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 2
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 3
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 4
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 5
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 6
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 7
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 8
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 9
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) 10
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 11
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 12
WHAT: Defining One Event Potentially multiple MAX records ˗ One or more OT claims » Visits to multiple physicians » Claims for institutional and professional charges, eg: outpatient 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 13
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 14
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 15
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 16
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 ˗ 17
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 18
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 19
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) 20
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