Data Quality Management Control (DQMC) Program

1. Data Quality Management Control (DQMC) Program TSgt Jody Callender Air Force Data Quality Manager AFMOA/SG3YR

2. Overview • DQ Program • Systems • DQ CHCS Initiative • FY07 Updates • Take Away • Questions

3. Data Quality Manager Data Quality Assurance Team DQMC Review List Commander’s Monthly Data Quality Statement Department of Defense INSTRUCTION DQMC Program DODI 6040.40Military Health System Data Quality Management Control Procedures

4. Key Players DQ Manager GPM MEPRS and Credentials Manager Budget Analyst Coding/Billing Supervisor CHCS Administrator DQ team meets monthly Keep meeting minutes for at least two years Review Metrics Report monthly to Executive Committee DQ Team Roles and Responsibilities It is great to look – But are you working toward improvement?

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

6. DQ Team Responsibilities Cont… • DQMC Review List • Maintained locally • Tool to assist MTFs monthly in identifying and correcting financial and clinical workload data problems. • Commander’s Data Quality Statement • Facility Report Card • Specific information from the DQMC Review List • Commander signs/approves monthly • Forwarded through the MAJCOM to AF DQ 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 Sum of All Daily Totals of Open Clinics • 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 Total Appointments

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 (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, validated and approved prior to monthly MEPRS transmission? 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) Percentage of inpatient records whose assigned DRG codes were correct? • b) Inpatient Professional Services Rounds encounters E & M codes audited and deemed correct? • c) Inpatient Professional Services Rounds encounters ICD-9 codes audited and deemed correct? • d) Inpatient Professional Services Rounds encounters CPT codes audited and deemed correct? a) Percentage of inpatient records whose assigned DRG codes were correct?

12. Commander’s DQ StatementAvailability/Accuracy • Question 6. Outpatient Records • a) Is the documentation of the encounter selected to be audited available? Documentation includes documentation in the medical record, loose (hard copy) documentation or an electronic record of the encounter in AHLTA. (Denominator equals sample size.) • 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.) a, b, c, d-Audit Tool Generated

13. Commander’s DQ StatementAvailability/Accuracy • Question 6. Outpatient Records. CONT… • e) ) What percentage of completed and current (signed within the past 12 months) DD Form 2569s (TPC Insurance Info) are available for audit? 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 is only relevant to answering “Question 6f”) • f) What percentage of available, current and complete DD Form 2569s are verified to be correct in the Patient Insurance Information (PII) module 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,c,d,e,f Are the same as Questions 6.a,b,c,d,e,f • Question 7b-has been omitted for FY07

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 Inpatient Professional Services Rounds SADR encounters (FCC=A***)/#Sum WWR (Total Bed Days + Total Dispositions) Note: FY07 Goal 80% Internal Process (Month Statistical Report)

16. Commander’s DQ StatementAwareness • Question 9. System Design, Development, Operations, and Education/Training (E.4.c). • # of AHLTA SADR encounters / # of Total SADR encounters Note: Exclude APV (B**5, 7,8,9) and ER (BIAA) FY07 not scored. For management use and tracking purposes only. BDQAS

17. Commander’s DQ Statement • Question 10. 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. (Electronic Signature Authorized)

18. DQ System Architecture Clinical Data Mart Air Force TRICARE Ops Center Worldwide Workload Report Service Repository (BDQAS) WWR (Count Visits) DoD/VA SHARE MHS Data Repository MDR Coding Compliance Editor SADR (Encounters) CCE Standard Ambulatory Data Record Pop Health Portal SADR 1/SADR 2 PDTS ADM Extract Pharmacy Data Transaction System MHS Mart M2 EAS Repository TPOCS Billable Encounters WAM Count Visits & Raw Services EAS IV “Eligible” Encounters CPT Codes Units of Service

19. DQ Monitoring Tools • MHS Management Analysis and Reporting Tool (M2) • Used to extract data for PPS and AF Business Plan • Need to identify the M2 user in your facility • TMA WISDOM course • EASIV Repository • MEPRS data • Cost per data • 45 day processing period for current month • MEPRS Manager • TMA MADI Course

20. DQ Monitoring ToolsCont… • MEWACS • Trend analysis tool • Outlier indications • Review and correct data accordingly • Outliers are not always incorrect data • BDQAS • Data Quality Statement Reports • Compare and report values on DQ statement • Consistent reporting for questions: • 2a-b, 4b-d, 8a-d • New for FY07 question 9 (AHLTA Utilization) • “Point-in-time" reports • Updated on the 20th of the month • Display by MTF or MAJCOM • Contact BDQAS helpdesk for data inconsistencies or questions

21. BDQAS

24. How is your data used? • BRAC • Monitor efficiency of the healthcare system • Performance Based Budgeting – PPS • Medicare Accrual Fund • MTF Business Plans • Provider/Clinic Workload Productivity • Determine Level of Effort by all clinic staff • Reimbursements (TPC, Coast Guard, NOAA…etc) • Enable the Leadership to make informed decisions

25. Provider File • Civilian (Outside) Provider File • Pharmacy/Lab/Rad add the most Civilian Provider to CHCS • Is there a local policy? • Educate your ancillary staff • 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 • Smith / Johnson,S / Provider / Outside Provider • DEA/License # can be research on the web, if not provided • Do not use SSN (internal Providers only)

26. 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 #:

27. Potential Revenue Impact • Average # Claims for Outside Provider Scripts per Month • Large Facility 1500-3000 • Medium Facility 700 • Small Facility 300 • Average Amount Billed per claim: $50 • If your provider file has 100 outside providers that issued at least one script per month with missing data in their profile: provider specialty codes, DEA #, provider name and ID. • Potential Loss is $5,000 in billable claims per month • Potential Loss is $60,000 in billable claims per year

28. Provider Specialty Codes • Enter Provider Specialty Code (Be specific – notgeneral) • All PA’s – Provider Specialty Code 901 • All Technicians – Provider Specialty Code 900/521 • Lost revenue for codes 910 & above • FY07 zero workload • Prevent Encounter from flowing to TPOCS • Potential fraudulent billing • Provider Specialties 910 and above are Clinical Services • 923-Family Practice Clinic/001-Family Practice Physician • 949-Pediatric Clinic/040-Peditrician

29. 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 Workload = ZERO!!!!!! Value of Care

30. Today’s Situation • Lack of Training • No standard guidance and policies across the AFMS • Minimal accountability • Potential fraudulent billing • Inaccurate Data • Missing Critical Data Elements • Incorrect critical data elements • Loss revenue opportunities

31. FY08 Began Phase II analysis Mar 07-Sep 07 Monitor and Feedback – 60 days Feb 07 Forwarded Data Packages to MAJCOM Site Analysis Report to MAJCOM DQ Manager Mid Jan 07 Jan 07 Complete CHCS DQ Toolkit Guidance Dec 06 Baseline assessment – Validate and identify DQ problems Nov 06 Data Analysis – collection of CHCS Database Files Oct – Dec 06 Determine MAJCOM site priority Oct – Dec 06 Site Preparation – Initiates functional work plan and process review Oct 06 Internal Program Planning and Development – Initiates work plan Sep 06 CHCS DQ contract awarded CHCS DQ Status We are here:

32. FY07 Updates • Changes to FY07 DQ Statement • 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? • Questions 7b Removed - What percentage of E&M codes deemed correct? • Question 9 - # of AHLTA SADR encounters / # of Total SADR encounters Note: FY07 not scored (AHLTA Utilization) • Changed IBWA to “Inpatient Profession Services” • Approve digital signature for command statement • DQ Toolkit Guidance

33. DQ Tool Kit • FY07 DQ Guide • Reporting Consistency • Assistance with answering questions • General DQ information • CHCS DQ Continuity Handbook • CHCS standards • Processes/procedures for addressing CHCS issue and resolution • Reports • FY07 Workload Guidelines • Due to be Released Mar 07 • Includes DQ, MEPRS and Coding • AF supplemental guidance to DOD coding guidelines

34. Take Away • DQ is not just the DQ statement. • Data needs to be accurate and complete. • Cleaning the front end will show a return on the back end

35. 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

36. Useful Web Sites • Data Quality -  http://tricare.osd.mil/ocfo/mcfs/dqmcp/training.cfm • BDQAS – https://bdqas.brooks.af.mil/index2.htm • P2R2 -  https://p2r2.hq.af.mil/ • UBU - http://tricare.osd.mil/ocfo/bea/ubu/index.cfm • UBO - http://tricare.osd.mil/ocfo/mcfs/ubo/index.cfm • MEPRS – http://meprs.info • MEWACS - http://www.tricare.osd.mil/ebc/rm_home/mewacs/index.html • AF/SGY-https://kx.afms.mil/kxweb/dotmil/kj.do;jsessionid=640C4248B20F510C99BB60E38F3A36D5?functionalArea=ResourceMgmt • DFAS -  http://www.dash.mil/money/milpay/ • Pop Health -  https://phsd.afms.mil/phso/ • HIPAA -  http://tricare.osd.mil/ocfo/mcfs/ubo/hipaa.cfm • SAIC -  http://www.chcs-dm.com/

37. QUESTIONS?