Data Quality Management Control Program (DQMC)

I n t e g r i t y - S e r v i c e - E x c e l l e n c e

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Data Quality Management Control Program (DQMC)

Air Force Data Quality Program Manager


Overview

Data Quality (DQ) ProgramSystemsDQ Composite Health Care System (CHCS)

InitiativesFY09 UpdatesTake AwayQuestions


DQMC Program

Data Quality Manager

Data Quality Assurance Team

DQMC Review List

Data Quality Statement

INSTRUCTION

Department of Defense

DODI 6040.40Military Health System

Data Quality Management Control Procedures


DQ Team Roles and Responsibilities

Team Key Players DQ Manager Resource Management Office (RMO) Group Practice Manager (GPM) Medical Expense and Performance Reporting System (MEPRS) Credentials Manager Budget Analyst/Uniform Business Office (UBO) Coding/Billing Supervisor Clinical Systems Administrator(s)

It is great to look – But are you working toward improvement?


DQ Team Roles and Responsibilities

DQ team meets monthly

Review Metrics/Compliance Issues Provide deficiency correction plan and estimated

completion date (if applicable) Report monthly to Executive Committee Keep meeting minutes for at least two years Keep Review Lists for five years

It is great to look – But are you working toward improvement?


DQ Team Responsibilities Cont…

DQMC Review List Maintained locally Tool to assist Military Treatment Facilities (MTFs) in

identifying and correcting financial and clinical workload data problems monthly

Data Quality Statement Facility Report Card Specific information from the DQMC Review List Commander signs/approves monthly Forwarded through the regional office to AF DQ

Manager AF summary submitted to DQMC


Air Force

DQ System Architecture

MDRMDR

M2M2

WWR(Count Visits)

EAS IVEAS IV“Eligible” Encounters

CPT Codes Units of Service

WAMWAMCount Visits & Raw Services

SADR(Encounters)

TPOCSTPOCSBillable

Encounters

PDTSPDTS

Worldwide Workload Report

Standard Ambulatory Data Record

EAS Repository

ADMExtract

MHS Data Repository

MHS Mart

Service Repository (BDQAS)

Pharmacy Data Transaction System

Pop HealthPortal

CCE

Coding Compliance Editor

ClinicalData Mart

TRICAREOps Center

DoD/VA SHARE

SADR 1/SADR 2


“E” – Support “D” – Ancillary “A” – Inpatient “B” – Outpatient “C” – Dental

+ “F” – Special Programs

+ “G” – Readiness

EAS IVMoney

Manpower

Workload

CRIS

EAS-SA

CHCS / WAM

(Count only)

RECONCILE

Direct Care “Step Down”

Medical Expense and Performance Reporting System“MEPRS” -- Valuation

Defense Health Program Cost Accounting

OUTPUT

TotalCost

RVUs RWPs

ICD/E&M/CPTDRGsSIDR

SADRCHCS


MHS Management Analysis and Reporting Tool (M2) Used to extract data for PPS and AF Business Plan Need to identify the M2 user and alternate 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

DQ Monitoring Tools


Sample use of M2

M2 Query:


MEPRS Early Warning and Control System (MEWACS) Trend analysis tool Usage monitored by DQMC Outlier indications

Review and correct data accordinglyOutliers are not always incorrect data

DQ Monitoring Tools Cont…


BDQAS Ambulatory and Inpatient Metrics

FY “Point-in-time" Comparison Reports Updated on the 20th of the month Display by MTF or MAJCOM

MTF Rankings, Transmission Reports (daily/summary), Top DRG, "Principal" Diagnosis and Procedure Reports, E&M by Provider Specialty

Data Quality Statement Reports Compare and report values on DQ statement Consistent reporting for questions: 1a-b, 2a-b,

4b-d, 8a-d, 9

DQ Monitoring Tools Cont…


BDQAS


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

How is your data used?


Provider File

Civilian (Outside) Provider File Pharmacy/Lab/Rad are required to add the Civilian

Provider to CHCS. Is there a local policy? Create a local policy/standard operating procedure Educate and train the ancillary staff Use correct PSC linked to HIPAA Taxonomy

Provider naming convention, NPI, and DEA/License number should be strictly enforced and monitored Last Name/First Name, Middle Name or Initial (if available) Example: Smith / Johnson,S / Provider / Outside Provider Recommend subscribing to HCIdea to research

NPI/DEA/License # ; http://www.hcidea.org/


Provider Profiles (con’t)Incorrect fields in red:PROVIDER: SMITH, JOHN R Name: SMITH, JOHN RProvider Flag: PROVIDERProvider ID: Provider1234NPI Type/ID: Provider Class: DocPerson Identifier: 123-45-6789Person 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#: 99999999License #:

Corrected fields in red:PROVIDER: SMITH,JOHN R Name: SMITH,JOHN R Provider Flag: PROVIDERProvider ID: SMITHJRNPI Type/ID: 01/0125899Provider Class: OUTSIDE PROVIDERPerson Identifier: Person ID Type Code: Select PROVIDER SPECIALTY: 001 (FAMILY PRACTICE PHYSICIAN)Primary Provider Taxonomy: 207Q00000XCMAC Provider Class: -Select PROVIDER TAXONOMY:HCP SIDR-ID:Location: CHAMPUS SUPPORT Class: OUTSIDE PROVIDER Initials: JRSSSN: 123-45-6789 (Not Mandatory)DEA#: BM1212127 License #:


Pharmacy makes up 70 to 80% of your facilities collections

Average # Claims for Outside Provider Scripts per month Large Facility 1,500-3,000 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, NPI (new requirement mid FY08), 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

Potential Revenue Impact


Enter Provider Specialty Code (Be specific – not general) All PA’s – Provider Specialty Code 901 All Technicians – Provider Specialty Code 900 Independent Duty Medical Technician – Provider

Specialty Code 521 Lost revenue for codes 500 – 518 and 910 – 999

Zero workload RVU Prevent Encounter from flowing to TPOCS Impact on PPS

Provider Specialties 910 and above are Clinical Services

Provider Specialty Codes


Value of Care 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!!!!!!ZERO!!!!!!


Today’s Situation

Lack of CHCS Provider File Training More accountability needed Potential for fraudulent billing Inaccurate Data

Missing Critical Data Elements Incorrect Critical Data Elements

Loss of workload and revenue opportunities


AF CHCS DQ Initiative

Contract awarded Sept 06 Hired 2 contractors Review and analyze CHCS File and Table Build

Provider FileProvide functional and technical guidanceSite Analysis Report (SAR)

Establish CHCS DQ standardsProcess ownership of data elementsPolicies, business rules, and AFMS

standardization (CHCS DQ Continuity Handbook)


AF CHCS DQ Initiative Cont…

MTF Reporting Requirements Monthly Data Quality Statement SADR/CAPER Write Back Error Report

Data due Monthly on the 5th to Air Staff All Provider Report

Data due Quarterly on the 15th to Air StaffWorkbook is preparedSite Analysis Report (SAR) provided back to

MTFMTF corrects errorsPerformance Metrics


AFMS –CHCS Provider File % of Total Data Element Errors

By Error Type

Cycle

Error Type 1st 2nd 3rd 4th

SSN or Pseudo SSN 18,635 5,443 3,827 47,833

Generic Provider 2,466 2,918 2,200 11,292

Improper Signature Class 21,074 23,711 18,844 15,962

No DEA # 41,616 53,555 36,061 25,081

Provider Duplicate 8,479 10,599 6,565 6,487

Improper Naming Convention 46,257 53,099 29,458 20,019

# Provider Signature Classes Used 2,685 2,762 2,294 2,032

# Hospital Locations used for Providers 2,902 3,133 2,916 2,607

Total Errors 144,114 155,220 102,165 131,313

Total Elements Reviewed 2,800,616 3,060,656 3,087,072 2,774,672

% of Total Errors 5.15% 5.07% 3.31% 4.73%


Sample of a SAR

1.High-level Discoveries 2.Key Activities Review and Assessment Results3.Icons

Downward trend No change Upward trend

Activities Description Potential Impacts DQ Finding Rating

Provider Specialty Code

Validate all Provider Codes are mapped specific to provider’s area of expertiseValidate all PA’s – Provider Specialty 901 Validate all Nurses (RNs) – Provider Specialty Code 600Validate Technicians – Provider Specialty Code 900Certify no providers are mapped in the code ranges 910-999 and 500-518

- PPS-TPOCS claims-MTFs Business Plan

1445

Name Field Validate the proper naming convention structureValidate duplicate provider namesReview generic provider names

-TPOCS claims 1001 Social Security Number (SSN)

Validate required 9-digit field for internal providersReview pseudo SSN

-TPOCS claims 130


DQ Tool Kit

Data Quality Statement Guide Reporting Consistency Training document for new personnel

CHCS DQ Continuity Handbook, Version 2 CHCS Standardized Business Rules

FY08 Workload Guidelines Version 2.0 in final draft Brings together DQ, MEPRS, Coding and Billing AF supplemental guidance to DOD coding

guidelines

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CHCS DQ Initiative Roadmap

1st Quarter Provider File Submission

2nd Quarter Provider File Submission

3rd Quarter Provider File Submission

Oct-Nov 08

Nov-Dec 08

Dec- Jan 09

Jan – Feb 09

Feb–Mar 09

Mar- Apr 09

Apr-Jun 09

June-Aug 09

We are here:•Site Analysis of 63 sites completed 2nd Quarter

Aug- Sep 09 4th Quarter Provider

File Submission

Sep-Oct 08

CHCS DQ 1st Quarter Site Analysis Report

Update Continuity Book

CHCS DQ 2nd Quarter Site Analysis Report

Complete FY08 Performance Metrics


Sample of Continuity Handbook

Data Element Description AF DQ Standards

National Provider Identifier (NPI)

10-Digit number for electronic billing

For any provider flagged as “Provider” these files require an NPI number. If services are rendered by a provider containing no NPI, it will prevent claims to be paid for patients with Third Party Insurance

Provider File Standards and Business Rules


Sample of Workload Guidelines

Encounter Activity

Provider Type

Provider Specialty

Code

MEPRS Code for

Time Capture

MEPRS Code for

Workload

Count/Non-Count

indicator

Patient Encounter Business Rules

Coding Required

Billing Required

Nutritionist/Dietitian

Privileged Provider

704 - Dietician/ Nutritionist

B*** B*** Count Registered dieticians or licensed nutrition Professionals are responsible for providing medical nutrition therapy (MNT).

Yes Yes


DQ Web Page

Contact:

Ms. Michele Gowen, RHIA, CCSAir Force Data Quality Program Manager

Tel (703) 681-6504 DSN 761Fax (703) 681-6011 DSN 761

https://kx.afms.mil/kxweb/dotmil/kj.do?functionalArea=DataQuality

Documents, briefings, policies/directives, training

and links


Data Quality StatementCompleteness

Question 1. In the reporting month (include only B*** and FBN* accounts):

a) What percentage of clinics have complied with “End of Day” processing requirements, “Every clinic – Every day?” (B.5.(a))

Number of clinics with 100% EOD completed Total number of open clinic days for the month

BDQAS


Data Quality StatementCompleteness Cont…

Question 1. In the reporting month (include only B*** and FBN* accounts):

b) What percentage of appointments were closed in meeting your “End of Day” processing requirements, “Every appointment – Every day?” (B.5.(b))

Number of closed appointmentsTotal appointments for the month

BDQAS


Data Quality 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)


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 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

Data Quality StatementValidation and Reconciliation


Data Quality Statement Compliance

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 Calendar Day Following Month)

BDQAS d) SADR/ADM (Daily)

BDQAS


Data Quality Statement Rounds Compliance (New)

One calendar day of the attending professional services during each audited hospitalization will be audited from the randomly selected sample. For one day hospitalizations, that calendar day

will be audited. For all other hospitalizations, the registration

number will determine which calendar day will be audited. Odd numbers will use the first dayEven numbers will use the second day


Data Quality Statement Coding Accuracy Calculation

Use the following new formulas for Q5b-d (Internal Process), 6b-d (Audit Tool), 7b-c (Audit Tool):

ICD-9: Number of correct ICD-9 codes

Total number of ICD-9 codes

E&M: Number of correct E&M codes

Total number of E&M codes

CPT: Number of correct CPT codes

Total number of CPT codes


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?

Data Quality Statement Compliance


Question 5. Inpatient Records. CONT… e) What percentage of completed and current (signed

within the past 12 months) DD Forms 2569 (TPC Insurance Info) are available for audit? (How the patient answered is only relevant to answering “Question 6f”)

The DD Forms 2569 need to be available and current at the time of the audit to be in compliance with the UBO program.

Options for filing DD Form 2569: Maintain hardcopy DD Form 2569 in medical record Scan DD Form 2569 and store electronically Hardcopy DD Form 2569 stored in the MTF RMO/Business/TPC

Office

Data Quality Statement Availability/Accuracy


Question 5. Inpatient Records. CONT…

f) What percentage of available, current and complete DD Forms 2569s are verified to be correct in the Patient Insurance Information (PII) module in CHCS?

Internal Process based on Question 6e. Does not apply to OCONUS bases.



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



Question 6. Outpatient Records. CONT…

e) What percentage of completed and current (signed within the past 12 months) DD Forms 2569s (TPC Insurance Info) are available for audit?

Audit Tool Generated/Internal Process (This metric only measures whether or not a DD Form 2569 was collected/current in the record at the time of the encounter).

The DD Forms 2569 need to be available and current at the time of the audit to be in compliance with the UBO program.

f) What percentage of available, current and complete DD Forms 2569s are verified to be correct in the Patient Insurance Information (PII) module in CHCS?

Internal Process based on Question 6e. Does not apply to OCONUS bases.



Question 7. Ambulatory Procedure Visits (C.7.a,b,c,d,e)

Questions 7.a,b,c,d,e Are the same as Questions 6.a,c,d,e,f



Question 8. Comparison of reported workload data.

a) # SADR Encounters (count + non-count) / # WWR visitsBDQAS

b) # SIDR Dispositions / # WWR DispositionsBDQAS

c) # EAS Visits / # WWR Visits BDQAS

d) # EAS Dispositions / # WWR DispositionsBDQAS

e) # of Inpatient Professional Services Rounds SADR encounters (FCC=A***)/#Sum WWR (Total Bed Days + Total Dispositions) Note: FY09 Goal 80% (Will be graded red and green only)

Internal Process (Monthly Statistical Report)

Data Quality Statement Completeness


Question 9. System Design, Development, Operations, and Education/Training (E.4.a).

a. # of AHLTA SADR encounters / # of Total SADR encounters

Note: ALL SADR encounters including APV and ER

BDQAS

Note: This question is to gauge the penetration of AHLTA at our MTFs. It is understood that not all clinical modules are deployed in the current version of AHLTA.

Data Quality Statement AHLTA Penetration


Question 10. CHCS software used during the reporting month to identify duplicate patient registration records. (C.2a) a) What was the number of potential duplicate records in the reporting month?

Internal Process

Run the CHCS standard report – “Potential Duplicate Patient Search”. (For current advice about how to identify duplicate

records, please see TRICARE Data Quality Web page: http://www.tricare.osd.mil/ocfo/mcfs/dqmcp/refs_regs.cfm

Data Quality Statement AHLTA Penetration


Question 11. I am aware of data quality issues identified by the completed Commander’s Statement and Review List and when needed, have incorporated monitoring mechanisms and have taken corrective actions to improve the data from my facility. (Electronic Signature Authorized)

Data Quality Statement Awareness


Take Away

DQ is not just the DQ statement.

Data needs to be accurate, complete and timely.

Front-end processes are CRITICAL to back-end success


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.mil/ocfo/mcfs/dqmcp/management_control.cfm

BDQAS - https://bdqas.brooks.af.mil/index2.htm UBU - http://www.tricare.mil//ocfo/bea/ubu/index.cfm UBO -

http://www.tricare.mil/ocfo/mcfs/ubo/about.cfm MEPRS – http://meprs.info MEWACS - http://www.meprs.info/mol3/mol3.cfm DFAS - https://mypay.dfas.mil/mypay.aspx HIPAA -

http://tricare.osd.mil/ocfo/mcfs/ubo/hipaa.cfm SAIC - http://www.chcs-dm.com/


QUESTIONS?

Data Quality Management Control Program (DQMC)

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Transcript of Data Quality Management Control Program (DQMC)