1. 1 Direct Care Prof Encounters TMA / WISDOM Excerpt Direct Care Professional Encounters

2. 2 Direct Care Prof Encounters TMA / WISDOM Excerpt Objectives Describe the characteristics Describe cost and workload measures What elements should you select or avoid when making management decisions

3. 3 Direct Care Prof Encounters TMA / WISDOM Excerpt What’s in the File? Encounters in ambulatory clinics, including those by inpatients (MEPRS-B) Inpatient provider records (MEPRS-A) Some MEPRS-F ambulatory (Immunizations and Hearing Conservation) Some ancillary activities (in clinic) Mixed facility types

4. 4 Direct Care Prof Encounters TMA / WISDOM Excerpt Encounters by FY and 1 st Level MEPRS Code A=Inpatient; B=Ambulatory; C=Dental; F=Supplemental As of 2/9/07

5. 5 Direct Care Prof Encounters TMA / WISDOM Excerpt Various Facilities

6. 6 Direct Care Prof Encounters TMA / WISDOM Excerpt Historical Compliance Issues Requirement to complete SADR within 3 business days of encounter. Not always met Larger issue with getting the SADR at all Concept of appointment-inferred SADRs and their measures accounts for missing data, as most management questions require FY03 and forward incorporates the appointment- inferred concept. Older data use the “Raw” and “Total” concept based on the WWR

7. 7 Direct Care Prof Encounters TMA / WISDOM Excerpt Actual vs Inferred Completed encounter records compared to appointment records. Missing encounters “inferred” from appointments Person information based on appointed person No diagnosis or CPT codes Workload and cost measures inferred by Tmt DMIS ID, visit class (APV, Telcon, Other), and MEPRS3 Code Replaces Raw vs. Total in the FY03+ detail tables

8. 8 Direct Care Prof Encounters TMA / WISDOM Excerpt Procedure Codes Coded with CPT codes Evaluation & Management (E&M) Code - previously mandatory Up to four additional procedures Most records have no procedures (i.e., E&M Code is coded, but Procedure 1 – Procedure 4 is usually not coded) –This is not the case for Ambulatory Procedure Visit (APV) clinics

9. 9 Direct Care Prof Encounters TMA / WISDOM Excerpt Ambulatory Procedure Visit (APV)Flag: Indicates care delivered in ambulatory procedure unit (APU) Same Day Surgery Flag: Surgery done in an APU Ambulatory Surgery

10. 10 Direct Care Prof Encounters TMA / WISDOM Excerpt  Based on CPTs and first diagnosis code  E&M Code + first diagnosis determine E&M and medical APGs, respectively  Each additional CPT results in an APG  Maximum of 6 per record Ambulatory Procedure Groups

11. 11 Direct Care Prof Encounters TMA / WISDOM Excerpt  Based on CPTs codes  Each CPT code (E&M and 4 procedural codes) results in an APC  Used by Medicare  Maximum of 5 per record  FY05+ only Ambulatory Payment Classification

12. 12 Direct Care Prof Encounters TMA / WISDOM Excerpt Appt Status Appt Status Code is in the DETAIL table Appt Status Class is in the SUMMARY table Retained records do not include left without being seen (LWBS), no-shows, or cancellations

13. 13 Direct Care Prof Encounters TMA / WISDOM Excerpt  Numeric codes used for ambulatory care –Released –Referral –Admitted  Character values used for inpatient rounds care – values resemble those in inpatient data –Transfers –Routine Disposition Disposition Code

14. 14 Direct Care Prof Encounters TMA / WISDOM Excerpt  Service Date = Date of encounter  FY/FM and CY/CM are the year and month of the Service Date Date Field

15. 15 Direct Care Prof Encounters TMA / WISDOM Excerpt Provider Data Provider ID: Primary provider, unique to CHCS host Provider Specialty: –001 = FP Physician, etc –910+ do not indicate a provider specialty, but rather a “clinic” Provider Specialty, HIPAA: HIPAA taxonomy, e.g., 207K00000X = Allergy & Immunology Provider Type Code: full time, part time, house staff, etc Secondary Provider IDs also available, but not specialty

16. 16 Direct Care Prof Encounters TMA / WISDOM Excerpt APG Weights Every APG receives a weight Weight reflects relative consumption of MTF resources (includes provider) Aggregate APG weight computed as: 100% for the “heaviest” + 50% for others Reflects economy of scale Best overall workload measure for your facility, not for a provider

17. 17 Direct Care Prof Encounters TMA / WISDOM Excerpt APC Weights Every APC receives a weight APC Aggregate Weight = sum of the 5 weights on a record FY05+ only Used by Medicare for reimbursement

18. 18 Direct Care Prof Encounters TMA / WISDOM Excerpt Relative Value Units (RVUs) Numeric values quantify relative work and cost of health care services (CPT) Emphasis on provider contribution 3 main components in civilian tables: –Work –Practice Expense (Facility or Non-Facility) –Malpractice Most RVU fields based on “work” component

19. 19 Direct Care Prof Encounters TMA / WISDOM Excerpt Relative Value Units (RVUs) See Relative Value Units Primer [date].doc

20. 20 Direct Care Prof Encounters TMA / WISDOM Excerpt Cost Measures Full Cost, Variable Cost Clinician Salary; Other Labor; Lab; Rad; Rx; Other Ancillary; Other Primarily APG Based. (Clinician salary component based on RVUs.) 100% of highest, 50% of others FY05 and back: Based on MEPRS expense data from respective FY FY06+: Based on FY05 MEPRS expense data, inflated

21. 21 Direct Care Prof Encounters TMA / WISDOM Excerpt Odds and Ends Seasonal patterns Coding changes –Physical Therapy Coding Changes Idiosyncratic coding practices –Navy Obstetrics Workload (guidance to stop coding to BCC-Obstetrics and put in BCB- Gynecology) Use pregnancy diagnosis code along with BCB to obtain Obstetrics

22. 22 Direct Care Prof Encounters TMA / WISDOM Excerpt Navy Ob/Gyn Workload Starting in FY04, the Navy instructed their facilities to code all OB work in BCB instead of BCC BCC SADRs eventually disappear See next slide.

23. 23 Direct Care Prof Encounters TMA / WISDOM Excerpt Navy Ob/Gyn Workload

24. 24 Direct Care Prof Encounters TMA / WISDOM Excerpt Questions?

25. 25 Direct Care Prof Encounters TMA / WISDOM Excerpt Direct Care Lab-Rad Ancillary

26. 26 Direct Care Prof Encounters TMA / WISDOM Excerpt Objectives Characteristics. Cost and workload. Use in decision-making.

27. 27 Direct Care Prof Encounters TMA / WISDOM Excerpt What’s in the File? One or two records per test/exam. Just those for MEPRS B, C, D and FC (other MTFs and providers). FY05 and forward. Normal demographics and enrollment.

28. 28 Direct Care Prof Encounters TMA / WISDOM Excerpt Record counts for 1 st Level MEPRS Code B=Ambulatory; C=Dental; D=Ancillary FC=HC Svcs Support MEPRS1 Code, Ordering Record TypeFY B C D F Total % of Total Lab2006 30,318,78924,122199,4781,846,13332,388,52280% Rad2006 7,835,0167,21930,265 392,67088,265,17020% Total 38,153,80531,341229,7432,238,80340,653,692100%

29. 29 Direct Care Prof Encounters TMA / WISDOM Excerpt Radiology detail has one table. Lab detail tables are broken out by FY due to size. Summary tables also available.

30. 30 Direct Care Prof Encounters TMA / WISDOM Excerpt Procedure Codes Coded with CPT codes with Modifiers. Number of Services = Number of times procedure performed –Beware bilaterals! Some tests have “fake” 89240.

31. 31 Direct Care Prof Encounters TMA / WISDOM Excerpt CPT Modifiers for Laboratory (Unique Use) 1st Modifier:  00 = Technical Component for in-house work  26 = Professional Component (Pathologist)  32 = Technical Component for referral work  90 = External Laboratory

32. 32 Direct Care Prof Encounters TMA / WISDOM Excerpt CPT Modifiers for Radiology (Normal Use) 1st Modifier (Normal Use like Civilians):  00 = indicates the record came in with no modifier  26 = Professional Component (PC)  32 = Technical Component (TC)  Most exams will have one record for each modifier 2nd Modifier (Military Unique Use) :  50 = Bilateral with 26  51 = Bilateral with 32  99 = Multiple Modifiers  These differ from civilian practice where 50 is bilateral but 51 is multiple procedures.  The 2 nd modifier may or may not be present.

33. 33 Direct Care Prof Encounters TMA / WISDOM Excerpt Relative Value Units (RVUs) Normal application by CPT code. Work, practice expense components. Multiplied by corrected number of services.

34. 34 Direct Care Prof Encounters TMA / WISDOM Excerpt CHCS doubles the number of services for bilateral exams. This has been corrected in the RVU weights but not in the number of services. A new field, “number of services of record” will show the original number; whereas the “number of services” will be the corrected number. (Fields are present, but not populated correctly.) Radiology Examples

35. 35 Direct Care Prof Encounters TMA / WISDOM Excerpt  Service Date = Date of radiology exam or lab testing.  FY/FM and CY/CM and class based on this date. Date Field Provider Data Treatment DMIS ID and associated fields. Ordering DMIS ID/MEPRS Code is the Parent of the ordering MTF and only if on same CHCS Host.

36. 36 Direct Care Prof Encounters TMA / WISDOM Excerpt Cost Measures Full Cost, Variable Cost. Apportioning of costs based on RVUs.

37. 37 Direct Care Prof Encounters TMA / WISDOM Excerpt Odds and Ends Diagnosis codes and PPS Market Value fields are empty. Big holes in FY05 data, FY06 generally complete. At this time, there is no indication that missing data can be recovered. Anatomical Pathology departments using the CoPath system do not pass their workload into CHCS; thus this workload is missing. Duplicates are present but are only about 0.5% of the records. These will be removed in the October 2007 release. Transfusion medicine at MTFs which have an automated system should be viewed with caution as individual transactions may be recorded, not actual workload.

38. 38 Direct Care Prof Encounters TMA / WISDOM Excerpt Questions?