Data Quality Management Control Program Report

Data Quality Management Control Program Report TSgt Jody Callender Air Force Data Quality Manager AFMSA/SGSR

Overview • Revenue Cycle • Team Composition and Responsibilities • Commander’s Statement • Provider Files • Data Quality Issue Examples • References • Useful Links • Questions

What is Data Quality? Is the accurate reflection of the work performed in the MTF that can be used to make informed leadership/management decisions at all levels of command.

Data quality Management Controls are the driving force and conduit for ensuring effective and efficient operations Visual review for validating and streamlining major clinical business and resource management processes MTF Patient Accounting & Revenue Cycle Claims Submissions Account Follow-up Production Value (RVUs/RWPs) Cost per RVU/RWP (Efficiency) Coding Denial Management CCE Utilization/ Referral Management EWRAS TPOCS/ CMBB Payment Posting ADM/ P-GUI/ CHCSII Data Quality Management Electronic Billing Pre-cert/ Auth Appeals CHCS (Files & Tables) M2 Data Mart Encounter Document Payer Education MEPRS (MEWACS) Patient Check-in Ins Verif & Auth Contract Mgt Patient Access Resourcing (Money, Manpower, and Materiel) MTF Business Plan (Patient Management) Improved patient access, records documentation and coding accuracy Results are increased resourcing with reliable outcomes in the form of usable data AFMSA/SGSR

Data Quality Team • Data Quality Manager • Additional duty; full time in some instances • Usually a RMO function • 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

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

Data Quality Management Review List • Section A: Organizational Factors • Section B: Data Input • Section C: Data Output • Section D: Security • Section E: System Design, Development, Operations, and Education/Training

Data Quality Management Review List Section A: Organizational Factors • A.1. The MTF Commander signed last month's Data Quality Statement acknowledging responsibility for the quality of data reported from the MTF. • A.2. The MTF DQ Manager submitted the completed Commander's Data Quality Statement to the Service's respective DQ Manager(s). • A.3. The Data Quality Assurance Team or other designated structure met during the reporting month to complete the DQMC Review List. (Recommend attaching meeting minutes.) • A.4. The DQ Manager briefed the reporting month's DQMC Review List and Financial and Workload Data Reconciliation and Validation results to the MTF Executive Committee.

Data Quality Management Review List Section A: Organizational Factors • A.5. Does your MTF have a Coding Compliance Plan which has been reviewed annually for updates and quarterly for compliance? • A.6. Does your MTF have a UBO Compliance Plan which has been reviewed annually for updates and quarterly for compliance? • A.7. Has your Data Quality Manager/Assurance Team members attended: • a) TMA Data Quality Course? Date attended: __________ • b) Working Information to determine Optimal Management (WISDOM) Course? Date attended: __________ (If the Site has an M2 account holder) • c) MEPRS Application and Data Improvement (MADI) Course? Date attended:__________

Data Quality Management Review List Section B: Data Input • B.1. Are the most current written procedures, in accordance with MHS and Service guidelines, readily available and used by staff for entering, identifying, correcting and reprocessing data into the systems? (See TRICARE Data Quality Web Page/Hyper-Links and appropriate Service Web Sites.)a) MEPRS/EASb) ADM c) CHCSd) TPOCS • B.2. List the current version of software being used? (See TRICARE Data Quality Web Page/Hyper-Links and appropriate Service Web Sites for Approved Versions.) List Current Approved Version below:a) MEPRS/EAS a)_________________b) ADM b)_________________c) CHCS c)_________________d) TPOCS d)_________________ • B.3. Are reporting month central system upgrades (and associated loading activities) being received and loaded within 30 days of release? (See TRICARE Data Quality Web Page/Hyper-Links and appropriate Service Web Sites.) Examples are as follows:List reporting month Upgrades/Loads completed (examples include, but are not limited to CPT, ICD, DRG, etc):Note: (Examples of associated loading activities include, but are not limited to Medical Center Division File update, Department Service Location File update, MEPRS Code File update, etc.)

Data Quality Management Review List Section B: Data Input (con’t) • B.4. Were all rejected records corrected and retransmitted? (As applicable.) a) MEPRS/EAS b) ADM c) CHCS d) TPOCS (ADM to TPOCS) e) If the system is rejecting records, has a trouble ticket with the MHS Help Desk and/or Service help desk been filed (if required)? f) Do you have any open trouble tickets that have not been resolved within 14 calendar days or have a plan of action in place to resolve it? System___________Number_________Expected Resolution Date______

Data Quality Management Review List Section B: Data Input (con’t) • B.5. In the reporting month: Question 1 • a) What percentage of clinics have complied with "End of Day" processing requirements, "Every clinic - Every day?" (Question 1a of Commander's Statement.)b) What percentage of appointments were closed in meeting your "End of Day" processing requirements, "Every appointment - Every day?" (Question 1b of Commander's Statement.) #Closed Appts/Total Appts x days • How do I do that? • Initiate EOD Delinquent Report daily after last clinic closes, but before 2400 • Document results • To complete EOD processing on outstanding records, return to EOD processing, find the appointment by date and time, select the record and complete it • The EOD is now completed and the ADM (SADR) file has been generated

Data Quality Management Review List Section B: Data Input (con’t) • B.6. In accordance with legal and medical coding practices have all of the following occurred (See Applicable DoDD/DoDI on Medical Records Retention and Coding) : (Question “2” of Commander’s Statement) • a) What percentage of Outpatient Encounters, other than Ambulatory Procedure Visits (APVs), have been coded within 3 business days of the encounter? • All B*** Clinics and FBNA • Timeliness is in 3 business days – Completeness is in 28 days • b) What percentage of Ambulatory Procedure Visits have been coded within 15 days of the encounter? • All B**5/6/7/8 Clinics • Why? are APVs special because the use an abbreviated inpatient record • c) What percentage of inpatient records have been coded within 30 days after discharge? • Only bedded facilities need to answer this question • All MTFs need to complete SIDRs for AD patients admitted downtown in the same 30 day window

Data Quality Management Review List Section C: Data Output • C.1. 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: (Question 3 of Commander'sStatement.) • a) Was the monthly MEPRS/EAS financial reconciliation process completed? • b) Were monthly Inpatient and Outpatient MEPRS/EAS reconciliation processes completed (excluding coding audits performed in C.5 and C.6)? You need to do this before your transmit!

Data Quality Management Review List Section C: Data Output (con’t) • c) Has the MTF DQ Manager/MEPRS Manager reviewed the following facility information presented in the current version MEPRS Early Warning and Control System (MEWACS) Report? • 1. EAS IV Repository MEPRS data load status and compliance with 45-day reporting suspense. If the facility has a pattern (2 or more) of flagged cells on this tab, have they corrected it or developed a plan to correct it. Provide an explanation in the space below (Comments). • 2. MTF-specific summary data outliers and variance assessments. If the facility has any Prior Fiscal Year or Current Fiscal Year flagged cells on this tab, provide an explanation in the space below (Comments). • 3. WWR – EAS IV total ambulatory visit comparison. If the facility has any Prior Fiscal Year or Current Fiscal Year fiscal month data where WWR vs. EAS IV visit counts differ by greater than 5%, provide an explanation in the space below (Comments). • 4. Ancillary and Support expense allocation tests. If the facility is flagged in Prior Fiscal Year or Current Fiscal Year due to incomplete allocation of ancillary or support expenses, provide an explanation below (Comments), including projected date for submitting corrected data.

Data Quality Management Review List Section C: Data Output (con’t) • C.2. Was CHCS software used during the reporting month to identify duplicate patient registration records? a) What was the number of potential duplicate records in the reporting month? b) Do you have a process to reduce the number of duplicate records? c) Have the clinics with duplicate appointments/encounters been made aware of the error? • Have clinics determined how to correct the duplicate appointments/encounters and avoid the errors in the future? • C.3. Were system outputs transmitted to central repositories by date specified in TMA and Service guidelines? (Question 4 of Commander's Statement.) a) MEPRS/EAS (45 days) b) SIDR/CHCS (5th working day following month)c) WWR/CHCS (10th calendar day following month) d) SADR/ADM (Daily) # of Successful daily transmissions / # of days in the month.

Data Quality Management Review List Section C: Data Output (con’t) • C.5. In a random review of CHCS dispositions from the reporting month, the medical records staff determined the following percentages from a minimum sample of 30 records and/or sampling size as set by Service-Level Guidance, whichever is more, the degree to which: (See applicable DoDD/DoDI on Medical Records Retention and Coding and Service specific guidance) a) Percentage of inpatient medical records located? Note: Formula: Number of records available or documented as checked out/Number of records requested for audit b) Percentage of documentation that was complete. c) Percentage of inpatient records whose assigned DRG codes were correct? (Question 5 of the Commander's Statement.) Note: This is a comparison of the paper record to computerized coded information. d) Percentage of inpatient records whose DRG-related data elements were correct? e) Percentage of SIDRs completed (in a "D" status.)

Data Quality Management Review List Section C: Data Output (con’t) • C.6. In a random review of CHCS outpatient encounters from the reporting month, the medical records staff determined the following percentage from a minimum sample of 30 records and/or the sampling size as set by Service-Level guidance, whichever is greater: (Question 6 of Commander's Statement.) 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? (Denominator equals sample size.) b) What is the percentage of E & M codes deemed correct? (E & M code must comply with current DoD guidance.) Note: If the paper record does not indicate an E&M code was required and the computerized record does not have an E&M, the record is deemed correct. 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.) Note: If the paper record does not indicate a CPT was required and the computerized record does not have a CPT, the record is deemed correct. e) What is the percentage of current DD Form 2569s (TPC Insurance Info) maintained in the medical record (non-active duty only)? (See DoD 6010.15-M, MTF UBO Manual) Note Formula: Number of Current DD2569s/Number of Non-Active Duty records audited.

Data Quality Management Review List Section C: Data Output (con’t) • C.7. In a random review of CHCS Ambulatory Procedure Visits (APV) appointments from the reporting month, the medical records staff determined the following percentages from a minimum sample size of 30 "on-hand" records (extended/abbreviated) or maximum available if fewer than 30, (documentation of visit is included in record) and/or the sampling size as set by Service-Level guidance, whichever is greater: (Question 7 of Commander's Statement.) 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? (Denominator equals sample size.) b) What is the percentage of E & M codes deemed correct? (E & M code must comply with current DoD guidance.) Note: If the paper record does not indicate an E&M code was required and the computerized record does not have an E&M, the record is deemed correct. Note Formula: Number of Records with Correct E&M codes/Number of Records Audited requiring E&M codes. c) What is the percentage of ICD-9 codes deemed correct? Note Formula: Number of Records with Correct ICD codes/Number of Records Audited. d) What is the percentage of CPT codes deemed correct? (CPT code must comply with current DoD guidance.) Note: If the paper record does not indicate a CPT was required and the computerized record does not have a CPT, the record is deemed correct. Note Formula: Number of Records with Correct CPT codes/Number of Records Audited. e) What is the percentage of current DD Form 2569s maintained in the medical record (non-active duty only)? Note Formula: Number of Current DD2569s/Number of Non-Active Duty outpatient medical records audited.

Data Quality Management Review List Section C: Data Output (con’t) • C.8. Was a list of outpatient records, which were checked out of the record section more than 30-days, forwarded to the Medical Records Committee or higher authority for resolution? (Recommend using the CHCS Medical Records Tracking (MRT) module) (specify # records >30 days.)

Data Quality Management Review List Section C: Data Output (con’t) • C.9. Comparison of reported workload data. (Question 8 of Commander's Statement) a) # SADR encounters * / # WWR visits b) # SIDR dispositions* / # WWR dispositions c) # EAS visits / # WWR visits d) # EAS dispositions / # WWR dispositions e) # of IBWA SADR (RNDS appt type only) encounters (FCC=A***) / # SUM WWR Bed daysNote: FY05 data collection only, FY06 Goal 80%

Data Quality Management Review List Section D: Security • D1: Were responsibilities for computer security formally assigned? • Does your MTF have a Computer Security Program? – Yes • Is that person(s) appointed in writing? - Yes • D2: Is there a Security/Privacy Program in place to address HIPAA compliance for • Password Protection? • Access to systems? • Confidentiality of data? • Level of access to MEPRS/EAS, CHCS, ADM, TPOCS? • D.3. 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? • Have Security Key privileges been withdrawn from inappropriate users?

Data Quality Management Review List Section E: System Design, Development, Operations, and Education/Training • E1. Was a System Administrator appointed in writing for each system? • MEPRS/EAS, CHCS, ADM and TPOCS • E2. Are procedures and documentation in place to ensure that all assigned personnel responsible for data entry receive training and education on CHCS, MEPRS/EAS, TPOCS and ADM • E3. Was a process in place that allows users to submit suggestions concerning new or enhanced requirements through the Systems Change Request process – Yes, the AF has a policy

Data Quality Management Review List Section E: System Design, Development, Operations, and Education/Training (con’t) • E4: Was a process in place, such as System Incident Report, where users can identify issues affecting system functioning and operations? • E5: Were written procedures in place to assure routine system software and hardware maintenance? • E6: Are their points of contact identified for equipment failure issues? • E7: Are there contingency plans in place, such as creating nightly backup tapes?

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

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)

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

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

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)

Medical Expense Performance Reporting System “MEPRS” RVUsb EAS IV Financial Data System R E C O N C I L E Direct Care “Step Down” Money “E” – Support “D” – Ancillary “A” – Inpatient “B” – Outpatient “C” – Dental “F” – Special Programs “G” – Readiness O U T P U T Total Cost Personnel Data System Manpower CHCS / WAM (Count only) RVUs RWPs CHCS SADR ICD/E&M/CPT DRGs SIDR Workload Defense Health Program Cost Accounting AFMSA/SGSR

MEPRS.INFO

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

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

QUESTIONS?

Data Quality Management Control Program Report