Data Quality Section, PASBA. 2 Overview Regulatory Guidance Program Management Organizational Factors System Inputs, Processes, and Outputs

DATA QUALITY MANAGEMENT CONTROL

PROGRAM

Data Quality Section, PASBA

2

Overview

Regulatory Guidance Program Management Organizational Factors System Inputs, Processes, and Outputs

CHCS ADM MEPRS/EAS TPOCS MEWACS

Patient Records Accountability

Coding Audits Sampling Size and Techniques Inpatient Records Outpatient Records

Workload Comparison System Security System Design,

Development, Operations, and Education and Training

Regulatory GuidanceDODI 6040.40

Military Health System Data Quality Management Control Procedures

3

Department of Defense

INSTRUCTION

Regulatory GuidanceDODD 6040.41

Medical Records Retention and Coding at Military Treatment Facilities

4


DIRECTIVE


Medical Encounter and Coding at Military Treatment Facilities

5


DIRECTIVE


Custody and Control of Outpatient Medical Records

6


DIRECTIVE

Program Management

Data Quality Manager Data Quality Assurance Team Intermediate Command DQ Manager Service Data Quality Manager DQMC Review List Commanders Monthly Data Quality

Statement (internet based)

7

System Inputs, Processes, and Outputs

Composite Health Care System (CHCS) Armed Forces Health Longitudinal

Technology Application (AHLTA) Ambulatory Data Module (ADM) Medical Expense and Performance

Reporting System (MEPRS) / Expense Assignment System (EAS)

MEPRS Early Warning and Control System (MEWACS)

Defense Medical Human Resources System –Internet (DMHRS-i)

Third Party Outpatient Collection System (TPOCS)

8

Data InputMEPRS/EAS, ADM, CHCS, TPOCS Written Procedures Current Versions Upgrades & Updates Rejected Records End of Day Processing

Percentage of Clinics Percentage of Appointments

Timely Coding Completion

9

Commander’sData Quality Statement

Q. 1. What percentage of appointments was closed in meeting your “End of Day” processing requirements, “Every appointment – Every day?” (B.5.)

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Q. 2. In accordance with legal and medical coding practices, have all of the following occurred: a) What percentage of Outpatient Encounters,

other than APVs, have been coded within 3 business days of the encounter? (B.6.(a))

b) What percentage of APVs have been coded within 15 days of the encounter? (B.6.(b))

c) What percentage of Inpatient records have been coded within 30 days after discharge? (B.6.(c))

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Data OutputMEPRS/EAS, ADM, CHCS, TPOCS

EAS Financial Reconciliation Inpatient and Outpatient Workload

Reconciliations MEWACS Review Timely Data Transmittal Workload Comparison

12


Q. 3. Medical Expense and Performance Reporting System for Fixed Military Medical and Dental Treatment Facilities Manual (MEPRS Manual) DoD6010-13-M, dated April 7, 2008, paragraph C3.3.4, requires report reconciliation (C.1.)

a) Was monthly MEPRS/EAS financial reconciliation process completed, validated and approved prior to monthly MEPRS transmission?

13



b) Were the data load status, outlier/variance, WWR-EAS IV, and allocations tabs in the MEWACS document reviewed and explanations provided for flagged data anomalies?

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c) For DMHRS-i, what is the percentage of timecards submitted by the suspense date?

d) For DMHRS-I, what is the percentage of approved timecards by the suspense date?

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Data OutputMEPRS/EAS, ADM, CHCS, TPOCS CHCS

Duplicate Records Timely Data Transmittal

Standard Inpatient Data Record (SIDR) Worldwide Workload Report

Inpatient Records Accountability Documentation Coding SIDRs completed (in a “D” status)

Workload Comparison

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Q. 4. Compliance with TMA or Service-Level guidance for timely submission of data (C.3.).

a) MEPRS/EAS (45 calendar days)

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- b) SIDR/CHCS (5th and 20th calendar day of the month)

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- c) WWR/CHCS (10th calendar day following month)

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Q. 4. Compliance with TMA or Service-Level guidance for timely submission of data (C.3).

d) SADR/ADM (daily)

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Data Output

A minimum of 30 records/encounters should be pulled randomly from the entire population of MTF inpatient medical records for the audit data month.

A random audit of 30 records per MTF will provide a statistical confidence level of 90%, with a confidence interval/sampling error range of plus or minus 15%.

The PASBA is generating a monthly DD Form 2569 audit pull-list for auditing of other health insurance .

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Data OutputInpatient Coding

Coding DRG Codes Related Data Elements (C.5)

All Diagnoses Any Procedures Sex Age Discharge/Disposition

Percentage of SIDRs Completed (D-Status)

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Q. 5. Outcome of monthly inpatient coding audit: (C.5.c.f.g,h,i,j)

a) What percentage of inpatient records

whose assigned DRG codes were correct?

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b) Inpatient Professional Services Rounds encounters E & M codes audited and deemed correct?

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c) Inpatient Professional Services Rounds encounters ICD-9 codes audited and deemed correct?

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d) Inpatient Professional Services Rounds encounters CPT codes audited and deemed correct?

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Data OutputMEPRS/EAS, ADM, CHCS, TPOCS

ADM Timely Data Transmittal

Standard Ambulatory Data Record (SADR) Error Logs Workload Comparison

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Data OutputOutpatient Coding

Sample Size Accountability

Percentage Located or Properly Checked Out Checked-out Over 30-Days?

DD Form 2569 (Third Party Insurance Information)

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Q.6. Outpatient Records. (c.6.a,b,c,d,e,f)

a) Is the documentation of the encounter selected to be audited available? Documentation includes documentation in medical record, loose (hard copy) documentation or an electronic record of the encounter in AHLTA?

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Data OutputOutpatient Coding

E&M Codes ICD-9 Codes CPT Codes

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Q. 6. Outpatient Records.

b) What is the percentage of E & M codes deemed correct? (E & M code must comply with current DoD guidance.)

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c) What is the percentage of ICD-9 codes deemed correct?

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d) What was the percentage of CPT codes deemed correct? (CPT code must comply with current DoD guidance.)

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Question 7 Ambulatory Procedure Visits (C.7.a,b,c)

Questions 7.a,b,c, are the same as Questions 6.a,c,d,,

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Q. 8. Outcome of monthly inpatient audit: (C.8a,b,c,d,e,f)

a) What percentage of completed and current (signed within the past 12 months) DD Form 2569s are available for audit?

b) What percentage of available, current and complete DD Form 2569s are verified to be correct in the Patient Insurance Information (PII) module in CHCS?

35


Q. 8. Outcome of monthly outpatient audit: (C.8a,b,c,d,e,f)

c) What percentage of completed & current (signed within the past 12 months) DD Form 2569s (TPC Insurance Info) are available for audit?

d) What percentage of available, current and completed DD Form 2569s are verified to be correct in the Patient Insurance Information (PII) module in CHCS?

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Q. 9. Comparison of reported workload data (C.9).

a) # SADR Encounters (count only visits / # WWR visits

b) # SIDR Dispositions / # WWR Dispositions c) # EAS Visits / # WWR Visits d) # EAS Dispositions / # WWR Dispositions e) # IPSR SADR encounters (FCC=A***)/# Sum

WWR (Total Bed Days + Total Dispositions + Live Births + Bassinet Days)

Note: Question e, FY11 Goal is 80%.

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Data OutputWorkload Comparison

Q.9a SADR Visits / WWR Visits

Should have an equal number of visits. Encounters – Omit Appt. Status of “No-

Shows,” “Canceled,” and Disposition Code “Left Without Being Seen”.

Encounters – Include Appt. Status “TelCon” Only SADR Records Marked with an Appt.

Status of “C” (complete) Are To Be Included. Only “count” encounters are included.

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Q.9b SIDR Dispositions / WWR Dispositions

Must Match Only SIDRs With a Disposition of Status of “D”

Are To Be Included SIDRs – Exclude Carded for Record Only (CRO)

and Absent Sick Records

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Q. 9c EAS Visits / WWR Visits

Must Match Include MEPRS Functional Cost Code B**

(Outpatient) and FBN (Hearing Conservation) Include APVs

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Q. 9d EAS Dispositions / WWR Dispositions

Must Match Only SIDRs with a Disposition Status of “D”

are to be included

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Q. 9e IPSR encounters (FCC=A***)/# Sum WWR (Total Bed Days + Total Dispositions + Live Births + Bassinet Days) Must Match Only SIDRs with a Disposition Status of “D” are

to be included. Insure WWR calculation includes live births

(section 01) and Bassinet Days (section 00).

Note: FY11 Goal is 80%

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Q.10. - System Design, Development, Operations and Education/Training (E.4.i).

# AHLTA SADR encounters/# of Total SADR encounters

Note: FY11 compliance goal is 95%.. (* It is understood that not all clinical

modules are deployed in the current version of AHLTA.)

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Q.11.- CHCS software used during the data month to identify duplicate patient registration records. (C.2a)

- What was the number of potential duplicate records in the reporting month?

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Q.12.- Provide the number of incomplete and non-transmitted SIDRs for the month. (F.1)

Note: This question on the DQ Statement is only a requirement for Army sites and will not be reported to TMA.

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Q.13.a.- Provide the number of loose forms/documents/papers that are currently waiting to be filed, either electronically or in the hard-copy medical record. (F.2.a)


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Q.13.b.- Provide the number of loose forms/documents/papers that are currently waiting to be filed, either electronically or in the hard-copy medical record, 30 days after an active duty soldier has retired or separated from the service. (F.2.b)


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Q. 14. – I am aware of data quality issues identified by the completed Commander’s Statement and Review List and when needed, have incorporated monitoring mechanisms and have taken corrective actions to improve the data from my facility.

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Security

Are there internal controls and procedures in place to approve and manage assignment of security key privileges?

Have all security key holders been identified and their need for security key privileges validated by the CIO or designee?

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System Design, Operations, and Education/Training

System Administrator Appointed In Writing for Each System

Training and Education Procedures and Documentation

System Change Request Process System Incident Report Routine Maintenance Points of Contact for Equipment Failure

Issues Contingency Plans Trouble tickets

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Data Quality Section, PASBA

Chief DQ Section PASBATim Bacon, [email protected]

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BACKUP SLIDES

53

METRIC MANIA

Department of Army

Strategic Readiness System(SRS)

Review &

Analysis

TMA metrics

BALANCED SCORECARD

- Promote, Sustain and Enhance Soldier Health- Train, Develop and Equip a Medical Force that Supports Full Spectrum Operations - Deliver Leading Edge Health Services to Our Warriors and Military Family to Optimize Outcomes

For more information go to: https://ke2.army.mil/bscThis is a dynamic, living document

America’s Premier Medical Team Saving Lives and Fostering Healthy and Resilient PeopleArmy Medicine…Army Strong!

Pat

ien

t/C

ust

om

er/

Sta

keh

old

er CS 6.0 Inspire Trust in

Army Medicine

CS 4.0 Responsive Battlefield

Medical Force

CS 1.0 Improved Healthy and Protected

Families, Beneficiaries and

Army Civilians

CS 3.0 Improved Healthy and Protected Warriors

CS 5.0 Improved Patient and Customer

Satisfaction

IP 10.0 Optimize Medical

Readiness

IP 13.0 Build Relationships and Enhance Partnerships

LG 18.0 Improve Training and Development

IP 11.0 Improve Information

Systems

CS 2.0 Optimized Care and Transition of Wounded, Ill, and

Injured Warriors

IP 12.0 Implement

Best Practices

IP 14.0 Improve Internal and

External Communication

LG 20.0 Improve Knowledge

Management

LG 17.0 Improve Recruiting and

Retention of AMEDD Personnel

Inte

rna

l P

roce

ssL

ea

rnin

g

an

d G

row

th

LG 19.0 Promote and Foster a

Culture of Innovation

Maximize Value in Health Services

Provide Global Operational Forces Build the Team Balance Innovation

with StandardizationOptimize Communication and

K nowledge Management

Fee

db

ack

Ad

jus

ts R

eso

urc

ing

De

cisi

on

s

IP 8.0 Improve Quality,

Outcome-Focused Care and Services

IP 7.0 Maximize Physical and Psychological

Health Promotion and Prevention

IP 9.0 Improve Access and Continuity of

Care

IP 16.0 Synchronize

Army Medicine to Support Army

Stationing & BRAC

R 21.0 Optimize

Resources and Value

R 22.0 Optimize Lifecycle Management

of Facilities and Infrastructure

R 23.0 Maximize

Human Capital

EN

DS

ME

AN

SW

AY

S

Re

sou

rce

IP 15.0 Leverage Research,

Development and Acquisition

= CofS Accountability

OTSG

Command Management System(CMS)

Why should you care? What can you do to help?

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MEDCOM STRATEGY MAP

GOALS:

• Improve overall health & wellness of enrolled beneficiaries.

• Improve patient access and satisfaction.

• Improve effectiveness of peacetime direct care system.

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KEYS TO SUCCESS

• Improve Data Quality Efforts

• Cultural Change

• Improve Access to Care

• Tie Financing to PerformancePBAM – Performance Based Adjustment Model

Army Health System

MedicalGreen-Suit

Military

Total MEDCOMDHP Human Resources

WT Population ~ 12,000

Population Requiring Healthcare (Demand)

MEDCOM Capacity (Human Capital)

MEDCOM direct care capacity cannot meet the Healthcare demand of the around 3 million eligible beneficiaries (MEDCOM cares for 1.414 million enrolled & 300K users)

Reasons include: -Population dispersion (especially among Retirees & their Families) -Efficiency demands (numerous small population centers) -Military structure supports Readiness – not peacetime healthcare

AD

ADFM

65+

Ret/RetFM (<65)

Army Health System

23% 63% 1%24% 67% 7%24% 63% 11%24% 65% 9%25% 66% 6%26% 67% 7%27% 62% 9%27% 61% 9%28% 63% 8%28% 65% 6%28% 61% 9%30% 59% 9%30% 62% 6%31% 61% 7%32% 61% 6%33% 60% 7%33% 59% 7%33% 58% 7%35% 61% 4%38% 58% 4%

47% 48% 4%61% 36% 3%Tricare/military

Kaiser PermanenteAARP

MedicareMedicaid

BCBS of MichiganCare first BCBS

PacifiCare/ SecureHumana

Medicare and Part DOther health plan

AnthemHighmark

Blue Cross & Blue ShieldWellPoint

UnitedHealthecare-NetBCBS of Illinois

CoventryAetnaCigna

Health Care Services CorpUnitedHealcare

Highly satisfied Satisfied Dissatisfied Highly dissatisfied

Overall satsfation with health plan

Overall Satisfaction With Health Plans

“And the Winner is…” Managed Care Magazine, September 2008 pp 41-46

Data -Wilson Health Information LLC Annual Survey Jan-Feb 2008

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DATA QUALITY

• Increased emphasis on MTF submissions

• Improved reporting timeliness

• Improved accuracy SIDRs

SADRs

MEPRS

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• Combines Multiple Data Systems• Current Enrollment (ECM)- Assumes Historical Space-A

work• Potential Enrollment (MTF Business Plans)• EBSM- Forecast population changes• Ops- UNCLASSIFIED Deployments and Redeployments by

location by month• ARTS- Deployed personnel from MTF

• Provides Adjusted Enrollment for those Active duty deployed, and redeploying

• Adjusts MTF enrollment capacity based on deployed PCMs (1000/Per deployed PCM)

• Future Development to include:• Adjustments for Backfilling PCMs from another MTF• Forecast ARTS deployments- (Pending Deployments)• Deployment to CMS

Enrollment Capacity Forecast Model (ECFM)

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USE OF THE DATA

TMA = Gospel

“Garbage In, Garbage Out”

OTSG = Disaster

MTF = Nuclear Fire Storm

61

• The data matter

• Cultural shift

• Use the CMS

• Ask: What are we asking our staff to do?

Priorities

62

Standardize Core R&A for Medical Treatment Facilities

• No standard R&A approach in MEDCOM

• MTF Cdrs create their own “TOC”

• MTF’s spend a lot of time designing/developing

the “TOC”

• Cdrs and staffs learn together at the expense

of

Organizational Performance

• R&A provides the Azimuth….critical to direction

and success

63

Core Measures for MTFs

• Enrollment

• Productivity

• Access

• Patient Satisfaction

• Coding Accuracy

• Prevention/HEDIS

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End-of-Day (EOD) Processing MTF staff will determine the status of each appointment as accurately as possible. EOD processing will be correctly completed at the end of each business day.

Pending: The MTF appointment information system assigns this initial status for an appointment that has been booked for a patient for a future date or time. All pending appointments must be changed to one of the final encounter statuses in order to complete End-of-Day processing.

Kept: The patient has a booked appointment, arrives at the MTF/clinic, and is treated by provider.

Walk-in: The patient does not have a scheduled appointment, arrives at the clinic, and is assigned a time to see the provider the same day. This status will not be changed at End-of-Day processing.

Sick Call: An Active Duty member arrives at a clinic for a pre-arranged block of time for care. This status will not be changed at End-of-Day processing.

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End-of-Day (EOD) ProcessingPatient Cancellation: A patient with a scheduled appointment notifiesThe MTF in accordance with local procedures that they will not keep the appointment.

No-Show: A scheduled appointment that the patient does not keep. Determinations of no-shows will be in accordance with local procedures.

Facility Cancellation: The MTF cancels an available/open appointmentor cancels a patient’s scheduled appointment.

Left Without Being Seen: The patient has a booked appointment, arrivesat the clinic, and is checked in, but decides to leave without seeing the provider.

Admin: The admin status is used on appointments or telephone consultsthat do not represent actual contact with a patient. The status must beAssigned in End-of-Day processing. A transaction with this status will not bepassed to ADM or AHLTA and will not be coded or included in SADR.

66

End-of-Day (EOD) ProcessingOccasions of Service: This status on a patient appointment indicates nomedical decision was made by a privileged provider who is directly Responsible for the management of care for the patient. This status willno longer be used on telephone consults. This transaction will pass fromCHCS to the Ambulatory Data Module (ADM), is always non-count, and maybe used to assess level of effort. ADM and AHLTA do not recognize this status as an appointment for completion. Therefore this status will NOT prompt the provider to code the encounter and will avoid generating a Standard Ambulatory Data Record (SADR).

Telephone Consultation: When a provider answers a telephone consult inAHLTA, the provider will be asked by the system, “Does this meet the out-patient visit criteria?” If the provider is a technician, nurse, or other non-count provider or the clinic is a non-count clinic, the workload type responsewill be defaulted to No (non-count) and cannot be changed in AHLTA. If the provider is a privileged provider and the clinic is a count clinic, the defaultwill be Yes (count). The provider should change the response to No if it does not meet the visit criteria.

67

Walk-ins 1. A walk-in is a patient who seeks care without a scheduled appointment,Arrives at the clinic, and is assigned a time to see the provider the same day.

2. There is no ATC Standard for walk-in appointments.

3. Walk-ins are not designed for use as a schedulable event.

4. High utilization of walk-ins can create data quality challenges for the MTF and make the process of measuring/explaining access, and assessing demand more complex.

5. High rates of walk-ins may also make business plan targeting difficult since theyare unplanned events.

6. Excessive walk-in activity can reduce the appointments available to patientsrequesting care on the telephone.

7. However, if clinics utilize the walk-in function to get patients seen in a manner that is more timely/convenient for the patients, this is recognized as good customerservice from the patient’s perspective.

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Medical Expense and Performance Reporting System (MEPRS)

1. The DoD Manual 6010.13-M, MEPRS for Fixed Medical and Dental TreatmentFacilities. Provides a definition of MEPRS codes (also know as functional costcodes, FCC).

2. Define your CHCS File-and-Build Hospital Locations so that each clinic has only one associated MEPRS code.

3. Ensure that each MEPRS code has the four characteristics of: a. A defined physical space (e.g., square footage) b. Associated expenses (e.g., supplies) c. Associated personnel time (e.g., work hours) and d. Associated workload (e.g., visits, procedures, etc.)

4. Manual provides definition and criteria of a visit (count vs. non-count)

5. Defense Medical Human Resources System – internet (DMHRS-i), there has been significant improvement in timecard reporting. Need to pay attention to the accuracy of the information being entered into the system.

70https://pasba3.amedd.army.mil/login/login.fcc

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1) In the data month (include only B*** and FBN* accounts): a) What percentage of appointments were closed in meeting your “End of Day” processing requirements, “Every appointment – Every day?”

Reporting Month Dec 2010 Jan 2011

Data Month Oct 2010 Nov 2010

Army 100% 100%

ERMC 99% 99%

0606 - HEIDELBERG 100% 100%

0607 - LANDSTUHL 99% 99%

0609 - VILSECK 100% 100%

NRMC 100% 100%

0037 - WASHINGTON DC 100% 100%

0061 - FT. KNOX 100% 100%

0069 - FT. MEADE 99% 100%

0086 - WEST POINT 100% 100%

0089 - FT. BRAGG 100% 100%

0121 - FT. EUSTIS 100% 100%

0122 - FT. LEE 100% 100%

0123 - FT. BELVOIR 99% 100%

0330 - FT. DRUM 100% 100%

PRMC 100% 100%

0052 - FT. SHAFTER 100% 100%

0610 - CAMP ZAMA 100% 100%

0612 - SEOUL 100% 100%

SRMC 100% 100%

0001 - REDSTONE ARSENAL 100% 100%

0003 - FT. RUCKER 100% 100%

0047 - FT. GORDON 100% 100%

0048 - FT. BENNING 100% 100%

0049 - FT. STEWART 100% 100%

0060 - FT. CAMPBELL 100% 100%

0064 - FT. POLK 100% 100%

0098 - FT. SILL 100% 100%

0105 - FT. JACKSON 100% 100%

0109 - FT. SAM HOUSTON 100% 100%

0110 - FT. HOOD 100% 100%

WRMC 100% 100%

0005 - FT. WAINWRIGHT 99% 99%

0008 - FT. HUACHUCA 100% 100%

0032 - FT. CARSON 100% 100%

0057 - FT. RILEY 100% 100%

0058 - FT. LEAVENWORTH 99% 99%

0075 - FT. LEONARD WOOD 100% 100%

0108 - FT. BLISS 100% 100%

0125 - FT. LEWIS 100% 100%

0131 - FT. IRWIN 100% 100%

Legend: N/A 95% - 100% 80% - 94% 0% - 79% or No Response

80

2) In accordance with legal and medical coding practices, have all of the following occurred (see applicable DoDD/DoDI on Medical Records Retention and Coding): a) What percentage of Outpatient Encounters, other than Ambulatory Patient Visits (APVs), have been coded within 3 business days of the encounter (e.g., if the day of encounter is Monday, then coding must be completed by the third business day, Thursday, close of business)?



Army 92% 93%

ERMC 96% 96%

0606 - HEIDELBERG 94% 96%

0607 - LANDSTUHL 98% 98%

0609 - VILSECK 93% 93%

NRMC 92% 93%


0061 - FT. KNOX 96% 91%

0069 - FT. MEADE 92% 93%

0086 - WEST POINT 81% 85%

0089 - FT. BRAGG 95% 97%

0121 - FT. EUSTIS 93% 95%

0122 - FT. LEE 97% 96%

0123 - FT. BELVOIR 90% 92%

0330 - FT. DRUM 93% 96%

PRMC 88% 89%

0052 - FT. SHAFTER 88% 89%

0610 - CAMP ZAMA 95% 98%

0612 - SEOUL 90% 90%

SRMC 92% 93%


0003 - FT. RUCKER 96% 97%

0047 - FT. GORDON 93% 94%

0048 - FT. BENNING 96% 97%

0049 - FT. STEWART 93% 91%

0060 - FT. CAMPBELL 97% 96%

0064 - FT. POLK 91% 95%

0098 - FT. SILL 94% 96%

0105 - FT. JACKSON 93% 96%

0109 - FT. SAM HOUSTON 84% 85%

0110 - FT. HOOD 91% 91%

WRMC 92% 94%


0008 - FT. HUACHUCA 95% 96%

0032 - FT. CARSON 94% 96%

0057 - FT. RILEY 98% 98%


0075 - FT. LEONARD WOOD 97% 99%

0108 - FT. BLISS 89% 92%

0125 - FT. LEWIS 88% 89%

0131 - FT. IRWIN 95% 96%


81

0 1 2 3 4 5 6-7 8-1415-21

22-2829-60

61-9091-120

>120

0%

20%

40%

60%

80%

100%

120%

Time to Completion of Outpatient Encounters - FY 2009(Overall)

1st Quarter (2008/10-2008/12) 2nd Quarter (2009/01-2009/03) 3d Quarter (2009/04-2009/06) 4th Quarter (2009/07-2009/09)

Time (Days) to Completion

% E

ncou

nter

s Com

plet

ed in

Tim

e In

terv

al

see detail of percentage encoun-ters closed after 2 weeks...

82

8-14

15-21

22-28

29-60

61-90

91-120

>120

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%

Time to Completion of Outpatient Encounters(among encounters lasting more than 1 week)

1st Quarter (2008/10-2008/12) 2nd Quarter (2009/01-2009/03) 3d Quarter (2009/04-2009/06) 4th Quarter (2009/07-2009/09)

Time (Days) to Completion

% E

ncou

nter

s Com

plet

ed in

Tim

e In

terv

al

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2) In accordance with legal and medical coding practices, have all of the following occurred (see applicable DoDD/DoDI on Medical Records Retention and Coding): b) What percentage of APVs has been coded within 15 calendar days of the encounter?



Army 94% 93%

ERMC 98% 98%


0607 - LANDSTUHL 100% 100%

0609 - VILSECK

NRMC 97% 98%


0061 - FT. KNOX 100% 100%

0069 - FT. MEADE 99% 97%

0086 - WEST POINT 90% 90%

0089 - FT. BRAGG 100% 99%

0121 - FT. EUSTIS 100% 100%

0122 - FT. LEE

0123 - FT. BELVOIR 100% 100%

0330 - FT. DRUM 22% 78%

PRMC 97% 96%

0052 - FT. SHAFTER 97% 96%

0610 - CAMP ZAMA

0612 - SEOUL 99% 95%

SRMC 86% 94%

0001 - REDSTONE ARSENAL

0003 - FT. RUCKER

0047 - FT. GORDON 46% 96%

0048 - FT. BENNING 100% 100%

0049 - FT. STEWART 92% 93%

0060 - FT. CAMPBELL 98% 100%

0064 - FT. POLK 87% 81%

0098 - FT. SILL 99% 95%

0105 - FT. JACKSON 96% 98%


0110 - FT. HOOD 98% 99%

WRMC 98% 84%


0008 - FT. HUACHUCA

0032 - FT. CARSON 99% 99%

0057 - FT. RILEY 99% 100%


0075 - FT. LEONARD WOOD 100% 100%

0108 - FT. BLISS 95% 95%

0125 - FT. LEWIS 99% 64%

0131 - FT. IRWIN 89% 88%


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2) In accordance with legal and medical coding practices, have all of the following occurred (see applicable DoDD/DoDI on Medical Records Retention and Coding): c) What percentage of inpatient records has been coded within 30 calendar days after discharge (for MTFs with inpatient capability)?



Army 86% 95%

ERMC 100% 100%


0607 - LANDSTUHL 100% 100%

0609 - VILSECK 0% 0%

NRMC 98% 98%


0061 - FT. KNOX 100% 100%

0069 - FT. MEADE 0% 0%

0086 - WEST POINT 100% 100%

0089 - FT. BRAGG 93% 90%

0121 - FT. EUSTIS 0% 0%

0122 - FT. LEE 0% 0%

0123 - FT. BELVOIR 100% 100%

0330 - FT. DRUM 0% 0%

PRMC 100% 100%

0052 - FT. SHAFTER 100% 100%

0610 - CAMP ZAMA 0% 0%

0612 - SEOUL 100% 100%

SRMC 78% 98%


0003 - FT. RUCKER 0% 0%

0047 - FT. GORDON 99% 93%

0048 - FT. BENNING 100% 100%

0049 - FT. STEWART 100% 100%

0060 - FT. CAMPBELL 100% 100%

0064 - FT. POLK 100% 99%

0098 - FT. SILL 100% 99%

0105 - FT. JACKSON 99% 100%


0110 - FT. HOOD 0% 100%

WRMC 81% 85%

0005 - FT. WAINWRIGHT 100% 100%

0008 - FT. HUACHUCA 0% 0%

0032 - FT. CARSON 100% 100%

0057 - FT. RILEY 100% 100%


0075 - FT. LEONARD WOOD 100% 100%

0108 - FT. BLISS 66% 97%

0125 - FT. LEWIS 99% 0%

0131 - FT. IRWIN 0% 100%


85

Auditing for DD Form 2569, Other Health Insurance

• Non active duty only.

• MEPRs FCC of “B” and “FBN”.

• Eliminated all “B” MEPRS which have a fourth

level code of 2.

• Minimum of 50 encounters for SADRs, SIDRs,

APVs. (Encounters for parent and child MTF)

• Increased number of encounters pulled for MTFs

when requested.

• Randomly selected encounters.

86

8.a) INPATIENT DISPOSITIONS: What percentage of completed and current (signed within the past 12 months) DD Form 2569s (Third Party Collection Insurance Info) is available for audit (non-active duty encounters only)? (See DoD 6010.15-M, MTF UBO Manual)



Army 96% 95%

ERMC 100% 98%


0607 - LANDSTUHL 100% 98%

0609 - VILSECK 0% 0%

NRMC 95% 87%


0061 - FT. KNOX 100% 97%

0069 - FT. MEADE 0% 0%

0086 - WEST POINT 0% 100%

0089 - FT. BRAGG 83% 80%

0121 - FT. EUSTIS 0% 0%

0122 - FT. LEE 0% 0%

0123 - FT. BELVOIR 100% 97%

0330 - FT. DRUM 0% 0%

PRMC 100% 98%

0052 - FT. SHAFTER 100% 97%

0610 - CAMP ZAMA 0% 0%

0612 - SEOUL 100% 100%

SRMC 92% 99%


0003 - FT. RUCKER 0% 0%

0047 - FT. GORDON 80% 100%

0048 - FT. BENNING 100% 100%

0049 - FT. STEWART 79% 100%

0060 - FT. CAMPBELL 100% 100%

0064 - FT. POLK 100% 100%

0098 - FT. SILL 100% 97%

0105 - FT. JACKSON 100% 100%

0109 - FT. SAM HOUSTON 100% 92%

0110 - FT. HOOD 100% 100%

WRMC 98% 99%

0005 - FT. WAINWRIGHT 100% 100%


0032 - FT. CARSON 100% 93%

0057 - FT. RILEY 100% 100%



0108 - FT. BLISS 98% 94%

0125 - FT. LEWIS 98% 100%

0131 - FT. IRWIN 100% 100%


87

8.c) OUTPATIENT ENCOUNTERS: What percentage of completed and current (signed within the past 12 months) DD Form 2569s (TPC Insurance Info) is available for audit (non-active duty encounters only)? (See DoD 6010.15-M, MTF UBO Manual)



Army 81% 83%

ERMC 82% 75%


0607 - LANDSTUHL 95% 85%

0609 - VILSECK 67% 62%

NRMC 78% 86%


0061 - FT. KNOX 97% 96%

0069 - FT. MEADE 87% 94%

0086 - WEST POINT 74% 71%

0089 - FT. BRAGG 52% 62%

0121 - FT. EUSTIS 90% 96%

0122 - FT. LEE 95% 95%

0123 - FT. BELVOIR 90% 95%

0330 - FT. DRUM 91% 91%

PRMC 90% 86%

0052 - FT. SHAFTER 90% 83%

0610 - CAMP ZAMA 100% 100%

0612 - SEOUL 81% 75%

SRMC 88% 79%


0003 - FT. RUCKER 82% 74%

0047 - FT. GORDON 100% 78%

0048 - FT. BENNING 100% 93%

0049 - FT. STEWART 100% 75%

0060 - FT. CAMPBELL 100% 46%

0064 - FT. POLK 93% 90%

0098 - FT. SILL 96% 60%

0105 - FT. JACKSON 63% 70%


0110 - FT. HOOD 92% 95%

WRMC 79% 82%


0008 - FT. HUACHUCA 68% 70%

0032 - FT. CARSON 90% 90%

0057 - FT. RILEY 100% 100%



0108 - FT. BLISS 42% 36%

0125 - FT. LEWIS 64% 100%

0131 - FT. IRWIN 88% 94%


88

8.e) APVs: What percentage of the completed and current DD Form 2569s (TPC Insurance info.) is available for audit (non-active duty encounters only)? (See DoD 6010.15M, MTF UBO Manual)



Army 96% 92%

ERMC 103% 98%

0606 - HEIDELBERG 85% 100%

0607 - LANDSTUHL 96% 96%

0609 - VILSECK 0% 0%

NRMC 87% 81%


0061 - FT. KNOX 100% 100%

0069 - FT. MEADE 86% 94%

0086 - WEST POINT 0% 100%

0089 - FT. BRAGG 80% 90%

0121 - FT. EUSTIS 90% 92%

0122 - FT. LEE 0% 0%

0123 - FT. BELVOIR 97% 97%

0330 - FT. DRUM 100% 44%

PRMC 92% 93%

0052 - FT. SHAFTER 90% 87%

0610 - CAMP ZAMA 0% 0%

0612 - SEOUL 93% 100%

SRMC 100% 99%


0003 - FT. RUCKER 0% 0%

0047 - FT. GORDON 100% 100%

0048 - FT. BENNING 100% 100%

0049 - FT. STEWART 100% 97%

0060 - FT. CAMPBELL 100% 100%

0064 - FT. POLK 100% 100%

0098 - FT. SILL 100% 100%

0105 - FT. JACKSON 100% 100%

0109 - FT. SAM HOUSTON 100% 90%

0110 - FT. HOOD 100% 100%

WRMC 97% 97%

0005 - FT. WAINWRIGHT 100% 100%


0032 - FT. CARSON 92% 96%

0057 - FT. RILEY 100% 100%


0075 - FT. LEONARD WOOD 100% 100%

0108 - FT. BLISS 96% 86%

0125 - FT. LEWIS 86% 98%

0131 - FT. IRWIN 100% 100%


89

10. a) Number of AHLTA SADR encounters / number of total SADR encounters.



Army 91% 92%

ERMC 96% 96%

0606 - HEIDELBERG 100% 100%

0607 - LANDSTUHL 92% 92%

0609 - VILSECK 100% 100%

NRMC 95% 94%


0061 - FT. KNOX 92% 86%

0069 - FT. MEADE 97% 97%

0086 - WEST POINT 94% 93%

0089 - FT. BRAGG 92% 93%

0121 - FT. EUSTIS 97% 98%

0122 - FT. LEE 100% 100%

0123 - FT. BELVOIR 98% 99%

0330 - FT. DRUM 92% 91%

PRMC 93% 93%

0052 - FT. SHAFTER 91% 91%

0610 - CAMP ZAMA 99% 100%

0612 - SEOUL 98% 99%

SRMC 88% 90%


0003 - FT. RUCKER 98% 99%

0047 - FT. GORDON 83% 87%

0048 - FT. BENNING 99% 98%

0049 - FT. STEWART 91% 92%

0060 - FT. CAMPBELL 91% 94%

0064 - FT. POLK 100% 100%

0098 - FT. SILL 78% 89%

0105 - FT. JACKSON 85% 87%


0110 - FT. HOOD 78% 79%

WRMC 90% 92%


0008 - FT. HUACHUCA 97% 100%

0032 - FT. CARSON 99% 100%

0057 - FT. RILEY 74% 79%



0108 - FT. BLISS 81% 82%

0125 - FT. LEWIS 90% 91%

0131 - FT. IRWIN 97% 100%


90

11) Use CHCS during the data month to identify potential duplicate patients and appointments. a) For CHCS/AHLTA hosts only, what was the number of potential duplicate records in the data month for all MTFs under the host?



Army 866 421

ERMC 31 32

0606 - HEIDELBERG

0607 - LANDSTUHL 31 32

0609 - VILSECK

NRMC 44 62

0037 - WASHINGTON DC

0061 - FT. KNOX 17 24

0069 - FT. MEADE

0086 - WEST POINT 2 13

0089 - FT. BRAGG 25 25

0121 - FT. EUSTIS

0122 - FT. LEE

0123 - FT. BELVOIR 0 0

0330 - FT. DRUM 0 0

PRMC 72 37

0052 - FT. SHAFTER 32 26

0610 - CAMP ZAMA

0612 - SEOUL 40 11

SRMC 380 182

0001 - REDSTONE ARSENAL 0 0

0003 - FT. RUCKER 122 121

0047 - FT. GORDON 14 11

0048 - FT. BENNING 15 8

0049 - FT. STEWART 5 15

0060 - FT. CAMPBELL 0 0

0064 - FT. POLK 162 0

0098 - FT. SILL 8 8

0105 - FT. JACKSON

0109 - FT. SAM HOUSTON

0110 - FT. HOOD 54 19

WRMC 339 108

0005 - FT. WAINWRIGHT 2 5

0008 - FT. HUACHUCA 10 3

0032 - FT. CARSON 18 21

0057 - FT. RILEY 58 2

0058 - FT. LEAVENWORTH 3 1

0075 - FT. LEONARD WOOD 30 33

0108 - FT. BLISS 197 22

0125 - FT. LEWIS 19 19

0131 - FT. IRWIN 2 2

91

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Documents

Data Quality Section, PASBA. 2 Overview Regulatory Guidance Program Management Organizational Factors System Inputs, Processes, and Outputs