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

1. Title: Using M2 to Manage MTF Data QualitySpeaker: Dr. Rich Holmes and Wendy Funk Session: R-6-1000

2. 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

3. 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.

4. DQ Issues Affected by Recent Changes to PPS

5. Implementation of Unit of Service Limits in RVU Calculations 5

6. 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

7. 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)

8. 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.

9. 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.

10. Service-Wide Impact of UOS Changes in FY10 Excludes nurse workload, which will no longer be credited in PPS

11. 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

12. 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!

13. Quantity Limits in Clinic Records

14. 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!

15. Quantity Limits in Clinic Records These are single encounters in MTFs in FY10 *Meant modifier “55” (follow up)

16. 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

17. Clinician-Administered Drugs

18. 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!

19. Clinician-Administered Drugs Clinician-Administered Drugs (HCPCS “J”)

20. Ongoing DQ Issues

21. Clinician-Administered Drugs BUT “J” IS NOT THE ONLY HCPCS THAT MATTERS!)

22. Clinician-Administered Drugs BUT “J” IS NOT THE ONLY HCPCS THAT MATTERS!)

23. Use of New Patient E&M Codes 23

24. 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

25. 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

26. New Patient E&M Codes

27. 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

28. New Patient E&M Codes • At MTF-level, some MTFs have shown improvement in new patient E&M coding, while others have not.

29. New Patient E&M Codes • At MTF-level, some MTFs have shown improvement in new patient E&M coding, while others have not.

30. Coding Creep. . . 30

31. Coding Creep. . . MHS Worldwide Average (non ERs), October 2005 through January 2011 31

32. Coding Creep. . . Average E&M Code Intensity MHS Worldwide Average (non ERs), October 2005 through January 2011 32

33. Coding Creep. . . One Medical Examination Clinic. . . October 2005 through January 2011 33

34. Coding Creep. . . Average E&M Code Intensity in Emergency Rooms MHS Worldwide Average (ERs), FY2006 through FY2010 34

35. Admitting Routine Same Day Surgeries 35

36. 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

37. 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)

38. 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.

39. 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

40. MTFs and Tonsillectomies

41. 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!

42. Inpatient Procedures Coded in B Clinics

43. 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.

44. Inpatient Procedures Coded in B Clinics

45. 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.

46. Coding of Group Sessions 46

47. 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

48. Group Service Records 48

49. Group Service Records Same doctor, same day and clinic, same appointment time 49

50. Data Quality Affecting Readiness or Continuity of Care