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Direct Care Prof Encounters Direct Care Professional Encounters 3/19/2018 TMA / WISDOM Excerpt 1 Direct Care Prof Encounters Direct Care Professional Encounters 3/19/2018 TMA / WISDOM Excerpt 1

Direct Care Prof Encounters Objectives • Describe the characteristics • Describe cost and workload Direct Care Prof Encounters Objectives • Describe the characteristics • Describe cost and workload measures • What elements should you select or avoid when making management decisions 3/19/2018 TMA / WISDOM Excerpt 2

Direct Care Prof Encounters What’s in the File? • • • Encounters in ambulatory Direct Care Prof Encounters 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 3/19/2018 TMA / WISDOM Excerpt 3

Direct Care Prof Encounters by FY and 1 st Level MEPRS Code A=Inpatient; B=Ambulatory; Direct Care Prof Encounters by FY and 1 st Level MEPRS Code A=Inpatient; B=Ambulatory; C=Dental; F=Supplemental As of 2/9/07 3/19/2018 TMA / WISDOM Excerpt 4

Direct Care Prof Encounters Various Facilities 3/19/2018 TMA / WISDOM Excerpt 5 Direct Care Prof Encounters Various Facilities 3/19/2018 TMA / WISDOM Excerpt 5

Direct Care Prof Encounters Historical Compliance Issues • Requirement to complete SADR within 3 Direct Care Prof Encounters 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 • FY 03 and forward incorporates the appointmentinferred concept. Older data use the “Raw” and “Total” concept based on the WWR 3/19/2018 TMA / WISDOM Excerpt 6

Direct Care Prof Encounters Actual vs Inferred • Completed encounter records compared to appointment Direct Care Prof Encounters 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 MEPRS 3 Code • Replaces Raw vs. Total in the FY 03+ detail tables 3/19/2018 TMA / WISDOM Excerpt 7

Direct Care Prof Encounters Procedure Codes • Coded with CPT codes • Evaluation & Direct Care Prof Encounters 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 3/19/2018 TMA / WISDOM Excerpt 8

Direct Care Prof Encounters Ambulatory Surgery • Ambulatory Procedure Visit (APV)Flag: Indicates care delivered Direct Care Prof Encounters Ambulatory Surgery • Ambulatory Procedure Visit (APV)Flag: Indicates care delivered in ambulatory procedure unit (APU) • Same Day Surgery Flag: Surgery done in an APU 3/19/2018 TMA / WISDOM Excerpt 9

Direct Care Prof Encounters Ambulatory Procedure Groups · Based on CPTs and first diagnosis Direct Care Prof Encounters Ambulatory Procedure Groups · 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 3/19/2018 TMA / WISDOM Excerpt 10

Direct Care Prof Encounters Ambulatory Payment Classification · Based on CPTs codes · Each Direct Care Prof Encounters Ambulatory Payment Classification · 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 · FY 05+ only 3/19/2018 TMA / WISDOM Excerpt 11

Direct Care Prof Encounters Appt Status • Appt Status Code is in the DETAIL Direct Care Prof Encounters 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 3/19/2018 TMA / WISDOM Excerpt 12

Direct Care Prof Encounters Disposition Code · Numeric codes used for ambulatory care – Direct Care Prof Encounters Disposition Code · 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 3/19/2018 TMA / WISDOM Excerpt 13

Direct Care Prof Encounters Date Field · Service Date = Date of encounter · Direct Care Prof Encounters Date Field · Service Date = Date of encounter · FY/FM and CY/CM are the year and month of the Service Date 3/19/2018 TMA / WISDOM Excerpt 14

Direct Care Prof Encounters Provider Data • Provider ID: Primary provider, unique to CHCS Direct Care Prof Encounters 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. , 207 K 00000 X = Allergy & Immunology • Provider Type Code: full time, part time, house staff, etc • Secondary Provider IDs also available, but not specialty 3/19/2018 TMA / WISDOM Excerpt 15

Direct Care Prof Encounters APG Weights • Every APG receives a weight • Weight Direct Care Prof Encounters 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 3/19/2018 TMA / WISDOM Excerpt 16

Direct Care Prof Encounters APC Weights • Every APC receives a weight • APC Direct Care Prof Encounters APC Weights • Every APC receives a weight • APC Aggregate Weight = sum of the 5 weights on a record • FY 05+ only • Used by Medicare for reimbursement 3/19/2018 TMA / WISDOM Excerpt 17

Direct Care Prof Encounters Relative Value Units (RVUs) • Numeric values quantify relative work Direct Care Prof Encounters 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 3/19/2018 TMA / WISDOM Excerpt 18

Direct Care Prof Encounters Relative Value Units (RVUs) See Relative Value Units Primer [date]. Direct Care Prof Encounters Relative Value Units (RVUs) See Relative Value Units Primer [date]. doc 3/19/2018 TMA / WISDOM Excerpt 19

Direct Care Prof Encounters Cost Measures • Full Cost, Variable Cost • Clinician Salary; Direct Care Prof Encounters 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 • FY 05 and back: Based on MEPRS expense data from respective FY • FY 06+: Based on FY 05 MEPRS expense data, inflated 3/19/2018 TMA / WISDOM Excerpt 20

Direct Care Prof Encounters Odds and Ends • Seasonal patterns • Coding changes – Direct Care Prof Encounters 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 3/19/2018 TMA / WISDOM Excerpt 21

Direct Care Prof Encounters Navy Ob/Gyn Workload • Starting in FY 04, the Navy Direct Care Prof Encounters Navy Ob/Gyn Workload • Starting in FY 04, the Navy instructed their facilities to code all OB work in BCB instead of BCC • BCC SADRs eventually disappear See next slide. 3/19/2018 TMA / WISDOM Excerpt 22

Direct Care Prof Encounters Navy Ob/Gyn Workload 3/19/2018 TMA / WISDOM Excerpt 23 Direct Care Prof Encounters Navy Ob/Gyn Workload 3/19/2018 TMA / WISDOM Excerpt 23

Direct Care Prof Encounters Questions? 3/19/2018 TMA / WISDOM Excerpt 24 Direct Care Prof Encounters Questions? 3/19/2018 TMA / WISDOM Excerpt 24

Direct Care Prof Encounters Direct Care Lab-Rad Ancillary 3/19/2018 TMA / WISDOM Excerpt 25 Direct Care Prof Encounters Direct Care Lab-Rad Ancillary 3/19/2018 TMA / WISDOM Excerpt 25

Direct Care Prof Encounters Objectives • Characteristics. • Cost and workload. • Use in Direct Care Prof Encounters Objectives • Characteristics. • Cost and workload. • Use in decision-making. 3/19/2018 TMA / WISDOM Excerpt 26

Direct Care Prof Encounters What’s in the File? • • One or two records Direct Care Prof Encounters 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). FY 05 and forward. Normal demographics and enrollment. 3/19/2018 TMA / WISDOM Excerpt 27

Direct Care Prof Encounters Record counts for 1 st Level MEPRS Code MEPRS 1 Direct Care Prof Encounters Record counts for 1 st Level MEPRS Code MEPRS 1 Code, Ordering Record Type Lab FY 2006 B 30, 318, 789 C 24, 122 D 199, 478 F 1, 846, 133 Total % of Total 32, 388, 522 80% 392, 670 Rad 2006 Total 7, 835, 016 7, 219 30, 265 8 8, 265, 170 20% 38, 153, 805 31, 341 229, 743 2, 238, 803 40, 653, 692 100% B=Ambulatory; C=Dental; D=Ancillary FC=HC Svcs Support 3/19/2018 TMA / WISDOM Excerpt 28

Direct Care Prof Encounters Radiology detail has one table. Lab detail tables are broken Direct Care Prof Encounters Radiology detail has one table. Lab detail tables are broken out by FY due to size. Summary tables also available. 3/19/2018 TMA / WISDOM Excerpt 29

Direct Care Prof Encounters Procedure Codes • Coded with CPT codes with Modifiers. • Direct Care Prof Encounters Procedure Codes • Coded with CPT codes with Modifiers. • Number of Services = Number of times procedure performed – Beware bilaterals! • Some tests have “fake” 89240. 3/19/2018 TMA / WISDOM Excerpt 30

Direct Care Prof Encounters CPT Modifiers for Laboratory (Unique Use) • 1 st Modifier: Direct Care Prof Encounters CPT Modifiers for Laboratory (Unique Use) • 1 st Modifier: v 00 = Technical Component for in-house work v 26 = Professional Component (Pathologist) v 32 = Technical Component for referral work v 90 = External Laboratory 3/19/2018 TMA / WISDOM Excerpt 31

Direct Care Prof Encounters CPT Modifiers for Radiology (Normal Use) • 1 st Modifier Direct Care Prof Encounters CPT Modifiers for Radiology (Normal Use) • 1 st Modifier (Normal Use like Civilians): v 00 = indicates the record came in with no modifier v 26 = Professional Component (PC) v 32 = Technical Component (TC) v. Most exams will have one record for each modifier • 2 nd Modifier (Military Unique Use): v 50 = Bilateral with 26 v 51 = Bilateral with 32 v 99 = Multiple Modifiers Ø These differ from civilian practice where 50 is bilateral but 51 is multiple procedures. Ø The 2 nd modifier may or may not be present. 3/19/2018 TMA / WISDOM Excerpt 32

Direct Care Prof Encounters Relative Value Units (RVUs) • Normal application by CPT code. Direct Care Prof Encounters Relative Value Units (RVUs) • Normal application by CPT code. • Work, practice expense components. • Multiplied by corrected number of services. 3/19/2018 TMA / WISDOM Excerpt 33

Direct Care Prof Encounters Radiology Examples CHCS doubles the number of services for bilateral Direct Care Prof Encounters Radiology Examples 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. ) 3/19/2018 TMA / WISDOM Excerpt 34

Direct Care Prof Encounters Date Field · Service Date = Date of radiology exam Direct Care Prof Encounters Date Field · Service Date = Date of radiology exam or lab testing. · FY/FM and CY/CM and class based on this date. 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. 3/19/2018 TMA / WISDOM Excerpt 35

Direct Care Prof Encounters Cost Measures • Full Cost, Variable Cost. • Apportioning of Direct Care Prof Encounters Cost Measures • Full Cost, Variable Cost. • Apportioning of costs based on RVUs. 3/19/2018 TMA / WISDOM Excerpt 36

Direct Care Prof Encounters Odds and Ends • Diagnosis codes and PPS Market Value Direct Care Prof Encounters Odds and Ends • Diagnosis codes and PPS Market Value fields are empty. • Big holes in FY 05 data, FY 06 generally complete. At this time, there is no indication that missing data can be recovered. • Anatomical Pathology departments using the Co. Path 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. 3/19/2018 TMA / WISDOM Excerpt 37

Direct Care Prof Encounters Questions? 3/19/2018 TMA / WISDOM Excerpt 38 Direct Care Prof Encounters Questions? 3/19/2018 TMA / WISDOM Excerpt 38