1. To code, or not to code: that is the question: Whether 'tis nobler in the mind to suffer (786.5) The calls and emails of outrageous fortune, Or to take arms against a sea of uncoded T’cons, And by opposing end them? To be denied leave, and sleep (307.41) No more; and by taking leave we temporarily end The heart-ache (419.9) and the thousand emails That my in-box is heir to, 'tis a consumption (011.9) Devoutly to be wish'd against. Jim Cox, in his year of discontent 2005

2. Coding Overview and the Commander’s Statement May 2008 DQMC

3. Why this matters to Data Quality Coded data is used to make decisions regarding: –Population health –Funding –Anticipating which mix of providers is needed –Justifying new equipment You need to know the quality of your data to decide how much to trust it

4. How this affects DQ This talk is mostly about –How to ensure your reported data are correct –How to do an audit that actually tells you something

5. Ways to employ this info in your DQ programs We will discuss the most successful ways to improve your coding –Teach –Use –Audit – this includes taking action on issues found during the audit and correcting them, permanently

6. Goal Quality data on which to base sound decisions –For you –For your Commander –For your Service –For the Military Health System (MHS)

7. Data Goal Corollary You give me bad data, I’ll make bad decisions

8. Suggested Coding “Solution” Have each new provider, prior to receiving privileges to practice at your MTF, spend 4 hours with a good coding trainer –Option to “test out” of the class by passing test composed of examples of quality documentation which the provider will enter the correct diagnoses/external causes of injury, evaluation and management code(s) with modifiers, procedure code(s) and any other applicable HCPCS code(s)

9. Coding Basics International Classification of Diseases –Diagnoses, why patients seek/receive care –Also used for inpatient institutional workload –Explains why the provider did the service Used to support medical necessity Current Procedural Terminology –Type of service furnished, office visit, x-ray –Used for professional services workload –Used for outpatient institutional workload

10. Coding Basics Codes are assigned based on documentation Diagnosis codes are assigned differently based on the setting (inpatient or outpatient) Military Health System has special coding requirements, which are logical, and are needed to accurately reflect services http://www.tricare.mil/ocfo/bea/ubu/coding_guidelines.cfm

11. One-on-one Training Overview Each training is specific to the specialty involved (e.g., training is different for obstetrics, orthopedics and occupational therapy) 1 hour documentation/diagnoses 1 hour evaluation and management/modifiers/quantity 1 hour procedures/supplies/training 1 hour practice

12. Training Goals Learn basics of good documentation Learn basics of outpatient (not inpatient or APV) ICD/E&M/CPT/HCPCS coding Learn when to ask for coding assistance Become comfortable asking coder questions (it also gets the coder comfortable working with the provider)

13. Measure Success of Training Random audit of provider’s first week of documentation/coding and provide immediate feedback Random audit of provider’s first month and provide immediate feedback Continue to audit/provide one-on-one feedback until documentation and coding are consistently at acceptable level

14. Professional Staff Meeting Arrange to have coder auditor have maximum of 5 minutes at professional staff to review issues common to the facility Arrange to have coders permitted to attend professional staff –This will permit a non-threatening environment for providers and coders to interact –Coders need continuing education too

15. Coder Training If you have AHLTA, your coder must be trained to use AHLTA –Need to know so coder can figure out why something happens Have periodic training on military unique issues in UBU Coding Guidelines Review updated ICD codes in September Review updated CPT/HCPCS codes in December Recommend a goal be that coder becomes certified – AAPC or AHIMA is fine

16. Use Your Data If you try to learn a foreign language, but don’t ever need to use it – how much effort will you put into learning the new language? If you get plunked down in a different country where no one speaks your language – how much effort will you put into learning the new language?

17. Use Your Data A provider wants to go to a conference to learn to treat autistic children (in Banff, Alberta in January) Radiology wants another fluoroscopy unit A provider wants to go to an 8-week dermatology course at another medical center A provider wants a piece of equipment to do hip replacements

18. 1. What does this tell you?

19. Answer: You have ten fewer hips that need replacing in May than you did in December, if your population did not change. What you need to know is – DEMAND/BACKLOG, –PRODUCTION, –IS THERE IN-HOUSE CAPACITY, –COST IN-HOUSE, –COST DOWNTOWN

20. Graphs 8 points make a trend IF they reflect a changing variable Weekly/monthly/annual grafts do NOT indicate a trend UNLESS time is a variable For hip replacements TIME is NOT a variable Looking at DQ metrics over time do not represent at “trend”

21. Looking at DQ Metrics If there is a change – up or down –Something happened A change indicates you need to know what changed –A provider who understands how to code came/left –A new coder was hired –A coder took a class and trained the department

22. Now to a quick look at coding related data in the data quality statement

23. 2a. % Outpatient Encounters, other than APVs, coded in 3 days

26. 2b. % APVs coded in 15 days

27. 2c. % Inpatient records coded in 30 days post d/c?

28. 5a. Inpatient % DRG correct?

29. 5b. Inpatient Professional Services E&M

30. 5c. Inpatient Professional Services ICD9

31. 5d. Inpatient Professional Services CPT

32. 6a. Documentation available?

33. 6b. Outpt E/M

35. 6c. Outpt ICD-9

36. 6d. Outpt CPT

37. 6e. % DD Form 2569s (TPC Insurance Info)

38. 6f. % DD Form 2569s in the Patient Insurance Information (PII) module in CHCS?

39. 7a. (APV) documentation available?

40. 7b. APV ICD-9

42. 7c. APV CPT

43. 7d. APV DD Form 2569s available

44. 7e. APV DD Form 2569s in PII (C.7)

45. 8e. # of Inpatient Professional Services Rounds SADR encounters

46. 9. (E.4.c) # of AHLTA SADR encounters / # of Total SADR encounters.

49. Objectives Use your DQ metrics appropriately Understand “Random” When Applied to Audits

50. Running a Business Would you like to know –Your customers needs –Your customers wants –How much it costs to make your product –For how much you can sell your product

51. Running a Business Would you like to know –Your customers ICD-9-CM diagnosis data (6c) Demographic data (e.g., age, gender, OHI) Patient categories (PATCATs) –How much it costs to make your product Medical Expense Performance and Reporting System (MEPRS) Provider specialty codes/HIPAA taxonomy (resident or physician) –For how much you can sell your product Relative Value Units (RVUs) and Relative Weighted Products (RWPs) (6b, 5)

52. Data Quality = $$$ Patient Registration –PATCATS - $$$ - $180 M last year (get your Coast Guard, VA, DoD civilians, cosmetic surgery, and civilian emergencies correct…) –Identifying injuries (Medical Affirmative Claims) - $$$ $16.5M last year – demonstrates how poorly we identify these cases –Other Health Insurance (DD 2569) - $$$ $103.1 M last year Documentation - $$$ –Must have document filed in record –Coding - $$$

53. Close Close counts in atomic bombs Close counts in horseshoes Close does not count in coding –If there is no code, then there is no code and we use an “unlisted code” Yes, we do bill for Active Duty services (in MSA we bill Coast Guard, in MAC will bill)

54. Bottom Line It appears that for most bases, there is no problem getting outpatient documentation. Is this what you are hearing from your doctors? –For AHLTA documentation, I sure hope it is there –How are you doing for things not in AHLTA such as Emergency Department, Obstetrics, etc?

55. What do these slides tell us? If TMA has coding resources, they should only be offered to the bases reporting coding below 80%? How is your Service interpreting these data? How is your Service dividing funds? Manpower? Training slots?

56. Audits All data included population –Each encounter equally likely to be selected –Right now there are encounters in the D and F MEPRS not being audited, telephone calls… Random selection of sample from entire population A person will continue to code in the same manner he has coded unless acted upon by an outside source

57. Random vs Targeted Do random to find problem areas –For instance, 100 records with SADRS in a month from all SADRS in the MTF Then do targeted to better define the problem –For instance, you find a nurse practitioner in pediatrics with diagnosis errors on both records audited. Will you do a more detailed audit of nurse practitioners, or pediatric providers, or all records with the diagnoses that were wrong?

58. Your Commander Signs: 9. I am aware of data quality issues identified by the DQMC Review List and when needed, have taken action to improve the data from my facility.

59. Objectives Use your DQ metrics appropriately Understand “Random” When Applied to Audits

60. Questions