mil/medsys/easiii/index.htm •  MEWACS -  http://www.tricare.osd.mil/ebc/rm_home/mewacs/index.html

  28. QUESTIONS?

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