Hm306 week 1 ppt 2

1. © 2016© 2016
A Practical Approach to Analyzing
Healthcare Data
Chapter 2 – Data in Healthcare

2. © 2016
Data Quality
• Validity
– Accuracy of the data
– Ability of the data to measure the attribute it is
intended to measure
• Reliability
– Repeatability or reproducibility of the results

3. © 2016
Types of Validity
• Face validity
– Does the metric appear to measure the quantity it was intended to measure?
– Often assessed via expert opinion
– Weakest form of validity measure, but should be the first step is assessing validity of a new test or
metric
• Content validity
– Are the components of the metric necessary and sufficient to measure the quantity?
– In survey design, this content validity ensures that there are not irrelevant questions
• Construct validity
– Is the measurement tool capturing the construct to be measured?
– In survey design, this may be measured by asking similar questions about a topic (or construct) to
ensure consistency in the responses
• Criterion validity
– Does the metric agree with an accepted gold standard for measuring the same quantity?
– A new less expensive laboratory test may be compared against another accepted test for
measuring the same quantity. If the test results agree, then the new test has criterion validity

4. © 2016
Types of Reliability
• Inter-rater reliability – measures the reproducibility or
consistency of the metric between two different raters
• Intra-rater reliability – measures the reproducibility or
consistency of the metric between two different time points
using the same rater
• Statistics to measure reliability
– Kappa statistic or Cohen’s Kappa
• Measures inter or intra rater reliability
• 0.41 to 0.60 – moderate
• 0.61 to 0.80 – substantial
• 0.81 to 1.00 – almost perfect
– Cronbach’s Alpha
• Measures internal consistency between questions
• Acceptable level >= 0.70

5. © 2016
Types of Healthcare Data
• Internal data
– Electronic health records
– Claims and billing data
– Patient satisfaction surveys
• External data
– Registries (may be both internal/external)
– Statewide databases
– Medicare claims data

6. © 2016
Diagnostic Data
• Formerly ICD-9-CM
• Transitioned to ICD-10-CM on 10/1/2015
• Even after transition, both coding systems
will be utilized for data profiling and
analysis
• ICD was designed as a disease tracking
system, but used in the US as a payment
driver under prospective payment systems

7. © 2016
Diagnostic Data - IPPS
• CMS pays for inpatient services provided
to Medicare patients via an inpatient
prospective payment system (IPPS)
• Payment is based on diagnosis related
groups (DRG) – ICD-9 diagnosis and
procedure codes are combined with other
demographic data to ‘group’ patients in the
DRGs for determination of payment
• DRGs are further grouped into MDCs
• ICD-9, ICD-10 and DRG codes are all
updated based on the federal fiscal year
starting on October 1.

8. © 2016
Diagnostic Data - IPPS
ICD-9
Diagnosis
DRGMDC
MDC 05 –
Cardiovascular
Disease
MS-DRG 293 –
Congestive Heart
Failure W/O
CC/MCC
428.21 – Acute
systolic heart failure
428.1 –Left heart
failure
MS-DRG 282 –
Acute Myocardial
Infarction W/O
CC/MCC
410.01 – AMI of
anteolateral wall –
initial episode
410.22 – AMI of
inferolateral wall –
subsequent episode
Note: This is an simplified example of the IPPS coding hierarchy.
Secondary diagnoses, procedures and patient demographics are
required to determine the DRG assigned to a discharge.

9. © 2016
CMS – IPPS Rule Table 5
• Listing of all MS-DRGs valid for payment during the designated
federal fiscal year (10/1 to 9/30)
• Updated annually
• Weights determine payment, but may be used as a proxy for
severity or resource intensity of patients
• Mean LOS figures may be used as external benchmarks

10. © 2016
Procedural Data
• Procedures performed on a patient may be
submitted for payment based on two coding
systems:
– ICD-9 (ICD-10-PCS after 10/1/2015)
• Used for hospital inpatient procedures
• Updated on 10/1 of each year (federal fiscal year)
– Healthcare Common Procedure Coding System
(HCPCS)
• Level 1 – Current Procedure Terminology (CPT®)
• Level 2 – HCPCS start with a letter
• Updated based on calendar year

11. © 2016
Procedural Data - OPPS
• Outpatient Prospective Payment System
(OPPS)
– Payment for Medicare hospital outpatient
services
– HCPCS codes are assigned to Ambulatory
Payment Classifications (APC) for payment
• Updated on a calendar year basis
• APCs have weights that are used to derive
the payment for each service or set of
services

12. © 2016
CMS – OPPS Rule Addendum B
• Listing of all APCs valid for payment during the
designated calendar year
• Updated annually
• Weights determine payment, but may be used as a
proxy for severity or resource intensity of patients

13. © 2016
Pharmacy Data
• National Drug Codes (NDC)
– FDA website
– http://www.fda.gov/Drugs/InformationOnDrugs/uc
m142438.htm
• Therapeutic Classification Groups
– OVID Field Guide
– http://resourcecenter.ovid.com/site/products/fieldg
uide/ipab/List_of_AHFS_Pharmacologic-.jsp
• RxNorm
– National Library of Medicine
– http://www.nlm.nih.gov/research/umls/rxnorm/

14. © 2016
National Drug Codes
• National Drug Codes (NDC)
– 11 digit codes
– Labeler - Manufacturer (digits 1-5)
– Product Code - Drug name (digits 6-9)
– Package Code - Size and type (digits 10 -11)
• Example NDC code
Source: http://www.drugs.com/ndc.html

15. © 2016
Therapeutic Classification Groups
• Classified according to
categories established
by the American
Hospital Formulary
(AFHS)
• Hierarchical coding
system

16. © 2016
RxNorm
• What is RxNorm?
– Normalized naming system for generic and brand
name drugs and relationships
– Includes many software components
• Why RxNorm?
– Supports transmission of information about drug use
between organizations

17. © 2016
Administrative Data
• Revenue Codes
• Place of Service Codes
• Claims Processing Codes
• Relative Value Unit Data

18. © 2016
Revenue Codes
• Four digit code
• Used to categorize charges into ‘departments’ on UB-04 or 837I
billing records
• NOT necessarily the same department found in provider
accounting system
• Standard across providers
• Allows comparison of departmental charges and costs across
providers
http://www.resdac.org/sites/resdac.org/files/Revenue%20Center%20Table.txt

19. © 2016
Place of Service Codes
• Used on
professional
claims (HCFA-
1500 or 837P)
to specify the
type of location
that the service
was performed

20. © 2016
Claims Processing Codes
• Claim Adjustment Reason Codes – used to communicate why the full charge
was not paid for a service line (contractual allowances)
• Remittance Advice Remark Codes – Used to convey information about
remittance processing or to provide a supplemental explanation for an
adjustment already described by a Claim Adjustment Reason code.
• Claim Status Codes- Used in the Health Care Claim Status Notification (277)
transaction in the STC01-2, STC10-2, and STC11-2 composite elements.
http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/

21. © 2016
Relative Value Unit Data
• Assigned to CPT and HCPCS codes to determine the
Medicare fee schedule payment
• Used as a measure of the resource intensity required to
deliver a service or procedure to a patient
• Updated annually
• Data for CPT 71010 – Single View Chest X-Ray
http://www.cms.gov/apps/physician-fee-schedule/search/search-
results.aspx?Y=0&T=4&HT=0&CT=0&H1=71010&M=5

22. © 2016
Hospital Data Flow
Registration
• Demographic information
• Insurance information
Charge
Capture
• Procedures performed
• Medications dispensed
• Diagnostic tests
Discharge
• ICD-9 procedure and diagnosis codes assigned (inpatient)
• CPT/HCPCS codes assigned (outpatient)
• Claim scrubbed for potential errors
• Claim submitted for payment
Remittance
Advice
• Payment received
• Reason for denials

23. © 2016
Physician Practice Data Flow
Appointment
Date
• Demographic information
• Insurance information
Charge
Capture
• ICD-9 diagnoses
• CPT procedures
Note: in physician office CPT and ICD-9 diagnoses are linked
Claim
Submitted
• Co-payment paid (often at time of service)
Response
from Payer
• Payment received
• Reason for denials

24. © 2016
Sources of Data
• Internal Data
– Claims
– Departmental Databases
– Clinical Data Repository
• External Data
– Medicare
– State Databases
– Other organizations

25. © 2016
Claims Data
• UB-04 Claim form (CMS-1450)
– Hospital services
– Submitted via 837I transaction set
– 5010 format
• CMS-1500 Claim Form
– Physician services
– Submitted via 837P transaction set
– 5010 format

26. © 2016
Departmental Databases
• HIMS
• Laboratory Information System (LIS)
– May use Logical Observational Identifiers Names and Codes (LOINC)
• Radiology Information System (RIS)
– Images available through Picture Archiving and Communication System
(PACS)
• Patient Accounts Database
– Includes financial data
– Charges
– Payments
– Accounts receivable/accounts payable
– Payroll
– General ledger
– May be called a practice management system in a physician office

27. © 2016
Clinical Data Repository
• Organizes data from many different sources
• Contains a variety of data types:
– Unstructured data
• Transcribed
• Dictation
• Images or video clips
– Structured or discrete data
• Codes
• Charge items
• Medication records

28. © 2016
Other Internal Data
• Registries
– Cancer
– Trauma
– Birth
– Diabetes
– Implants
– Transplants
– Immunizations

29. © 2016
External Data
• Medicare
– Inpatient
– Outpatient
– Part B Utilization (Physician)
• State Databases
• HCUP
• MGMA

30. © 2016
Medicare Claims Data
• MedPAR File
– All Medicare inpatient claims for a given federal fiscal year (10/1 – 9/30)
– Data source for many of the labs accompany text
– One record for each inpatient stay
– Used as the basis for IPPS DRG relative weight changes
• Standard Analytic Outpatient File
– All Medicare outpatient claims for a given calendar year
– Multiple files that must be combined to summarize at the claim level
– An extract of this file (HOPPS) is the basis for changes to OPPS APC relative weights
• Part B Utilization File
– Summary file by calendar year
– Includes information by specialty and for top HCPCS codes:
• Allowed services (volume)
• Allowed charges
• Payment amount

31. © 2016
CMS Payment Rule Impact Files
• Released annually
– Inpatient prospective payment (IPPS)
– Outpatient prospective payment (OPPS)
• Includes data elements that may be used for benchmarking
– Hospital Demographics
• Urban/rural setting
• Region
• Ownership
• Teaching/non-teaching status
• Number of beds
– Operational Statistics
• Volume
• Average daily census
• Payment adjustment factors
• Ratio of cost to charge for cost estimation
• Case mix index
• Medicare percentage
• Value based purchasing performance
• Payment level (current and projected)

32. © 2016
Data.medicare.gov
• Central repository for Medicare ‘compare’
databases

33. © 2016
State Databases
• Utah
– Office of Healthcare Statistics
– Hospital utilization
– Ambulatory surgery center utilization
– Query tools to locate specific data
• Massachusetts
– Massachusetts Community Health Information Profile
(MassCHIP)
– Standard reports – ‘instant topics’
– Downloadable query software for producing custom
reports

34. © 2016
HCUP
• http://hcupnet.ahrq.gov/
– Data elements
• Statistics on Hospital Stays
• Readmission Rates
• Emergency Department Use
• AHRQ Quality Indicators
– Online query system
• Data sets that may be licensed
– National Inpatient Sample (NIS) – all payer inpatient data
– Kids’ Inpatient Database (KID) – pediatric inpatient data
– Nationwide Emergency Department Sample (NEDS) – all payer
emergency department data
– State Inpatient Databases (SID) – all payer data for selected states
– State Ambulatory Surgery Databases (SASD) – all payer data for
selected states
– State Emergency Department Databases (SEDD) – all payer data for
selected
states

35. © 2016
HCUP Sample Query