Data Quality Management Control Program Report

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

2. Overview • MHS Patient Accounting “Revenue” Cycle • Team Composition and Responsibilities • Data Quality Checklist/Commander’s Statement • Data Quality • MEPRS • References • Useful Links

3. 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.

4. 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

5. Data Quality Team • Data Quality Manager • Additional duty; full time in some instances • 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

6. 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 their 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 • Does your commander know what he/she is signing?

7. 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

8. 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.

9. 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:__________

10. Data Quality Management Review List Section A: Organizational Factors • A.8. Was there evidence in meeting minutes or other sources of corrective plans, of appropriate resourcing and actions to follow-up on the previous month's negative findings?  (For any data quality issue related to systems operation that cannot be resolved at the MTF, the issue should be noted in the comments section of this Review List with the related trouble ticket number and must be noted in the comments section on the monthly Data Quality Statement.) 

11. 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.)

12. 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______

13. 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

14. 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) 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 day 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

15. 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) a)  Was the monthly MEPRS/EAS financial reconciliation process completed, validated, and approved by the MTF Resource Manager prior to MEPRS monthly transmission? b)  Were monthly Inpatient and Outpatient MEPRS/EAS reconciliation processes completed (excluding coding audits performed in C.5 and C.6)?

16. 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. 

17. 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? d) 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)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.

18. 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) (Question 5) 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 5a 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.) f) Percentage of IBWA Rounds encounters audited and deemed correct? (Question 5b of the Commander’s Statement).

19. 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(a) of Commander's Statement.) (See applicable DoDD/DoDI on Medical Records Retention and Coding and Service specific guidance) (Question 6) 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 completed and current (signed within the past 12 months) DD Form 2569s (TPC Insurance Info) maintained in the medical record (non-active duty only)? (See DoD 6010.15-M, MTF UBO Manual) f) What percentage of the completed and current DD Form 2569s in the medical records were verified to be correct in the Patient Insurance file in CHCS?

20. 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(b, c, d, e) of Commander's Statement.) (See applicable DoDD/DoDI on Medical Records Retention and Coding and Service specific guidance) (Question 7) 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.

21. Data Quality Management Review List Section C: Data Output (con’t) 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 completed and current (signed within the past 12 months) DD Form 2569s (TPC Insurance Info) maintained in the medical record (non-active duty only)? (See DoD 6010.15-M, MTF UBO Manual)f) What percentage of the completed and current DD Form 2569s in the medical records were verified to be correct in the Patient Insurance file in CHCS? • 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.)

22. Data Quality Management Review List Section C: Data Output (con’t) • C.9.  Comparison of reported workload data.  (Question 8)a)  # SADR encounters * / # WWR visits b)  # SIDR dispositions* / # WWR dispositionsc)  # EAS visits / # WWR visitsd)  # EAS dispositions / # WWR dispositions • e) # of A*** SADRs that were completed by the attending provider/service (FCC=A***) / # SUM WWR ( Total Bed days + Total Dispositions)Note: FY06 Goal 80%Validate Service report to the criteria below:*  For ADM Encounters, omit Appt Status of "No-Show," "Canceled," and Disposition Code "Left without being seen," but include Appt Status "TelCon."*  For WWR visits and MEPRS visits use outpatient visits that include APV's.*  Only SADR records in B**** and FBN* clinics that are marked complete “C” will be included, or SIDRs with a Disposition Status of "D" will be included.*  Since WWR now collects visit information on B codes and FBN, ADM and MEPRS should also include FBN and B MEPRS codes for encounters/visits.* SIDRS to exclude Carded for Record Only (CRO) and absent sick records (primarily Army issue.) • * For IBWA SADR completion insure WWR calculation includes lives births (section 01) and Bassinet Days (section 00).Note: If b - d above, are greater than 100%, i.e., 103%, recorded percentage will be 97%.

23. 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?

24. 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

25. 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?

26. Data Quality “The Rest of the story!” • Data quality begins with proper CHCS file/table set up • Provider/Clinic Profiles • Standardized Appointments • Count/non-count flags • File/Table Build/Updates • Assigning Workload to the proper MEPRS/FCC codes • Site Definable MEPRS Table • Inappropriate MEPRS Code by Location Report • Coding Audits to ensure accuracy

27. Provider Profiles • PCM/all others distinction (right provider to encounter) • Privileging process and profile connection • Non-credentialed provider profiles (nurses and techs) • Provider types • Critical to assign provider type even though not a required field! • Adding providers to groups (within clinics…ER group) • Set appointment types and workload types allowed • Validate Provider Profiles on a regular basis • Provider Specialty Codes will automatically populate the HIPPA Provider Codes in CHCS • Don’t forget about your Civilian Providers!

28. Provider Profiles (con’t) • Who inputs your provider file? • It should be your Credentials Office • Things to improve your provider file • Be consistent • Last Name, First Name Middle Initial • Enter Provider Type – MD, PA, NP… • Flag Provider – Provider/Non-Provider/Lab • 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

29. Provider Profiles (con’t) • Default Provider MEPRS Code Ad Hoc • DEFAULT MEPRS from User Order Entry Preferences (from the Clinical User File) • MEPRS associated with the DEFAULT LOCATION (from the Clinical User File) • MEPRS associated with "Location" field in Provider file • MEPRS associated with "Clinic ID" field in Provider file • Ancillary Order generation • The computer has to know where to send the results • Correct Appointment Types and Workload Types assigned • Are you getting FULL credit for your workload? • MEPRS Codes that are not on the AF ASD Table = ZERO Credit • Examples: BZZZ and PMTA

30. CHCS - Clinic Profiles • Clinics Set up is Critical • Assign Appointment types • Assign Providers • Template Management • Group vs. Place of Care • Place of Care is where workload is generated and assigned • MEPRS Code assignment • Recommend MEPRS Program Manager is the only person to assign MEPRS codes • Must conform to WAM business rules or workload will not transmit to WWR or EAS IV

31. CHCS - Patient Registration • Establish critical registration points • Limit to as few as possible • Ongoing training for all persons responsible for updating demographics • Ensure even mini-reg functions are tightly controlled • Update/Verify Patient Demographics each time a patient calls for an appointment • Don’t forget to verify their Other Health Insurance • Every non-active duty patient must have an DoD 2569 in their medical record and it must be less than 365 days old. • All OHI needs to be entered into CHCS PII file • Duplicate Patient Report – Run at a minimum monthly

32. 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

33. MEPRS Processing • How can I check on my MEPRS data centrally? • MEWACS • www.meprs.info • EAS IV Repository • M2

34. 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

35. 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

36. QUESTIONS?