Monthly MA APCD / Case Mix User Workgroup Webinar

Monthly MA APCD / Case MixUser Workgroup WebinarOctober 28, 2014

AgendaI.II.III.IV.V.AnnouncementsCommon Application Issues / QuestionsPresentation on DRGsPresentation on E-CodesQuestions from Current APCD Users

Announcement – APCD WebcastNEHI will convene national expertsand thought leaders to explore theopportunities, challenges andlessons learned in accessing andleveraging APCDs to advancehealth services research.The discussion will highlightexisting models, the opportunitiesand challenges for expanded dataaccess and use, and the potentialfor these systems to evolve overtime.Register -databases-unlocking-thepotential/view

Announcement – APCD Symposium CHIA is in the preliminary stages of planninga research symposium featuring APCDresearch Please contact Adam Tapply[adam.tapply@state.ma.us] if you areinterested in getting involved

Common Application QuestionsQuestion:When can I apply for 2013 APCD data?Answer: Release 3.0 application materials areexpected to be ready in December 2014 Will be announced at this workgroup and viaeblast[NOTE: 2013 Case Mix data is available now]

Reminders Re: Application Revisions Please title revised documents in the followingformat “Name of Revised Document Date” (i.e.“Revised Application Form 10.24.14)If application form is revised, it must be resigned with the date of the revisionPlease bold or highlight changes in applicationform and data spec workbookPlease send an IRBNet message or “lock yourpackage” once you are finished with revisions

What DRG versions available inCHIA Inpatient Case Mix Data?

Review: Definition of DRGDiagnosis Related GroupA classification system that groups patientsaccording to diagnosis, type of treatment, age,and other relevant criteria. Under theprospective payment system, hospitals are paida set fee for treating patients in a single DRGcategory, regardless of the actual cost of care forthe individual.Source: CMS http://www.cms.gov/apps/glossary/default.asp

Over the Past 30 years Multiple Versions of DRGshave been Created and RefinedThe Three Most Commonly Used DRGs Decade (2004-2013) in HDD All Patients Diagnosis Related GroupsAP-DRG All Patients Refined Diagnosis Related GroupsAPR-DRG Medicare (CMS) Diagnosis Related GroupsCMS-DRG

13 Year (2001-2013) History of Diagnosis RelatedGroup (DRG) Versions in Massachusetts InpatientHospital Discharge Data (HDD)HDDFiscalYearVHAFAP-DRG AP-DRG AP-DRG AP-DRG AP-DRG APR-DRG APR-DRG APR-DRG APR-DRG DRGVersion Version Version Version Version Version Version Version Version XXXXXVHAFDRG CMS-DRG CMS-DRG CMS-DRG CMS-DRG CMS-DRGVersion Version Version Version Version Version252627282930XXXXXXX

What is the difference betweenthe DRG versions?

AP-DRG History and Massachusetts HDD Use TimelineAll Patients Diagnosis Related Groups (AP-DRG) was developed in 1987 through agreement between New York StateDepartment of Health and 3M Health Information Systems Software in conjunction with the National Association ofChildren’s Hospitals and Related Institutions. AP-DRGs are similar to original DRGs developed by Yale University forCMS, but also include a more detailed DRG breakdown for non-Medicare patients, particularly newborns andchildren. Its development was driven by legislation instituting DRG-prospective payment for all non-Medicare patientsand evaluated to ensure its applicability to neonatal, pediatric patients and patients with HIV. The features of AP-DRGcategories recognize resource intensity* associated with: Six Distinct Neonate Birth Weight RangesHIV in the presence or absence of 12 re tructural* Differences betweenMedicare-DRG, AP-DRG, APR-DRG Versions 12MedicareDRGAP-DRGAPR-DRGMultiple Complicationsand Comorbidities notrecognizedMultiple Complicationsand Comorbidities notrecognizeMultiple Complicationsand ComorbiditiesrecognizedNewborn Birthweightnot UsedNewborn BirthweightUsedNewborn BirthweightUsedNo Risk of MortalitySubgroupNo Risk of MortalitySubgroupIncludes Risk ofMortality SubgroupNational Association ofChildren’s HospitalsPediatric ModificationsNot IncludedLimited Inclusion ofNational Association ofChildren’s HospitalsPediatric ModificationsComplete Inclusion ofNational Association ofChildren’s HospitalsPediatric ModificationsLimited use of HIVInfection MDCComplete use of HIVInfection MDCComplete use of HIVInfection MDC* Source: 3M Health Information Systems Research Report No. 5-98

If I want to identify the potentialdelivery records, which DRG isthe best for me?

Comparison of Differences inCMS DRG Version 30 and APR DRG VersionTop Ranking Delivery Groupings by Charges forMassachusetts 1793769CMS Version 30 DRGCesarean section w/o CC/MCCVaginal delivery w/o complicating diagnosesCesarean section w CC/MCCVaginal delivery w complicating diagnosesVaginal delivery w sterilization &/or D&CPostpartum & post abortion diagnoses w/o O.R. procedureOther antepartum diagnoses w medical complicationsNeonate w other significant problemsExtensive O.R. procedure unrelated to principal diagnosis w CCOther antepartum diagnoses w/o medical complicationsVaginal delivery w O.R. proc except steril &/or D&CPrematurity w/o major problemsNeonates, died or transferred to another acute care facilityPrematurity w major problemsFull term neonate w major problemsPostpartum & post abortion diagnoses w O.R. 9633544626621580APR DRG* Version 30 DRGCesarean deliveryVaginal deliveryVaginal delivery w sterilization &/or D&CPostpartum & post abortion diagnoses w/o procedureOther antepartum diagnosesNeonate birthwt 2499g, normal newborn or neonate w other problemVaginal delivery w complicating procedures exc sterilization &/or D&CExtensive procedure unrelated to principal diagnosisNeonate bwt 2000-2499g w other significant conditionNeonate bwt 1500-1999g w or w/o other significant conditionOther O.R. proc for obstetric diagnoses except delivery diagnosesNeonate birthwt 2499g w other significant conditionNeonate birthwt 2499g w major anomalyD&C, aspiration curettage or hysterotomy for obstetric diagnosesNeonate bwt 2000-2499g, normal newborn or neonate w otherproblemNeonate bwt 2000-2499g w major anomalyNeonate, transferred 5 days old, not born here* Note: APR DRG includes additional Subclassgroupings by Category for Severity of Illness andRisk of Mortality

Comparison of CMS-DRG to APR-DRG for 4Single Liveborn Cases*PDX V3000: Single liveborn, born in hospital, delivered withoutmention of cesarean sectionAdmission age in days: 0Discharge status: HomeBirthweight: 500GCase 1Case 2SecondaryDiagnosesCMS DRGAPR DRGCase 3748.4391591 Subclass 1Case 4748.4770.8748.4770.8753.0390389389591 Subclass 2591Subclass 3591 Subclass 4DescriptionCongenital Cystic LungRespiratory Failure of NBRenal AgenesisNormal Newborn/ Newborn withother significant problems/FullTerm Neonate w/ Maj. Prob.Neonate, birth weight 500-749G,without major procedureCMS DRGAPR 141Payment weights*** Source: Lisa Lyons, An Overview of 3MTM All Patient Refined Diagnostic Related Groups (3M APR DRG), July 13, 2012, 3M HIS** Payment weights are budget neutral and computed from a national database

Comparison of CMS-DRG to APR-DRG for Preterm Infant** Source: All Patient Refined DRGs, a Methodology Overview, 2006, 3M HIS, SAPR-Methodology.pdf

How complete are the ExternalCause of Injury Codes (MC040)in APCD?

2009-2012 MA APCD Injury Diagnosesand External Cause of Injury CodesAll InjuryPrincipalDiagnosisE-Codes11.7% of all APCDInjury PrincipalDiagnosis ClaimLines have anaccompanying ECode8.7% have an ECode in theDedicated E-CodeField (MC040)3% have an E-Codepopulating anOther DiagnosisCode FieldAccidentRelatedInjuryE-Codes10% of All InjuryPrincipal Diagnoseshave Yes (Code 1)for AccidentIndicator (MC126)40% of these claimlines have an ECode in the E-Codefield or OtherDiagnosis CodeFieldEmploymentRelatedInjuryE-Codes2% of All InjuryPrincipal Diagnoseshave a Yes (Code 1)for Employment*Related (MC128)88% of these claimlines have an ECode in the E-Codefield or OtherDiagnosis Fields* Note: MA APCD doesnot include Workers’Compensation, AutoInsurance and otherclaims not paid byMedical Insurance.Case Mix includes dataregardless of paymentsource.

Questions from MA APCD UsersQUESTION The “Service Provider Number” (MC024) is listed as alinkage element but many of the records have a NULLvalue. We cannot link elements with NULL values.ANSWER For MassHealth and Health Safety Net, the ServiceProvider Number (MC024) is always as the BillingProvider (MC076), so they did not populate the fieldMC024. There are other carriers where that scenario is also truebut they did redundantly populate the service providernumber with the billing provider number.

QUESTION Is there an identifier for patients that is NOT theirSSN? We would like to track patients across plansand over time, but would like to avoid accessinghigh-level identifying info such as SSNs.ANSWER CHIA has created in APCD an MEID that allowsyou to track patients across plans and over time. For more information, refer to our Master PatientIndex presentation from last pdf

QUESTION Is it possible to determine race/ethnicity of a patient?ANSWER In the APCD, the eligibility file has race and ethnicity databut the completeness of that varies across carriers.[Thresholds for Race and Ethnicity are both 3%] Case mix data has more complete race and ethnicitydata

QUESTION Are payments to the Department of Mental Health orDepartment of Corrections included in APCD?ANSWER Yes.

QUESTION We are interested in learning more about high-deductible healthplans. Can we determine whether a plan is a HDHP in the producttype field? (or is there another indicator that we could use?)ANSWER The Product File has field PR012 Annual Per Person DeductibleCode which defines the Total Per Person Deductible for allbenefits under this product using the following coding options000 No per person deductible001 Deductible Total under 1,000002 Deductible Total of 1,000 thru 1,999003 Deductible Total of 2,000 thru 2,999004 Deductible Total greater than 3000999 Not Applicable

QUESTION If a claim is denied, we understand that it is not reflectedin APCD. Are there any instances where a denied claimmight appear (i.e., initially denied but later paid, partiallypaid, or other circumstances)?ANSWER Yes, if a claim was originally paid then later denied orpartially paid with specific claim lines denied.

Upcoming Schedule 11/13 – Data Privacy Committee Meeting 11/20 – Data Release Committee Meeting[a week early due to Thanksgiving] 11/25 – User Workgroup Webinar

Questions? General questions about the APCD:(CHIA-APCD@state.ma.us) Questions related to APCD applications:(apcd.data@state.ma.us) Questions related to Casemix:(casemix.data@state.ma.us)

Oct 28, 2014 · HDD Fiscal Year AP-DRG Version 12 AP-DRG Version 14.1 AP-DRG Version 18 AP-DRG Version 21 AP-DRG Version 25.1 A