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Data Quality Management Control Program (DQMC). Air Force Data Quality Program Manager. Overview. Data Quality (DQ) Program Systems DQ Composite Health Care System (CHCS) Initiatives FY09 Updates Take Away Questions. Data Quality Manager Data Quality Assurance Team DQMC Review List

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data quality management control program dqmc

Data Quality Management Control Program (DQMC)

Air Force Data Quality Program Manager

overview
Overview
  • Data Quality (DQ) Program
  • Systems
  • DQ Composite Health Care System (CHCS) Initiatives
  • FY09 Updates
  • Take Away
  • Questions
dqmc program
Data Quality Manager

Data Quality Assurance Team

DQMC Review List

Data Quality Statement

Department of Defense

INSTRUCTION

DQMC Program

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)

DQ Team Roles and Responsibilities

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

dq team roles and responsibilities1
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

DQ Team Roles and Responsibilities

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

dq team responsibilities cont
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
dq system architecture
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

slide8
Medical Expense and 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

dq monitoring tools
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 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 cont
DQ Monitoring Tools Cont…
  • MEPRS Early Warning and Control System (MEWACS)
    • Trend analysis tool
    • Usage monitored by DQMC
    • Outlier indications
      • Review and correct data accordingly
      • Outliers are not always incorrect data
dq monitoring tools cont1
DQ Monitoring ToolsCont…
  • 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
how is your data used
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
provider file
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
Provider Profiles (con’t)

Corrected fields in red:

PROVIDER: SMITH,JOHN R

Name: SMITH,JOHN R

Provider Flag: PROVIDER

Provider ID: SMITHJR

NPI Type/ID: 01/0125899

Provider Class: OUTSIDE PROVIDER

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: 123-45-6789 (Not Mandatory)

DEA#: BM1212127

License #:

Incorrect fields in red:

PROVIDER:SMITH, JOHN R

Name:SMITH, JOHN R

Provider Flag: PROVIDER

Provider ID:Provider1234

NPI Type/ID:

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 #:

potential revenue impact
Potential Revenue Impact
  • 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
provider specialty codes
Provider Specialty Codes
  • Enter Provider Specialty Code (Be specific – notgeneral)
    • 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
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!!!!!!

Value of Care
today s situation
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
AF CHCS DQ Initiative
  • Contract awarded Sept 06
    • Hired 2 contractors
    • Review and analyze CHCS File and Table Build
      • Provider File
      • Provide functional and technical guidance
      • Site Analysis Report (SAR)
    • Establish CHCS DQ standards
      • Process ownership of data elements
      • Policies, business rules, and AFMS standardization (CHCS DQ Continuity Handbook)
af chcs dq initiative cont
AF CHCS DQ Initiative Cont…
  • MTF Reporting Requirements
    • Monthly Data Quality Statement
    • SADR/CAPER Write Back Error Report
      • Should be run monthly
    • All Provider Report
      • Data due Quarterly on the 15th to Air Staff
      • Workbook is prepared
      • Site Analysis Report (SAR) provided back to MTF
      • MTF corrects errors
      • Performance Metrics
sample of a sar
Sample of a SAR
      • High-level Discoveries
      • Key Activities Review and Assessment Results
      • Icons
  • Downward trend  No changeD Upward trend
dq tool kit
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
slide29
CHCS DQ Initiative Roadmap

Aug- Sep 09

4th Quarter Provider

File Submission

June-Aug 09

  • We are here:
  • Analysis of 63 sites being completed for 3rd Quarter

Apr-Jun 09

Update Continuity Book

Mar- Apr 09

3rd Quarter Provider File Submission

Feb–Mar 09

CHCS DQ 2nd Quarter Site Analysis Report

Jan – Feb 09

Dec- Jan 09

2nd Quarter Provider File Submission

Nov-Dec 08

CHCS DQ 1st Quarter Site Analysis Report

Oct-Nov 08

1st Quarter Provider File Submission

Sep-Oct 08

Complete FY08 Performance Metrics

sample of continuity handbook
Sample of Continuity Handbook

Provider File Standards and Business Rules

dq web page
DQ Web Page

Contact:Ms. Michele Gowen, RHIA, CCS

Air Force Data Quality Program Manager

Tel (703) 681-6504 DSN 761

Fax (703) 681-6011 DSN 761

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

Documents, briefings, policies/directives, training

and links

data quality statement completeness
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 statement completeness cont
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 appointments

Total appointments for the month

BDQAS

data quality statement timeliness
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)

data quality statement validation and reconciliation
Data Quality 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 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 statement compliance
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
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 day
      • Even numbers will use the second day
data quality statement coding accuracy calculation
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

data quality statement compliance1
Data Quality Statement Compliance
  • 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 availability accuracy
Data Quality Statement Availability/Accuracy
  • 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 accuracy1
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.

data quality statement availability accuracy2
Data Quality Statement Availability/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

data quality statement availability accuracy3
Data Quality Statement Availability/Accuracy
  • 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.

data quality statement availability accuracy4
Data Quality Statement Availability/Accuracy
  • 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
data quality statement completeness1
Data Quality Statement Completeness
  • Question 8. Comparison of reported workload data.
    • a) # SADR Encounters (count + non-count) / # 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: FY09 Goal 80% (Will be graded red and green only)

Internal Process (Monthly Statistical Report)

data quality statement ahlta penetration
Data Quality Statement AHLTA Penetration
  • 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 penetration1
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 awareness
Data Quality Statement Awareness
  • 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)
take away
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
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
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/
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