1. From Registration to Accounts Receivable – The Whole Can of Worms 2007 UBO/UBU Conference From Registration to Accounts Receivable – The Whole Can of Worms 2007 UBO/UBU Conference 1 Briefing: RVUs and RWPs, An Advanced View Speaker:Rich Holmes, Wendy Funk Date:22 March 2007 Time:1010 - 1100 – Track 1 1110 - 1200 – Track 2

2. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 2 DATA MANAGEMENT WKLD

3. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 3 Objectives Part 1 – RWPs Describe the role of coding in MHS management as effected through weighted workload measures Describe how WWR, MEPRS, and Appointment Data allow ready detection of uncoded services Describe RWPs, including their basis in claims Describe how SIDRs get RWPs assigned, and the damage poor coding can cause Part 2 – RVUs Describe RVUs and their components, and contrast to APGs and APCs Describe how RVUs are assigned to SADRs Describe limitations to RVU measurements in direct care, to include differences from civilian coding and the absence of needed fields

4. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 4 Introduction Weighted Workload is available in both direct and purchased care data This session focuses on the application of workload to direct care data – Cannot generalize to purchased care – Data collection techniques are too different! – Wisdom course, TFMEP for more info

5. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 5 Chronology of the Can Health Services

6. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 6 Captured Lost Never Coded Health Services Chronology of the Can

7. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 7 Miscoded Well coded Captured Lost Never Coded Health Services Chronology of the Can

8. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 8 Paid $ UnPaid Underpaid $- UnPaid Miscoded Well coded Captured Lost Never Coded Health Services Paid $ Chronology of the Can

9. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 9 Management Based on Workload Impute Workload Ignore Lost Workload

10. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 10 Cooking from the Can Weighted Workload is used in the MHS for all sorts of “ high-stakes ” purposes: – Budget Development (PPS) – Business Planning – Productivity Reporting / Analysis – Venture Capital Program – Make vs. Buy Studies – TRICARE for Life (MERHCF) Program – GWOT tracking and funding

11. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 11 Workload and Reporting Systems

12. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 12 Basic Workload 20 Quarters 100 Pennies Pile A Pile B

13. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 13 Raw Workload Pick a Pile: If you get to keep the pile and spend it! If you have to carry the pile in your pocket Pile A

14. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 14 Raw workload: – Counts of services – Very common for basic statistical reporting – Some limited types of productivity InpatientAmbulatoryOther AdmissionsEncountersScripts DispositionsVisitsLab Tests Days Raw Workload

15. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 15 Raw Workload Cost per Bed Day: – Normal newborns: $1,000 – All other newborns:$2,000 Cost per encounter – Ambulatory Procedure Visit:$2,015 – Family Practice:$ 190 Cost per radiology exam – X Ray:$ 25 – MRI:$ 321

16. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 16 Weighted Workload 20 Quarters = $5.00 100 Pennies = $1.00 Pile A Pile B

17. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 17 Worldwide Workload Report WWR contains monthly tabulated workload counts Summary data: Treatment DMISID, Work center, Bencat, workload amount – Admissions – Dispositions – Bed days – Countable outpatient visits – Countable inpatient visits

18. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 18 TypeAFNTotal ADM131,76245,39386,389263,544 BED448,125135,809273,624857,558 DSP131,72445,34286,240263,306 IPV208,40424,28793,425326,116 OPV13,562,7026,621,3018,230,31228,414,315 WWR Workload for FY 06 Worldwide Workload Report

19. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 19 MEPRS Financial system with workload data from CHCS Conceptually the same as WWR, but without bencat May not get updated for minor changes Much slower than WWR Days & Dispositions, IPV and OPV, lab and rad RVUs Treats ICUs differently

20. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 20 WWR vs. MEPRS – FY06 WorkloadMEPRSWWR Bed Days789,055857,558 Dispositions243,478263,306 Inpatient Visits328,539326,116 Outpatient Visits26,676,10028,414,315 Admissions 263,544 As of 6 March 2007, several sizable MTFs have not reported all the MEPRS for FY06

21. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 21 ICU Days in “A” MEPRS Codes MEPRS Code DescriptionMEPRS Days WWR Days AACCoronary Care ICU07,084 AAHMedical ICU039,910 ABCSurgical ICU026,707 ADCNeonatal ICU029,452 ADEPediatric ICU02,736 Total ICU Days0105,889

22. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 22 MEPRS Workcenter Days in MEPRS Days in WWR Difference Pediatrics50143269 Nursery892250642 Neonatal ICU0711-711 Total Days1393 0 Labor, supplies, etc, are all captured in MEPRS with the “D” codes ($ ‘stepdown’ in costing, but not labor hours) WWR vs. MEPRS

23. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 23 ‘More Interesting’ Workload

24. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 24 Many Different Sources MEPRS and WWR are both designed to report tabulated workload statistics at MTFs – No weighted inpatient or ambulatory Other sources contain data that allow for more detailed analysis of workload – Encounters – Dispositions MEPRS and WWR still have a role in spotting missing records!

25. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 25 Inpatient Care Relative Weighted Products

26. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 26 Direct Care Inpatient Standard Inpatient Data Records (SIDR) – Each record is a hospital stay at an MTF – Each record is both an admission and a disposition – There can be a significant lag in record completion – Contains bed days and relative weighted products (RWPs) – Can tabulate records to generate workload statistics

27. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 27 Direct Care Inpatient Standard Inpatient Data Records (SIDR) – Case may span multiple months and even years – MEPRS & WWR split workload into the month where it occurs…. – And do not have the RWPs found in SIDRs for the “whole stay”

28. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 28 RWPs Relative Weighted Products – Measure of intensity of hospital care in an acute care setting – Has nothing to do with the providers – Incorporates room and board, OR, recovery, labs, etc. RWPs are applied to records based on: – DRG – Disposition Date – Length Of Stay (LOS) – Admission Source – Discharge Status

29. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 29 DRG-Based Payment For each DRG, TRICARE publishes a: – DRG Weight: represents the relative costliness of that DRG. vs all others in TRICARE acute care claims data – Mean length of stay for TRICARE – Short- and long-stay thresholds for TRICARE Relative costliness only incorporates acute care hospital charges Direct care data is not used in determining DRG weights – Think barracks effects, war injuries

30. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 30 tricare.osd.mil/drgrates

31. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 31 DRG Weight Examples Higher weight for surgical care! Incorporates charges for OR, recovery, etc. Higher weights for complicated care DR GDescription Weight Mean LOS SS TLST 370C SECTION W CC 0.8998 3.6 1 15 371C SECTION W/O CC 0.7210 3.0 1 8 372VAG DELIVERY W CC 0.5175 2.4 1 8 373VAG DELIVERY W/O CC 0.4038 1.9 1 5

32. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 32 DRG Weight Examples High-weight DRGs Low birthweight newborns Tracheostomy Burns Transplants Heart Procedures Low-weight DRGs Normal newborns Medical admissions Normal deliveries & antenatal care Minor surgeries

33. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 33 DRG-Based Payment Relative Weighted Product is usually the DRG weight – But less if you stay shorter than normal – And more if you stay longer than normal The next several slides describe the basic logic of calculating RWPs –Uses a cardiac procedural DRG

34. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 34 RWP Calculation DRGWgtALOSGMLOSSSTLSTPer Diem 109 Coronary Bypass w/o Cardic Cath 3.94316.25.72190.6918

35. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 35 RWP Calculation If you stay a “normal” length of time, then RWP equals the DRG weight Normal is defined by short and long stay thresholds DRGWgtALOSGMLOSSSTLSTPer Diem 109 Coronary Bypass w/o Cardic Cath 3.94316.25.72190.6918

36. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 36 RWP Calculation DRGWgtALOSGMLOSSSTLSTPer Diem 109 Coronary Bypass w/o Cardic Cath 3.94316.25.72190.6918 The RWP for short stay outliers is never greater than the DRG weight Outlier RWPs depend on length of stay “First day gets twice per diem, each additional day gets per diem, up to the DRG weight”

37. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 37 RWP Calculation DRGWgtALOSGMLOSSSTLSTPer Diem 109 Coronary Bypass w/o Cardic Cath 3.94316.25.72190.6918 The RWP for long stay outliers is always >= DRG weight. Outlier RWPs depend on length of stay. “DRG weight + 1/3 rd the per diem weight for each day in excess of long- stay threshold”

38. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 38 Example Calculation DRG 371 – C Section w/o CC WeightGLOSSSTLST Per Diem Weight 0.72103.0180.2403 Daily Weight: Total Weight / LOS LOSBaseOutlier DaysRWP RuleRWP 7 0.72100Inlier 0.7210 1Short Stay1 Twice per diem for first outlier day, per diem for extra 0.4807 20.72100Inlier 0.7210 10 0.72102 Weight + 33% per diem for outlier days 0.8812

39. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 39 RWP Unusual RWPs may result for: – Extensive rehab of wounded active duty – Infections, tooth extractions, “barracks effects” There are some special rules for transfers and very low birthweight newborns in addition to the basic logic described Note that all inlier cases receive the same credit for RWPs, regardless of length of stay Excruciating details available in documentation...

40. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 40 Top 10 DRGs by Volume —FY06 Direct Care Only DRGDRG DescCases 391NORMAL NEWBORN34,824 373 VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES29,888 630 NEONATE, BIRTHWT >2499G, W/O SIGNIF OR PROC, W OTHER PROB10,954 371CESAREAN SECTION W/O CC9,419 143CHEST PAIN6,686 372 VAGINAL DELIVERY W COMPLICATING DIAGNOSES6,246 359 UTERINE & ADNEXA PROC FOR NON- MALIGNANCY W/O CC3,923 430PSYCHOSES3,079 183 ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE >17 W/O CC2,854 370CESAREAN SECTION W CC2,773

41. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 41 Top 10 DRGs by RWP—MTFs Only DRGDRG DescDispRWP 373VAGINAL DELIVERY W/O CC29,88812,146 371CESAREAN SECTION W/O CC9,4196,839 541 ECMO OR TRACH W MV 96+HRS OR PDX EXC FACE, MOUTH & NECK W MAJ O.2845,307 143CHEST PAIN6,6863,908 391NORMAL NEWBORN34,8243,849 359 UTERINE & ADNEXA PROC FOR NON- MALIGNANCY W/O CC3,9233,824 544 MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY1,5203,591 372VAGINAL DELIVERY W CC6,2463,234 486 OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA4092,726 148 MAJOR SMALL & LARGE BOWEL PROCEDURES W CC8322,638

42. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 42 Case Mix Index (CMI)—Top 10 MTFs Tmt MTF NameCMI BROOKE AMC-FT. SAM HOUSTON 1.56 WALTER REED AMC-WASHINGTON DC 1.55 EISENHOWER AMC-FT. GORDON 1.30 59TH MED WING-LACKLAND 1.08 LANDSTUHL REGIONAL MEDCEN 1.05 WILLIAM BEAUMONT AMC-FT. BLISS 1.02 NNMC BETHESDA 1.01 10TH MED GROUP-USAF ACADEMY CO 1.00 MADIGAN AMC-FT. LEWIS 0.97 60TH MED GRP-TRAVIS 0.96 Case Mix = Average RWP

43. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 43 Miscoding Affecting RWPs Bad or missing diagnoses Wrong gender or age Missing procedures and diagnoses Typographical errors, such as dates UNGROUPABLE UNDERCODED LAUGHABLE

44. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 44 Questions Questions?

45. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 45 Contact Information Dr. Richard Holmes richard.holmes@nc.rr.com Ms. Wendy Funk wfunk@kennelinc.com

46. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 46 Ambulatory and Other Care Relative Value Units

47. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 47 Professional Encounters One SADR record per MTF provided care: – Routine Outpatient Visits – Ambulatory Procedure Visits – Emergency Room – Documented Telephone Consults – Inpatient Rounds Inpatient surgical encounter records are NOT required to be captured at MTFs Standard Ambulatory Data Records

48. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 48 Professional Encounters Hospital records (SIDRs) are captured for inpatient surgeries, but not provider records (SADRs)! – Providers earn no RVUs for this type of care! – Inpatient surgeries are A LOT of work! Leads to a significant understatement of workload for surgeons…… There are compliance problems with the SADR where there is policy! – You cannot assume that more SADRs means more workload! – It may be that compliance is improving! – An M2 User can check this using Appointment data

49. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 49 More about RVUs….

50. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 50 RVUs Designed to pay Providers, mostly working in their offices If working elsewhere, a separate bills pays the facility Relative Value Units – RVU assignment designed to be based on the procedure code, location, modifiers and units of service

51. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 51 What Are Work RVUs? Based on “How Long” And “How Skilled”

52. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 52 What Are RVUs? “Work” “Practice Expense” “Malpractice Expense”

53. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 53 Relative Value Units Three basic types: Work RVU: Provider effort & costliness Practice Expense RVU: – Overhead (supplies, bookkeeping, clean-up, etc) – Two types: One for when care delivered in own office, another for when care delivered elsewhere Malpractice RVU: To assist in paying malpractice premiums

54. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 54 CPTDescriptionWorkPractice – own off Practice - other Mal- practice 99201 Office/outpatient visit, new pt.0.450.490.150.03 99211 Office/outpatient visit, established pt.0.170.390.060.01 99281Emergency dept visit0.330.09 0.02 99291Critical care, first hour3.992.571.280.21 99295Neonate crit care, initial18.465.37 1.15 Some example E&M Code RVUs from Medicare table

55. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 55 Relative Value Units The MHS has focused heavily on work RVUs: Work RVUs do well for productivity measurement within specialties that are of similar costliness – Do not compare neurosurgeon’s to family practitioners! But they are only intended to explain costliness of provider labor, not all the other costs! Work RVUs don’t work well at all for specialties that are not usually ‘doc run.’ (e.g., PT/OT)

56. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 56 RVU Table The MHS weight table is different from what you would find elsewhere Incorporates weights for things not generally covered in the private sector, examples are: –Telephone consults –LASIK Adjusts global procedure codes to accommodate MHS-specific coding rules

57. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 57 The MHS RVU Weight Table AMA, ADA, CMS Define Codes MEDICARE Publishes Weights INGENIX Adds Weights MHS Adds Weights DC Policy Applied

58. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 58 RVU Fields in Direct Care Data Many varieties of RVUs available in central SADR data files (M2) Most fields are not available locally Many do not credit E&M when a procedure is present Policy for assigning RVUs is determined by Health Affairs – RVU policies are generally reconsidered annually Very much a “hot topic”

59. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 59 Selected RVU Fields in M2 Type of RVUCommentUsed for SimpleWork RVU. Straight sum of CPT/E&M and associated RVUs Currently used in business planning and PPS, but changing PPS WorkWork RVU number of doctors on the SADR. No E&M credit w/proc Best comparison for make/buy for office based care PPS FacilityPractice Expense, as if all care was provided in own office. No E&M credit w/proc Individual Work Discounted Sum, 100% credit for weightiest code, 50% for others. No E&M credit w/proc Productivity of an individual provider Organiza- tional Work Same as individual work RVU, times # of doctors on the SADR. No E&M credit w/proc Productivity at clinic level or higher

60. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 60 Code TypeCodeSimple RVUPPS WorkInd WorkOrg Work Straight Sum or Discount?Straight SumDiscounting E&M994990.00.000.0 CPT1304007.46 CPT2305204.32 2.16 CPT3991440.34 0.17 CPT4991450.13 0.065 Sum:12.25 9.855 Mult # MDN/AYes (2)N/AYes (2) Total12.2524.509.8519.71 Example

61. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 61 RVU Fields in Direct Care Data Many varieties of RVUs available in central SADR data files (M2) Most fields are not available locally! Policy for assigning RVUs is determined by Health Affairs – RVU policies are generally reconsidered annually Very much a “hot topic” The modifiers and units are service are currently not available in SADRs, so those cannot be considered when doing RVU assignment – They are collected, but are not forwarded on the SADR. – Systems change request has been in for several years to change this! – Caveats are appropriate when using this data!

62. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 62 Lack of Units of Service in SADR CodeDescriptionUnitsRVU "Should be” RVU 97032Electrical Stimulation, each 15 min10.25 97032Electrical Stimulation, each 15 min40.251.00 97530Therapeutic Exercises, each 15 min10.44 97530Therapeutic Exercises, each 15 min20.440.88

63. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 63 APCs and APGs RVUs are intended only to pay providers – Nothing about the RVU system addresses the institutional burden of care provided outside the office APCs and APGs are also important for outpatient care – Good for looking at ER or ambulatory procedure visits

64. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 64 APCs APCs: – Used by CMS to pay for most types of institutional outpatient care – TRICARE is to adopt this method of payment in June 2007 – APC weights represent the relative costliness of an APC, incorporating only the institutional outpatient costs – For care provided outside an office, the provider would be paid via RVU (work + other location practice expense) & the facility by APC – Only applicable for “out-of-office” type MTF care

65. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 65 APC Not available locally, but are in central data (M2) – Multiple APCs per record – Aggregate APC weight is the sum of all weights for each APC, though most payors (TRICARE also) will use a discounted sum (100% highest, 50% others) – Likely to change to using a discounted approach to be consistent with purchased care

66. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 66 APGs APGs are like APCs but never “got off the ground” – APGs and their weights incorporate ancillaries – Industry was unhappy with that, and APGs were not really implemented universally – APC concept replaced APG in industry – APGs will likely be phased out by the MHS – Unlike APCs, APG weights include professional component also

67. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 67 Weights and SADRs Central Data Systems (M2) have Inferred SADRs Based on closed appointments for which no SADR has been completed Has estimated weights – Based on historical experience in that MTF – In that clinic – For that appointment type Replaced with SADR when/if one arrives SADR Inferred SADR

68. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 68 Cautions Difficult to compare to purchased care Compliance trends may look like more productivity New coding rules may hide or look like trends Internal resource sharing docs do SADRs, too!

69. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 69 Miscoding Affecting RVUs and APGs Bad or missing diagnoses Wrong gender or age Missing procedures and diagnoses, or using wrong year’s codes Generic provider specialties Fake provider identities Typographical errors, such as dates Ungroupable Undercoded Laughable! No credit Fraud!?

70. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 70 Questions

71. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2007 UBO/UBU Conference From Registration to Accounts Receivable 71 Contact Information Dr. Richard Holmes richard.holmes@nc.rr.com Ms. Wendy Funk wfunk@kennelinc.com