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Title: Using M2 to Manage MTF Data Quality Speaker: Dr. Rich Holmes and Wendy Funk Session: R-6-1000. Objectives. After completing this session, the attendee can: Characterize the following DQ Issues Affected by Recent Changes to PPS: Treatment of Units of Service in RVU Calculations

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slide1

Title: Using M2 to Manage MTF Data QualitySpeaker: Dr. Rich Holmes and Wendy Funk

Session: R-6-1000

objectives
Objectives

After completing this session, the attendee can:

  • Characterize the following DQ Issues Affected by Recent Changes to PPS:
    • Treatment of Units of Service in RVU Calculations
    • Substituting the Ceiling on Maximum Units of Service
    • Usage of “J” Codes in B-Clinic SADRs and. . .
  • Characterize the following ongoing DQ Issues:
    • . . . Usage of other HCPCS Codes in B-Clinic SADRs
    • Usage of New E&M code for Established Patients
    • Coding Creep
    • Admitting Same Day Surgeries
    • Inpatient Procedures Coded in Ambulatory Clinics
    • Usage of Individual CPT Codes for Group Therapy
slide3

Objectives

After completing this session, the attendee can:

  • Characterize the following DQ Issues Affecting Readiness or Continuity of Care:
    • Case Management Workload and FTEs
    • MDC 23 Explosion in Utilization
  • Leverage the MHS Data Mart (M2)
    • Describe the M2.
    • Describe the process of retrieving and using a corporate document.
    • Describe how M2 can be used to write ad-hoc reports about data quality.
units of service limits
Units of Service Limits
  • There are three components associated with CPT coding:
    • The code itself
    • The code modifier – intended to add additional information about a procedure code
    • Units of service: Indicates the number of times a procedure code is performed on a data record.
  • Proper RVU assignment takes all of these into account, as well as:
    • Setting
    • Type and Number of Providers
units of service limits1
Units of Service Limits
  • There are three types of RVUs.
    • Work RVUs: represents provider costliness and effort
    • Practice Expense RVUs:
      • Represents a provider’s overhead costs, such as supplies, nurses, admin staff, etc..
      • Two types: “In Office” and “Out of Office”
    • Malpractice RVUs: intended to assist in covering malpractice premiums.
  • Initially, HA/TMA used only the work RVU for PPS, with no other adjustments for units of service, modifiers, etc. (Simple RVU)
  • Eventually, PPS implemented units of service, so that multiple instances of one CPT code could be credited. (Enhanced Simple RVU)
units of service limits2
Units of Service Limits
  • PPS also incorporated practice expense RVUs.
  • This was very important
    • Without units of service, the Services were underfunded; especially for physical therapy and mental health.
    • The work RVU usually is reflective of only about half of the cost of ambulatory care – was not the best resource allocation method.
  • Implementing “total RVUs” (work + PE) and units of service was a significant improvement in the PPS.
units of service limits3
Units of Service Limits
  • The initial implementation of the new RVU data elements that included units of service (UOS) was done without respect to the quality of the reporting of UOS.
  • Many of the records received, however, contained units of service that simply could not be true.
  • Limits were developed for each CPT code by TMA/BEA.
  • These limits can be obtained from M2, in the CPT/HCPCS table.
  • All SADR data were reprocessed to incorporate the limits.
    • When this was done, users were not notified
    • Many questions have arisen from MTFs whose RVUs dropped as a result. These MTFs typically had data quality problems.
service wide impact of uos changes in fy10
Service-Wide Impact of UOS Changes in FY10

Excludes nurse workload, which will no longer be credited in PPS

meprs code impacts of unit of service limits
MEPRS Code Impacts of Unit of Service Limits
  • For most MEPRS Codes; impacts of changes in RVU methodologies were minimal
  • However, a few had major changes
  • Both PT/OT and Mental Health utilize several codes that indicate a time increment.
  • The impact in medicine is mostly from the Nutrition Clinic.

11

cpt impacts of unit of service limits
CPT Impacts of Unit of Service Limits
  • Some selected extreme examples from SADRs
  • Each SADR represents care provided to one patient on one day.
  • The first three SADRs indicate that there were 80 patients were given more than 900 vaccinations at one visit!
  • The last SADR shows 159 encounters where the patients had up to 52 days of psych counseling in one day!
quantity limits in clinic records1
Quantity Limits in Clinic Records
  • TMA BEA sets “ceilings” on the maximum reasonable number of times a procedure could occur in an encounter.
  • If an MHS provider reports more than that number, the data are overwritten using the TMA BEA ceiling.
  • PPS calculates earnings based on the overwritten new number, and third-party billing when centralized would also see only the new number.

Here are some examples!

quantity limits in clinic records2
Quantity Limits in Clinic Records

These are single encounters in MTFs in FY10

*Meant modifier “55” (follow up)

quantity limits in clinic records3
Quantity Limits in Clinic Records

Impact on Replacing Impossible Quantities with “1”:

Army $3,260,417

Navy $1,448,307

Air Force $ 812,071

MHS $5,520,795

clinician administered drugs1
Clinician-Administered Drugs

Clinician-Administered Drugs (HCPCS “J”)

  • Represent $38 million dollars in the FY10 records.
  • PPS funded in FY2010, but will not in FY2011.
  • Can be billed for third-party collections.
  • In FY2010, $5.2 million was coded in clinician administered medications (J HCPCs) to patients who had other health insurance (OHI).
  • Not included in this are some outrageous quantities, although PPS did use them for reimbursement!
clinician administered drugs2
Clinician-Administered Drugs

Clinician-Administered Drugs (HCPCS “J”)

clinician administered drugs3
Clinician-Administered Drugs

BUT “J” IS NOT THE ONLY HCPCS THAT MATTERS!)

slide22

Clinician-Administered Drugs

BUT “J” IS NOT THE ONLY HCPCS THAT MATTERS!)

new patient e m codes
New Patient E&M Codes
  • Evaluation and Management Codes describe the nature of a provider to patient interface
  • An important feature of some E&M codes is the distinction between a new patient and an established patient.
    • New patients require more work that established patients
    • And therefore, providers receive higher reimbursement and RVUs for new patients
new patient e m codes1
New Patient E&M Codes
  • What is a new patient?
    • Defined based on CPT Coding Rules
    • A new patient is one who has not received any professional services from the physician, or another physician of the samespecialty who belongs to the same group practice, within the past three years.
  • The definition of a new patient doesn’t only mean “new to the provider”, it can mean “new to the practice” also.
  • To determine the extent to which new patient E&M codes are properly used:
    • Developed a history file
    • Person ID, MTF, date of service, specialty and MEPRS code
    • Compared with coding on each new/established SADR
    • Compared 2007 to 2010

25

new patient e m codes3
New Patient E&M Codes
  • Coding of new patient E&Ms has improved for 2 of the three Services from 2007 to 2010.

% of records that seem to be improperly coded

new patient e m codes4
New Patient E&M Codes
  • At MTF-level, some MTFs have shown improvement in new patient E&M coding, while others have not.
new patient e m codes5
New Patient E&M Codes
  • At MTF-level, some MTFs have shown improvement in new patient E&M coding, while others have not.
coding creep1
Coding Creep. . .

MHS Worldwide Average (non ERs), October 2005 through January 2011

31

coding creep2
Coding Creep. . .

Average E&M Code Intensity

MHS Worldwide Average (non ERs), October 2005 through January 2011

32

coding creep3
Coding Creep. . .

One Medical Examination Clinic. . .

October 2005 through January 2011

33

coding creep4
Coding Creep. . .

Average E&M Code Intensity in Emergency Rooms

MHS Worldwide Average (ERs), FY2006 through FY2010

34

admitting same day surgeries
Admitting Same Day Surgeries
  • Over the past several decades, the settings for many procedures has changed from inpatient to ambulatory
  • Using an ambulatory setting when appropriate is beneficial to both the patient and the health system.
  • Many health plans require pre-authorization for hospitalizations for care that is routinely provided in ambulatory settings.
    • This is because some patients have complications or co-morbidities that may require the admission.
  • No such pre-authorizations are required for MTF care.
  • Reimbursements are far greater for inpatient settings than for ambulatory
admitting same day surgeries1
Admitting Same Day Surgeries
  • AHRQ published a list of procedures where 90% or more of cases are done in an ambulatory setting; based on data from their Health Care Utilization Project (HCUP)
    • Russo, C.A., Elixhauser, A., Steiner, C., and Wier, L. Hospital-Based Ambulatory Surgery, 2007. HCUP Statistical Brief #86. February 2010. Agency for Healthcare Research and Quality, Rockville, MD.
    • http://www.hcup-us.ahrq.gov/reports/statbriefs/sb86.pdf
  • For this analysis, we selected tonsillectomies (with adenoid removal)
admitting same day surgeries2
Admitting Same Day Surgeries
  • MTF SIDR records were classified using the AHRQ Clinical Classification Software (CCS) for Procedures
    • AHRQ CCS groups either ICD-9 procedures or CPT procedures into categories
    • http://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp#downloadProvides a handy crosswalk.
  • All procedure codes on each SIDR were grouped and records that contained only the 4 selected procedures were retained.
  • Admissions from same day surgery and ER were excluded, as were cases with complications and co-morbidities.
admitting same day surgeries3
Admitting Same Day Surgeries
  • PPS Earnings for these ambulatory-type services were then calculated from the SIDRs
  • And using SADRs, for these same MTFs, PPS earnings were calculated for the same procedures (based on AHRQ CCS groupings), but when done in an ambulatory setting.
  • 7,474 uncomplicated tonsillectomies/adenoiodectomies were performed at MTFs in FY10.
  • For most MTFs, only 3% were performed in an inpatient setting
admitting same day surgeries4
Admitting Same Day Surgeries
  • Tonsils:
    • About half of all uncomplicated tonsillectomies done as inpatients were done at 3 MTFs.
    • These three MTFs earned almost 3 million dollars for these surgeries
    • If these had been done on an outpatient basis, there three sites would have earned only about a half a million dollars!
inpatient procedures coded in b clinics1
Inpatient Procedures Coded in B Clinics
  • PPS includes in its RWP (inpatient) earnings a “price per RWP” that includes both the hospital and all clinicians’ work for the inpatients.
  • UBU and CHCS create SADRs in B-Clinics, sometimes labeled as inpatients and sometimes not, but for patients who are clearly inpatients. If a B-clinic SADR is created, PPS pays RVU earnings in addition to the inpatient RWP earnings.
  • There are enormous differences on the extent to which B-Clinic SADRs are reported for inpatients, both between services, and between MTFs.
inpatient procedures coded in b clinics3
Inpatient Procedures Coded in B Clinics
  • A single patient admitted for a broken hip, reduced at one MTF but then transferred to a Medical Center for wound debridement, had as an inpatient:
    • 417 B-clinic SADRs
    • Which earned $50,089 for the medical center
    • In ADDITION to the PPS earnings for the 5 month stay.
group service records
Group Service Records

Group encounters require coding with special CPT or HCPCS to reflect that group counseling or other therapies are less effort per patient than individual care.

Appointment times (MDR only) show when groups are treated instead of individuals.

Conclusions are only as valid as the appointment times – “cattle call” sessions would appear to be groups.

Oddly, a handful of CPT codes give MORE weight for a group than for an individual, like H0004 and H0005 (alcohol and drug counseling). Perhaps it was intended that billing for such groups would not be individually identified?

On the next slide, the FY10 data are corrected into groups.

47

group service records2
Group Service Records

Same doctor, same day and clinic, same appointment time

49

slide50
Data Quality

Affecting Readiness or Continuity of Care

case management
Case Management
  • MTFs have special requirements for coding of case management
    • Significant Congressional Interest
    • Congress is requiring reporting of # of case managers and their case loads.
  • New coding guidelines utilize SADRs to capture information
  • And MEPRS to capture full-time equivalent case managers
  • Contained in UBU Coding Guidelines, Appendix E
case management coding
Case Management Coding
  • MEPRS codes:
    • Tri-Service consensus was not reached with regard to the use of MEPRS codes for case management.
    • The following codes are to be used exclusively for case management:
characteristics of case management records
Characteristics of Case Management Records
  • Case Managers are required by HA to submit at least one SADR per month that represents an acuity assessment
    • Not necessarily a provision of healthcare services, like most SADRs.
  • CM SADRs contain the same data elements as regular SADRs.
  • Provider ID represents the case manager.
  • Two new provider specialty codes were created:
    • Nurse Case Manager (613)
    • Social Worker Case Manager (714)
slide56

Characteristics of Case Management Records

  • Tri-Service case management work group decided that case managers would not make diagnoses.
  • Rather, case managers would use the following diagnosis codes on CM SADRs:
slide57

Characteristics of Case Management Records

  • Procedure Code is used to represent the case manager’s assessment of the patient’s acuity.
coding of case management
Coding of Case Management

The M2 SADR table can be used to review CM SADRs.

(Corporate document or ad-hoc)

Some issues have been identified with reporting

Use of MEPRS codes (FY10 data)

Red Font indicates that these RVUs would have earned PPS $ in 2010

coding of case management1
Coding of Case Management

Completeness of Data

There is no perfect method to identify how many case managed patients there should be.

The following chart shows selected MTFs that treat patients enrolled inWarrior in Transition Units (WTUs).

coding of case management2
Coding of Case Management

Completeness of Data

Requirement includes coding of CM data for active duty and non active duty. First priority was to implement coding for AD

coding of case management3
Coding of Case Management

Effect on MEPRS costs

One purpose of MEPRS is to allocate overhead costs to the areas that benefit (stepdown).

Costs recorded in MEPRS codes that begin with D and E are allocated.

Army uses FAZ2 for WTUs, and thus costs are not allocated.

slide65
MDC 23 as a % of total ambulatory encounters; by bencat and Service (FY2010; MEPRS B Codes; FBI and FBN)
types of care being recorded in mdc 23
Types of Care Being Recorded in MDC 23
  • Top Diagnoses in “Other”
  • Encounters for Unspecified Administrative Services (16% of other)
  • Periodic Preventive Exam (6%)
  • Issue of Repeat Prescription (4%)
unrealistic mdc 23 workload
Unrealistic MDC 23 Workload
  • One provider did more than 65,000 encounters in 212 work days.
    • Averages more than 300 encounters per day.
    • Averages more than 580 Total RVUs per day.
    • In FY10, these RVUs would have earned PPS $.
introduction of m2
Introduction of M2
  • What is M2?
    • MHS Mart
    • Data Mart containing a subset of the MHS Data Repository.
    • 1700 users of M2, across the MHS.
    • Includes DEERS, Direct Care and Purchased Care.
    • Easy to query; no programming knowledge required.
    • Analytical Tools, such as “Slice and Dice”.
    • Can upload and download data.
    • Significant advantage with multiple data sources all contained in one system.
    • Data Dictionary: http://www.tricare.mil/ocfo/bea/functional_specs.cfm
live m2 screen with menu of data files1
Live M2 Screen with Menu of Data Files
  • Folders are called “Classes”
  • Directories which contain the data files people query from
  • Behaves like directory structures in Windows
mtf data in m2
MTF Data in M2
  • M2 contains several data files sent from MTFs
  • Detailed event-level records:
    • Standard Inpatient Data Record
    • Standard Ambulatory Data Record (to be renamed “CAPER”)
    • MTF Laboratory, Radiology and Pharmacy
  • Summary records:
    • Medical Expense and Performance Reporting System
    • Worldwide Workload Report
  • M2 also contains several files that don’t originate at MTFs
    • For example, claims or DEERS records
mtf data files
MTF Data Files

SIDR

SADR

Lab/Rad

Pharmacy

MEPRS

WWR

using m2
Using M2
  • Users can write ad-hoc reports or can use already written “Corporate Documents”
  • Corporate Document Handbook is available
    • Describes the purpose, content and how to use each report
    • Financial Reports, Clinical Reports and Data Quality Reports
  • Corporate Reports are very easy to use
    • Users simply need to know their MTF DMISID
    • Tools within M2 (slice and dice) allow for analysis of data within the reports
data quality corporate documents
Data Quality Corporate Documents
  • Some examples of Data Quality Corporate Documents
  • Completeness of Data:
    • Inpatient Completeness (WWR vs. SIDR vs. MEPRS)
    • Ambulatory Completeness (WWR vs. SADR Count/No-Count vs. MEPRS)
  • Accuracy:
    • Ungroupable MS-DRGs on SIDRs
    • Unlisted Provider Specialty on SADR
    • Record Level Uncoded SADR Report
    • PDTS Most Expensive Drug Report
    • Invalid Provider ID
slide77

Steps for retrieving a corporate document:

  • File
  • Retrieve From
  • Corporate Documents
  • The following box will appear…
slide78

Select the document you wish to retrieve and then select “Retrieve”. If the “Open on Retrieval” box is selected, the document will open automatically.

ad hoc use of m2
Ad-Hoc Use of M2
  • The possibilities for analysis of data quality issues using ad-hoc M2 are limitless.
  • M2 records can be retrieved at detailed level, enabling easy visibility of the coding at each MTF.
  • To write an ad-hoc query, users:
    • Select the data file to use.
    • Select the data elements needed.
    • Create “filters” to limit the data to answer a specific question.
  • Recommend that users who write ad-hoc queries obtain training on the use and interpretation of MHS data.