Selective Review of Variables and Research Issues Gerri Barosso, - - PowerPoint PPT Presentation

Selective Review of Variables and Research Issues

Gerri Barosso, RD, MPH, MS Technical Advisor University of Minnesota

Overview

• Who

˗ Medicaid enrollees ˗ Provider information

• What

˗ Claims utilization information ˗ Identification of services ˗ Specific issues: ER, prenatal care, outpatient care, long term care claims

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WHO: Eligibility Information

• MAX Uniform Eligibility code, in all files
• Developed from state-specific crosswalks

˗ Cash assistance, eligibility group, limited waiver status 1999-2004 ˗ MAX 2005 forward waiver eligibility

• Utility of eligibility data

˗ Changes in eligibility can impact benefit level ˗ Identify coverage gaps, “churning” ˗ Identification of waiver program populations

• PS record for ineligible recipients with paid service

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WHO: Eligibility Information

• New waiver variables in MAX 2005

˗ Waiver type and ID, repeats three times ˗ Eligibility for 1915(c) waiver

» Home and Community Based Services » Included in monthly waiver type/ID variable, greater eligibility group detail reported in this variable eg: physically disabled, brain injured, HIV/AIDS, technology dependent, autism spectrum (2006) » Also annual or most recent enrollment

• Based on most recent month with any 1915(c) eligibility,

hierarchy applied for enrollment in multiple

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WHO: Managed Care Enrollees

• Dichotomous Yes/No not particularly useful
• Identification of type of managed care

˗ Information in Person Summary File ˗ Monthly, type/ID specified for up to 4 ˗ Medicaid Managed Care Combinations, monthly

• Need specific type of managed care plan to

determine effect on utilization records (claims)

˗ Primary Care Case Management, paid FFS ˗ Dental, behavioral health may not impact ability to study research question

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WHO: Medicare Dually Eligible

• Medicare Dual Code in PS detail gives on Medicaid

eligibility (aka “crossover code”)

• Dual identification in data requests

˗ Current: Bene _ID consistent across files ˗ Past with MAX: Use Medicare EDB HIC in MAX

• Limited claims information in MAX

˗ May be QMB/SLMB only, restricted Medicaid ˗ Crossover claims for Medicare coinsurance & deductible payments

» Procedure codes usually missing

˗ Potentially missing claims: state makes no payment beyond Medicare, claim missing from MSIS

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WHO: Provider Identification

• Provider

˗ Identifier in claims of limited value

» Billing, not servicing provider ID labeled as such 2005 forward » Clinic/OPD ID rather than professional provider » State-maintained directory

˗ Specialty

» Missing in some states » Code values are state-maintained

˗ Situation does not improve until MAX2009

» NPI » HIPAA-compliant provider specialty taxonomy

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WHAT: Diagnosis Codes

• IP Claims: 1999 forward 10 total

˗ Required, principle and secondary

• LT Claims: 1999 forward 5

˗ Often missing, may be reason for admission

• OT Claims: 1999 forward 2

˗ Not appropriate for all services ˗ Missing on transportation, DME, supplies, Lab/X-ray, premium claims

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WHAT: Chronic Disease Identification

• Usual considerations with ICD-9 diagnosis codes

˗ No rule-out codes ˗ Multiple ways to code some diagnoses ˗ Diagnosis codes often given for specific problem, not underlying chronic conditions ˗ Incomplete incidence and prevalence given point-in- time data

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WHAT: Identifying Services

• MSIS type of service vs MAX type of service
• MSIS type of service (TOS)

˗ Combination of provider type, service, program

» Difficult to categorize for some programs » States may classify differently » Many services end up in Other Services

• MAX TOS

˗ National/state mapping to uniform groups ˗ Primarily changes to 5 TOS:

» Re-assign MSIS “other” » TOS =15 LAB/X-ray » creation of TOS 51 (Durable Medical Equipment/Supplies), 52 (Residential Care), 53 (Psychiatric/Mental Health Services), and 54 (Adult Day Care)

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WHAT: Identifying Services

• Community Based LTC Services

˗ Flag assigned during MAX OT development ˗ Created from

» MAX TOS, Program Type – OR - » MAX TOS, Program Type, MSIS Basis of Eligibility (BOE) for aged/disabled

• The BOE is in the second byte of the “Max Uniform Eligibility

Code-for Month of Service”

˗ No added intelligence

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WHAT: Identifying Services

• Procedure code

˗ IP: principle, secondary ˗ OT: one procedure code

• National Procedure Codes (CPT-4, HCPCS II)

˗ Procedure Code Indicators not always correct ˗ Review data and coded TOS

• State Specific Procedure Codes

˗ Need to obtain state procedure formulary files ˗ Generally are for non-medical services: DME, mental health, substance abuse

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WHAT: Defining One Event

• Potentially multiple MAX records

˗ One or more OT claims

» Visits to multiple physicians » Claims for institutional and professional charges, eg:

• utpatient clinic, ER

˗ OT claim(s) and IP for same dates of service

» Institutional charges for inpatient stay » One or more professional claims for services provided IP, not salaried by hospital

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WHAT: Units of Service

• Quantity of Service Variable in OT, RX
• OT claims

˗ Number of visits or services reportable in discrete units ˗ Not for institutional, dental, lab, x-ray, capitation

• RX claims

˗ Medicaid drug rebate definition of unit ˗ Smallest unit of normal measure for the drug code ˗ Eg: 100 250mg tablets=100 units

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WHAT: Outpatient Care

• OPD Claims

˗ OT file ˗ may be missing procedure code ˗ filed on UB-04/CMS1450 or electronic equivalent ˗ Revenue center codes for some states ˗ Sometimes are “span” or bundled bills

» no specific procedures or line item detail

• Physician/Other professional claims

˗ OT file, inclusive of all places of service ˗ Filed on CMS1500 claim form or electronic equivalent

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WHAT: ER Claims

• Identification of ER Claims

˗ Apply multiple methods to fully capture

» MAX Place of Service in OT file » ER revenue centers or UB-92 codes in IP, OT » Physician claims in OT by procedure code

˗ ER visit resulting in admission may not be in the OT file but in the IP

» Remember the limitations: for duals, need Medicare claims to fully track ER visits

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WHAT: Prenatal Care/Deliveries

• Identify pregnant women, prenatal care

˗ Global billing codes used by physicians ˗ Claim for all care after delivery

• Deliveries

˗ Separate mother, infant claims, both using mother's ID ˗ Combined claims for mother, infant with mother's ID ˗ Separate mother & infant claims, each with own ID's ˗ Infants sometimes use mother’s ID for several months

• Delivery indicator in PS should not be used prior to

2006, indicator in IP can be used

• Some researchers have successfully linked

˗ Birth certificates if SSN on both ˗ Probabilistic

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WHAT: Long Term Care Claims

• Long Term Care Facility Service Billing

˗ NF's include different sets of services in bundled rate ˗ Non-bundled services reported in LT or OT ˗ Swing bed stays in IP, at least one state ˗ Monthly billing generally, but some weekly ˗ Offers example of good data practices

» Cross check to determine if you have cohort of interest » May need to use multiple variables to identify study cohort

• eg: Inpatient psychiatric services for ages 21-64, Place of

Service “aged hospital”, need demographics to resolve

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Additional Variable-specific Information

• Record layouts

˗ Most current on the CMS MAX website ˗ Source of variable, values ˗ Details of variable creation, guidelines for use

• Frequently Asked Questions (FAQs)

˗ CMS web site includes currently active FAQs ˗ ResDAC web site

» ResDAC FAQs, less detail on variables » Link to complete CMS FAQ in one document

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CMS Medicaid Data Assistance

• ResDAC

˗ www.resdac.org

» FAQs, data documentation

˗ 888.973.7322 OR resdac@umn.edu

» Individualized assistance

• CMS

˗ http://www.cms.gov/MedicaidDataSourcesGenInfo/07 _MAXGeneralInformation.asp (see presentation URL list)

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