Direct Care Inpatient Admissions (SIDR) VERONIKA PAV KENNELL

Direct Care Inpatient Admissions (SIDR) VERONIKA PAV KENNELL & ASSOCIATES, INC.

Objectives Describe a Standard Inpatient Data Record (SIDR) What is a record? How are records coded? How are TRICARE MS-DRGs different from Medicare? Highlight important data fields 2

Common Terms National Provider ID HIPAA Taxonomy Code ICD Diagnosis Code CPT/HCPCS Code MDC APC Basic Workload Person IDs Bencat/Bencat Common PCM ID Enrollment MEPRS Code Deployment Information Geography Case Manager ID Tmt DMIS ID MEPRS Code ICD Procedure Code CCS Category MS-DRG Service Dates Weighted Workload Demographics HCDP, ACV & ACV Group, Enrollment Group Enrollment Site Special HCDP Raw vs Total Record ID Case Manager DMISID 3

Standard Inpatient Data (SIDR) Record Each record represents the most recent version of a record for a patient dispositioned from an MTF. MTFs are considered Acute Care Facilities Includes both those records where the electronic record has been closed out (complete) and those still open (incomplete) – but the patient has been discharged More later Long Stay patients included in the file once discharged from the hospital (inconsistent with Purchased Care data) Includes Observation Stays If DX1 V719 (for FY15 and back) or Z049 (for FY16 forward) and DMISDAYS 2 then OBSFLAG Y; otherwise OBSFLAG N (Populated FY12 ) 4

Reported vs. Inferred SIDRs Timeliness: For MTFs, the requirement is to complete SIDR within 30 business days of patient discharge Completeness: Some records slow getting submitted More like 30-90 days depending on Treatment DMIS ID For patients that have been discharged, both electronically closed out records and those that have not been closed out are received from the sites Identified using Compliance Status (INFFLAG) I Inferred (record has not been closed out) R Reported (record closed out) 5

Inferred SIDRs Diagnosis and Procedure Code fields on inferred records do not have complete information Diagnosis 1 has temporary placeholders: FY15 and back: B200 (live birth), B700 (Disease), B900 (Injury) FY16 and forward: DOD0010 (live birth), DOD0011 (Injury), DOD0012 (Other) Workload measures (e.g., MS-DRG RWP) are averaged by Tmt DMIS ID and MEPRS Code for inferred records MHS GENESIS IOC: No SIDRs as of these dates for these sites: Oak Harbor: 7/15/17 Bremerton: 9/23/17 Madigan: 10/21/17 6

Reported vs. Inferred SIDRs FY 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 FM 1 2 3 4 5 6 7 8 9 10 11 12 Month Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Total Compliance I R 14 19,599 7 18,441 4 19,138 9 19,607 24 18,254 12 20,206 19 18,392 13 19,214 10 18,705 7 18,269 33 19,641 78 19,094 230 228,560 Total 19,613 18,448 19,142 19,616 18,278 20,218 18,411 19,227 18,715 18,276 19,674 19,172 228,790 Percent Inferred 0.07% 0.04% 0.02% 0.05% 0.13% 0.06% 0.10% 0.07% 0.05% 0.04% 0.17% 0.41% 0.10% FY 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 FM 1 2 3 4 5 6 7 8 9 10 11 12 Compliance I R 94 18,239 69 16,692 144 17,183 119 17,810 82 16,720 180 18,045 559 16,042 1,010 16,179 7,075 9,914 1,504 113 Total 18,333 16,761 17,327 17,929 16,802 18,225 16,601 17,189 16,989 1,617 Percent Inferred 0.51% 0.41% 0.83% 0.66% 0.49% 0.99% 3.37% 5.88% 41.64% 93.01% 146,937 157,773 6.87% Month Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Total 10,836 FY17: Varies by Tmt DMIS ID: Guam – 194 (10% of their total), San Antinio (SAMMC) - 18 FY18: At the beginning of a new FY, there’s a lag in loading new MS-DRG weights at MTFs, so see a backlog that has to be worked through *As of 7/18/18 7

What’s on a SIDR record?

Identifying Unique Records Record ID: CHCS Patient Register Number (PRN) Essentially a chronological counter at each MTF, 7 characters Use with Tmt DMIS ID for unique record (MTF) Patient Information: Patient SSN & DoD EDIPN, patient demographics (age, dob, gender, marital status), Sponsor SSN, Enrollment Group, Beneficiary Category, etc. 9

Date Fields Admission Date: (ADMDATE) Use to stratify admissions Disposition Date: (DISPDATE) Disposition date is used to allocate records to each FY file FY/FM and CY/CM: year and month of disposition date 10

Provider Information Tmt DMIS ID and Attributes (Treatment Service, Command, etc.) MEPRS Code of MTF department providing care Up to 4 MEPRS Codes -- Admitting, Dispositioning, Up to 2 Interim MEPRS3 Code, Admitting MEPRS3 Code, Dispositioning MEPRS3 Code, Second Service MEPRS3 Code, Third Service If patient in more work centers, info not available Admitting and Attending Providers: NPI, EDIPN, HIPAA Specialty Provider Assignment information comes from DMHRSi. 11

Diagnosis Codes Diagnosis 1 – Diagnosis 20: Diagnosis 1 is the principle diagnosis No decimal points FY15 and back ICD-9-CM FY16 and forward ICD-10-CM Both ICD-9-CM and ICD-10-CM have MHS Unique Codes Present on Admission (POA) Per diagnosis code 12

MHS Unique Diagnosis Codes There are 36 MHS Unique Codes in ICD-10 (FY 16 ) 535 MHS Unique Codes in ICD-9 (through FY 15) We already saw some of these on the Inferred Inpatient Records

MHS Unique Diagnosis Codes Most MHS Unique Codes will refer to care specific to the MHS, for example: pre- and postdeployment health assessments

Procedure Codes Procedure 1 – Procedure 20: Left justified; no decimal points FY15 and back ICD-9-CM FY16 and forward ICD-10-PCS 15

MDC and MS-DRG MDC: Major Diagnostic Category Based on Diagnosis 1 (primary diagnosis) 25 groupings typically related to a diagnosis involving a body system (e.g., 14 Mothers; 15 Newborns; 04 Respiratory) MS-DRG: TRICARE Diagnosis Related Group 825 MS-DRGs Based on Medicare with refinements made by TRICARE Not available on inferred SIDRs Remember, no diagnosis or procedure codes on inferred records! 16

Code Description MDC’s 14 Pregnancy, Childbirth, and the Puerperium 15 00 Unknown 01 Diseases and Disorders of the Nervous System 18 Newborns & Other Neonates with Conditions Originating in Perinatal Period Diseases and Disorders of the Blood, Blood Forming Organs, Immunological Disorders Myeloproliferative Diseases and Disorders, Poorly Differentiated Neoplasm Infectious and Parasitic Diseases, Systemic or Unspecified Sites 02 Diseases and Disorders of the Eye 19 Mental Diseases and Disorders 03 Diseases and Disorders of the Ear, Nose, Mouth, and Throat 20 Alcohol/Drug Use and Alcohol/Drug Induced Organic Mental Disorders 04 Diseases and Disorders of the Respiratory System 21 Injuries, Poisonings and Toxic Effects of Drugs 05 Diseases and Disorders of the Circulatory System 22 Burns 06 Diseases and Disorders of the Digestive System 23 07 Diseases and Disorders of the Hepatobiliary System and Pancreas 24 Factors Influencing Health Status and Other Contacts with Health Services Multiple Significant Trauma 08 Diseases and Disorders of the Musculoskeletal System and Connective Tissue 25 Human Immunodeficiency Virus Infections 09 Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast 28 Outpatient Drug and Adjunctive Dental (HCSR Only, not valid in SIDR) 10 Endocrine, Nutritional and Metabolic Diseases and Disorders 29 Not Classifiable 11 Diseases and Disorders of the Kidney and Urinary Tract 98 Diseases and Disorders of the Reproductive System 12 Diseases and Disorders of the Male Reproductive System PR Pre-Major Diagnostic Category, DRG May Occur in 1 or More MDC 13 Diseases and Disorders of the Female Reproductive System DO DoD Unique Codes (used only in CAPER) which are unique attributes Code Description 16 Blank Not Associated with any Specific MDC 17

TRICARE vs MEDICARE MS-DRGs Direct Care and Purchased Care have TRICARE MS-DRGs Exception is MHS GENESIS, which has Medicare MS-DRGs Major Differences: TRICARE has more Neonate MS-DRGs TRICARE has age specific MS-DRGs Alcohol, Allergic Reactions, Leukemia, etc.

TRICARE vs MEDICARE MS-DRGs Examples of Differences TRICARE MS-DRG 266 834 835 836 TRICARE Description ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE 0-17 ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE 17 W MCC ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE 17 W CC ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE 17 W/O CC/MCC Medicare MS-DRG 834 835 836 TRICARE MS-DRG 898 899 Medicare Description ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W CC ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W/O CC/MCC TRICARE Description ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY AGE 21 W/O MCC ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY AGE 21 W/O MCC Medicare MS-DRG 897 Medicare Description ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC

TRICARE vs MEDICARE MS-DRGs Examples of Differences TRICARE MS-DRG Description 789 NEONATE, BIRTHWT 2499G, W/O SIGNIF O.R. PROC, W MULT MAJOR PROB 790 NEONATE, BIRTHWT 2499G, W/O SIGNIF O.R. PROC, W MAJOR PROB 791 NEONATE, BIRTHWT 2499G, W/O SIGNIF O.R. PROC, W MINOR PROB 792 NEONATE, BIRTHWT 2499G, W/O SIGNIF O.R. PROC, W OTHER PROB 793 NEONATAL AFTERCARE FOR WEIGHT GAIN 794 NEONATAL DIAGNOSIS, AGE 28 DAYS

Top MS-DRG by Beneficiary Category

Top MS-DRG by Beneficiary Category

What to use? MDC 14 (Pregnancy, Childbirth, & the Puerperium) MS-DRG 766 (C-Section w/o CC) ICD-9 Diagnosis 65420 (Scar from Previous Cesarean Delivery) or ICD-10 Diagnosis O3421 (Maternal Care for Scar from Previous Cesarean Delivery) **************************************************** All OB care, not just deliveries? Just deliveries? MDC MS-DRG Specific kind of delivery? Diagnosis Code 23

Admission and Discharge Status 2015 0 1 4 5 6 7 8 L S 2017 2018 Source Of Admission Dispositions % Total Dispositions % Total Dispositions % Total Dispositions % Total ER, Direct to Military Hospital 77,337 30.9% 73,496 30.4% 70,852 31.0% 49,725 31.5% Direct to Mil Hosp, not ER 120,133 48.0% 117,345 48.5% 110,108 48.1% 75,208 47.7% Init Adm in Non-US Armed Svc Hosp, Tx to Mil Hosp (AD) 209 0.1% 191 0.1% 193 0.1% 125 0.1% Init Adm in Non-US Armed Svc Hosp, Tx to Mil Hosp (Non-AD) 76 0.0% 83 0.0% 203 0.1% 195 0.1% Tx from Army Hospital 276 0.1% 358 0.1% 516 0.2% 452 0.3% Tx from Navy Hospital 102 0.0% 108 0.0% 97 0.0% 58 0.0% Tx from AF Hospital 52 0.0% 12 0.0% 13 0.0% 5 0.0% Live birth this Hospital 46,740 18.7% 44,426 18.4% 41,317 18.1% 28,163 17.9% Adm resulting from APV, direct to MTF 5,467 2.2% 5,793 2.4% 5,491 2.4% 3,842 2.4% Total 250,392 241,812 228,790 157,773 Disposition Status Code 01 02 03 04 05 07 20 2016 Home, Self-care Transfer to Short Term Facility Discharged to Skilled Nursing Facility Discharged to Intermediate Care Facility Transfer to Other Left against medical advice Died Total 2015 2016 2017 2018 Dispositions % Total Dispositions % Total Dispositions % Total Dispositions % Total 241,803 96.6% 233,705 96.6% 220,357 96.3% 151,875 96.3% 5,395 2.2% 4,697 1.9% 4,750 2.1% 2,996 1.9% 868 0.3% 1,141 0.5% 1,208 0.5% 1,016 0.6% 615 0.2% 616 0.3% 791 0.3% 722 0.5% 1 0.0% 1 0.0% 512 0.2% 487 0.2% 510 0.2% 369 0.2% 1,198 0.5% 1,165 0.5% 1,174 0.5% 795 0.5% 250,392 241,812 228,790 157,773 *As of 7/18/18 24

Workload Measures Dispositions: Each record is a disposition To count dispositions, can count MTF PRNs, so set to 1 Bed Days: days as reported from MTF Bed Days have 0 (zero) days changed to 1 bed day Bed Days of Record: zero bed days not changed Bed Days in ICU: bed days spent in any intensive care unit Summing by FY and/or FM puts all the bed days in the month of discharge MS-DRG RWP Remember – these measures include inferred unless Compliance Status is filtered/conditioned! 25

MS-DRG RWP Relative Weighted Product (RWP) Intensity adjusted workload measure Based on MS-DRG weight (i.e., relative costliness of that MS-DRG, hospital costs only), LOS, and other factors Does not include provider’s costliness MS-RWP MS-DRG weight for most cases. Long Stay Outliers receive a little more for each day over the threshold; Short Stay Outliers receive a little less BEST WORKLOAD MEASURE! Inferred records have averages Let’s look at the MS DRG Relative Wegiht 26

MS DRG Relative Weights Relative weights are the basis of payment in TRICARE for acute care hospitals. All MTFs are acute care, only some private sector providers are (acute care hospital indicator can be used to discern) Annually, billed amounts from acute care hospitals are examined on TRICARE claims and compared by MS-DRG. Relative weights represent the relative billed amount for one MS-DRG vs. all others. An MS-DRG weight of 2 means the care was billed at twice the rate of an MS-DRG with a weight of 1. “Inlier” patients (within short and long stay thresholds) receive the relative weight as the RWP. Adjustments are made for LOS outliers and transfers. The RWP for DRG 637 is the same whether the LOS is 26 days or 2 days. 27

MS-DRG Relative Weights The relative weight reflects the relative billed amount in TRICARE for that MS-DRGs vs. all others. Remember these are inpatient hospital bills. The weights do not consider provider costliness. Note that there are no physician charges on hospital bills. 28

MS-DRG Relative Weights Highest Weight MS-DRGs – FY2017 29

MS-DRG Relative Weights Lowest Weight MS-DRGs – FY2017 30

MS-DRG RWP Relative Weighted Products (RWP) Inpatient Case Mix MS-DRG RWP / DISP Note: Additional filters have to be applied in purchased care (TED-I) so that only acute facilities (use Acute Care Hospital Indicator) are included and partial stays (use Discharge Status) are excluded. 31

Inpatient Workload Example Create a query to look at workload measures by Tmt DMIS ID for FY17: Dispositions Bed Days MS-DRG RWP Compute Average LOS (ALOS) and CMI. Look at the top 15 Tmt DMIS ID based on CMI. What do we know about these facilities: Population mix, medical specialties, etc.? 32

Workload Measures – FY17 Tmt Rank DMIS ID 1 0109 2 0067 3 0047 4 0014 5 0073 6 0104 7 0095 8 0125 9 0108 10 0052 11 0029 12 0124 13 0607 14 0079 15 0086 Tmt DMIS ID Bed Dispositions Name Days SAMMC 24,549 94,716 WRNMMC 13,359 58,946 EISENHOWER 4,372 20,702 TRAVIS 5,721 20,519 KEESLER 2,940 6,990 BEAUFORT 260 1,415 WRIGHT-PATT 3,653 8,189 MADIGAN 13,827 45,770 WM BEAUMONT 8,791 25,827 TRIPLER 11,596 50,045 SAN DIEGO 18,018 59,425 PORTSMOUTH 14,715 49,718 LANDSTUHL 4,731 14,166 NELLIS 4,161 8,760 KELLER 972 1,833 MS-DRG ALOS CMI RWP 31,690.05 3.86 1.29 16,626.60 4.41 1.24 5,185.02 4.74 1.19 6,457.51 3.59 1.13 3,139.56 2.38 1.07 268.83 5.44 1.03 3,605.23 2.24 0.99 13,598.65 3.31 0.98 8,547.79 2.94 0.97 11,014.73 4.32 0.95 16,983.89 3.30 0.94 13,358.45 3.38 0.91 3,997.32 2.99 0.84 3,396.83 2.11 0.82 773.11 1.89 0.80 WRNMMC: Trauma, Ortho, and Circulatory (looked by MDC) SAMMC: trauma center for the city of San Antonio, Burn Unit Eisenhower: deliveries sent downtown San Diego: 35% of workload for MDC 14 and 15 (moms and babies) Portsmouth: 40% of workload for MDC 14 and 15 (moms and babies) Keller: Sports Medicine residency Don’t just look at “how many” as “what kind” tells more of the story! *As of 7/18/18 33

Workload Measures – FY17 Omitting MS-DRGs 765-768, 774-775, 791-792, 795 (Deliveries and Newborns with low MSDRG weights) Rank Rank Omit All 1 1 2 2 3 10 4 5 5 4 6 8 7 9 8 12 9 3 10 11 11 7 12 13 13 14 6 15 Tmt DMIS ID 0109 0067 0052 0073 0014 0125 0108 0124 0047 0029 0095 0607 0123 0104 0621 Tmt DMIS ID Name Disp All SAMMC WRNMMC TRIPLER KEESLER TRAVIS MADIGAN WM BEAUMONT PORTSMOUTH EISENHOWER SAN DIEGO WRIGHT-PATT LANDSTUHL FT BELVOIR BEAUFORT OKINAWA 24,549 13,359 11,596 2,940 5,721 13,827 8,791 14,715 4,372 18,018 3,653 4,731 7,880 260 3,328 Disp Bed Days Omit 21,230 86,303 11,175 53,223 7,309 40,389 2,275 5,623 5,006 18,954 10,021 38,028 6,393 20,816 9,529 36,044 4,364 20,690 12,650 45,694 2,987 6,824 3,161 11,122 4,825 17,991 260 1,415 1,297 4,398 MS-DRG ALOS RWP 30,439.56 4.07 15,795.50 4.76 9,513.68 5.53 2,906.99 2.47 6,215.19 3.79 12,296.30 3.79 7,715.25 3.26 11,431.32 3.78 5,183.26 4.74 15,011.30 3.61 3,375.79 2.28 3,447.03 3.52 5,115.69 3.73 268.83 5.44 1,320.57 3.39 CMI CMI All Omit 1.29 1.43 1.24 1.41 0.95 1.30 1.07 1.28 1.13 1.24 0.98 1.23 0.97 1.21 0.91 1.20 1.19 1.19 0.94 1.19 0.99 1.13 0.84 1.09 0.78 1.06 1.03 1.03 0.61 1.02 “All”: no records omitted “Omit”: MS-DRGs listed above omitted 0079 Nellis and 0086 Keller dropped out of top 15 0123 Ft Belvoir and 0621 Okinawa are now in top 15 *As of 7/18/18 34

Questions [email protected] 35