Direct Care Professional Encounters (CAPER) - PowerPoint Presentation

1. Direct Care Professional Encounters (CAPER)Veronika PavKennell & Associates, Inc.

2. ObjectivesDescribe the characteristics of a Direct Care Professional Encounter RecordHighlight key elementsDescribe workload measures2

3. Common TermsNational Provider ID Tmt DMIS IDHIPAA Taxonomy Code MEPRS CodeICD Diagnosis Code ICD Procedure CodeCPT/HCPCS Code CCS CategoryMDC MS-DRGAPC Service DatesBasic Workload Weighted WorkloadPerson IDs DemographicsBencat/Bencat Common HCDP, ACV Group, Enrollment GroupPCM ID, PCM Type Enrollment SiteEnrollment MEPRS Code Eligibility GroupDeployment Information Raw vs TotalGeography Record ID3

4. What’s in the File?Record definition: one healthcare encounter between a patient and one or more MTF caregivers. Encounters in ambulatory clinics, including those by inpatients (MEPRS B)Inpatient provider records (MEPRS A)Rounds and Inpatient surgeries/proceduresCase Management (MEPRS E and F)Immunizations (MEPRS FBI and BHZ)Hearing Conservation (MEPRS FBN)Some ancillary activities (in clinic)For example, in clinic ultrasoundsThis includes telephone consults too!4

5. *Data as of 7/11/18Encounters by FY and MEPRS1 Code

6. From the appointment file, we know that an encounter occurred or was ‘Kept’. For these ‘Kept’ appointments, the inferred records are kept as place holders until the records are coded.Timeliness:Requirement to complete CAPER within 3 business days of encounter; 15 days for APVs - not 100% metCompleteness:Some records not received at allCoding Compliance6

7. Inferred CAPERsCompleted encounter records compared to appointment records. Missing encounters “inferred” from appointmentsPerson information to add enrollment, etc.No diagnosis or CPT codesWorkload and cost measures inferred by Tmt DMIS ID, visit class (APV, Telcon, Other), and MEPRS3 CodeIdentified using Compliance Status (APPTINF)I = Encounter record that has not been codedR = Coded encounter7

8. Appointment Status*As of 7/11/18, “Reported” only8

9. 9What’s on a record?

10. Identifying a Record The Appointment IEN (APPTIDNO) and the CHCS Host DMIS ID (HOSTDMIS) create a unique ID for each encounter in the CAPER file.Note: Linkages in CHCS enable users to link encounters to other files (e.g., pharmacy, ancillary, inpatient) using this this Record ID, but name of the variable APPTIDNO has variations across files (e.g. APPTIEN in Pharmacy-PDTS).10

11. Disposition CodeNumeric codes used for ambulatory care Released (e.g., 1) Referral (e.g., 4) Admitted (e.g., 7)Character values used for inpatient rounds care – values resemble those in inpatient data Transfers (e.g., A) Routine Disposition (e.g., F)11

12. Date FieldsEncounter Date = Date of encounterFY/FM and CY/CM = the year and month of the Encounter Date12

13. Provider DataProvider field, which providerProvider information available for Appt, Addtl 1 - Addtl 4:Provider Identifiers: EDIPN, NPI, IDMil Status: Active, Civilian, Guard, etc.Role: Attending, Assisting, Nurse, Para-Prof, etc.Specialty: 001 Fam Practice PhysicianSpecialty HIPAA: 207Q00000X Family PracticeSkill Type (CHCS)(e.g. 1&2 – privileged providers, 1R = Interns/Residents with License, 3 = Nurse Techs, 4 = Direct Care Para-Professionals, Residents w/o License)CAPER Skill Level (HIPAA-based)Assignment info (from DMHRSi)Provider information available for Referring Provider: EDIPN, NPI, ID, and DMIS ID13

14. Procedure DataCoded with CPT/HCPCS from CHCSEvaluation & Management Codes: CPT_1-CPT_3Procedure 1 – Procedure 10:CPT_4-CPT_13All blank on Inferred recordsXXXXX are CPT removed due to code editing*As of 7/11/18, FY17 reported, DHP sites and MEPRS B only14

15. ModifiersE&M Code # Modifier #Procedure # Modifier #Up to 3 modifiers per Procedure Modifier 1: Policy says code if it affects RVUModifier 2-3: Additional informationDirectly affect RVU choice from table or later calculationsE&M Code 1: CPT_1Modifiers: CPTMOD1_1 CPTMOD2_1 CPTMOD3_115

16. QuantityE&M Code # Quantity, Raw & # Quantity, AdjustedProcedure # Quantity, Raw & # Quantity, AdjustedQuantity: the number of times the procedure was performedAlso referred to as Units of Service (UOS)CPT Units of Service, Adjusted (cptuos1-cptuos13)Reduced when reported in excess of UOS limitUsed in RVU calculationsCPT Units of Service, Raw (cptunits1-cptsunits13)16

17. Quantity Adjustments*We haven’t discussed the Edit Flags yet, but we will. UOS exceeded limit for all 3 procedures; changed to UOS substituteChange Edit Flag*=1 (Units of Service changed, exceeded limit)UOS Edit Flag=Y17

18. Ambulatory Payment ClassificationAPC E&M #APC Proc #Assigned based on CPT codesApplied to CAPER B MEPRS, Facility RecordsEach CPT code results in an APC, max 13 per recordAPC Status Code (apcpsi1-apcpsi13) Used in RVU for multiple procedure discountingUses: Workload measurement, cost application and analysis, and PPS18

19. APC WeightsApplied to every APC on a “B” MEPRS, Facility RecordAdjusted for quantity and discounted per Status Code*Summed as APC Aggregate Weight* We haven’t discussed discounting yet either, but we’re getting there.19

20. Facility/Non-Facility FlagAffects provider practice and facility workload assignment, specifically, Practice Expense RVU, and APC weight used for PPS20

21. Relative Value UnitsNumeric values that quantify relative workload and costliness of health care services Emphasizes contribution by provider and practice3 components:Work Practice Expense (PE) – Office or Away From OfficeMalpractice (Not used with Direct Care)Applied to each CPT/modifier combination Simplistically, total RVU = (RVU * Quantity) for all CPTs 21

22. Enhanced [Work, PE, Total] RVUAggregate measures based on 13 CPTs, modifier impact, quantity adjusted (UOS limits applied), code edits, nurse creditsOne choice for direct vs. purchased care “ambulatory” comparisonDC: MEPRS B, FBI, FBNPC: Place of Service = 11, 20, 22, 23, 24, 53, 60, 65, 71, 72, Program Indicator Code not equal D.Willl have to build episodes to create ‘encounters’Direct and Purchased Care professional inpatient data collection are different and not comparable (but it’s getting better)Best measure to compare to Purchased Care (TED-NI)22

23. Provider Aggregate RVUsAggregate measures based on 13 CPTs, modifier impact, quantity adjusted (UOS limits applied)Code editing and the Change Edit FlagsAdditional modifier effectsMultiple procedure discountingProvider impactMultiple provider creditNurse credit code (Unlicensed residents when not supervised)Provider Aggregate is for the encounter, not a single provider!23

24. Change Edit FlagRecords up to 10 different edits to various fieldsData Quality Flags – Y or N valuesBilateral Code Edit Flag Prov/Proc Linkage Edit Flag TCON Edit FlagUOS Edit Flag Surgical Follow-up Edit Flag Purposes:Corrects known mis-coding problems (e.g., coding bilateral modifier AND quantity = 2) “Fixes” missing data (e.g., all E&M provider pointers are missing) Implements policy decisions (e.g., credit reassigned to Appt provider (physician) when additional provider 1 (nurse) is the only provider linked to a procedure)*except CPT Quantities24

25. Code Editing and Modifier Effect: Surgical Follow-upRVUs for S0810 (PRK) removed because modifier 55 indicates postoperative management onlyRVUs applied for surgical follow-up (per 99024)E&M Code and E&M RVUs Removed Change Edit Flag=787 – Surgical Follow-up (credited as 99024)8 – Surgical Follow-up (no credit for E&M)Surgical Follow-Up Edit Flag=Y 25

26. Code Editing: TELCONSAppointment Status=7Non-TELCON Procedure RVUs removedChange Edit Flag = B (TELCON – No additional credit for non-TELCON procedures)26

27. Inputs to RVUsRaw Materials:E&M and Procedure CodesModifiers Quantity (Units of Service)Facility/Non-Facility FlagAnd these for just Provider Aggregate:APC Status Code – Used to determine procedure discountingUp to 3 Providers (Appt Prov and Additional Prov 1-4)Provider SpecialtiesProvider/Procedure Pointers (not available in DAVINCI)Actions: Apply cleanup, modifier impact, multi-procedure discount, nurse credit, and multiple provider credit27

28. Weighted Workload RecapEnhanced [Work, PE, Total] RVUModifier effectsUnits of Service limits appliedMiscoding correctedNurse CreditE&M # Work or PE RVU, NPA (#=1-3) and Proc # Work or PE RVU, NPA (#=1-10) – these are Non-Provider Affected (NPA) RVUsProvider Aggregate [Work, PE, Total] RVU – these additional items are performed for Provider AggregateMultiple procedure discountingMultiple provider participation Provider [Work, PE, Total] RVU, Appt Prov and Addl Prov # (1-2)APC Aggregate Weight on Facility, “B” MEPRS records onlyProvider Aggregate and APC Aggregate Weight used in PPSRemember – Provider Aggregate RVU is for the encounter, not a single provider28

29. Odds and EndsMHS Genesis IOC – no CAPERs as of these datesFairchild: 2/7/17 Oak Harbor: 7/15/17Bremerton: 9/23/17 Madigan/McChord: 10/21/17Analyzing patternsDeployment of providers with no-to-slow backfillSnowbird effect (impact on cold/warm-climate sites)Coding practicesICD-9 vs ICD-10 diagnosis code changesIn ICD-10, no longer have extenders. See DOD unique codes (all start with DOD)Inpatient CAPERs (“A” CAPER) are being used for PPS and Provider ProductivityCreating “A” CAPER for Rounds are not really an issue“A” CAPER for inpatient procedures (MD performs coronary bypass) are at issue. Provider might be coding in Essentris and have no knowledge that workload is not being captured – they think they have done everything – but the MTF should be ensuring it goes through.

30. Odds and Ends ContinuedIncreasing use of ICD-9 diagnosis V68.9 Unspecified Administrative Purpose and Z02.89/Z02.9 Encounter for Other/Unspecified Administrative ExaminationsWe *think* these have been created to get documentation on the record – not that an actual encounter happened.V68.89 is supposed to be used when provider’s documentation is unavailable.These are actual encounters but again, they do not have an actual diagnosis code on them.*Estimated based on 10 months worth of data.

31. Questions31vpav@kennellinc.com