Understanding Standard Inpatient Data Records (SIDR)

Exploring the components and importance of Standard Inpatient Data Records (SIDR) including what a record is, how they are coded, the differences between TRICARE MS-DRGs and Medicare, and highlighting key data fields. Additionally, common terms related to this topic are discussed, and insights into reported vs. inferred SIDRs are provided. The content delves into the timeliness and completeness of SIDRs and touches on Inferred SIDRs' diagnosis and procedures.

• Inpatient Data Records
• SIDR
• TRICARE
• Medicare
• Data Fields

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

2. 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

3. 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

4. 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

5. Reported vs. Inferred SIDRs Timeliness: Timeliness: For MTFs, the requirement is to complete SIDR within 30 business days of patient discharge Completeness 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

6. Inferred SIDRs Diagnosis and Procedure 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 Workload measures (e.g., MS-DRG RWP) are averaged by Tmt DMIS ID and MEPRS Code for inferred records MHS GENESIS IOC 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

7. Reported vs. Inferred SIDRs Compliance Percent Inferred Compliance Percent Inferred FY FM Month I R Total FY FM Month I R Total 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 1 2 3 4 5 6 7 8 9 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 14 7 4 9 24 12 19 13 10 7 33 78 230 19,599 18,441 19,138 19,607 18,254 20,206 18,392 19,214 18,705 18,269 19,641 19,094 228,560 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 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% 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 1 2 3 4 5 6 7 8 9 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 1,010 7,075 1,504 94 69 144 119 82 180 559 18,239 16,692 17,183 17,810 16,720 18,045 16,042 16,179 9,914 18,333 16,761 17,327 17,929 16,802 18,225 16,601 17,189 16,989 1,617 0.51% 0.41% 0.83% 0.66% 0.49% 0.99% 3.37% 5.88% 41.64% 93.01% 10 11 12 10 11 12 113 10,836 146,937 157,773 6.87% 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

8. Whats on a SIDR record?

9. 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

10. 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

11. 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

12. 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

13. 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

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

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

16. 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

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

18. 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.

19. 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 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 MS-DRG 898 899 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

20. 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

21. Top MS-DRG by Beneficiary Category

22. Top MS-DRG by Beneficiary Category

23. 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? MDC Just deliveries? MS-DRG Specific kind of delivery? Diagnosis Code 23

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

25. Workload Measures 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 all the bed days in the month of discharge MS-DRG RWP Remember these measures include inferred unless Compliance Status is filtered/conditioned! 25

26. 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

27. 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

28. 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

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

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

31. MS-DRG RWP Relative Weighted Products (RWP) Inpatient Case Mix = MS 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. DRG RWP / DISP 31

32. 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

33. Workload Measures FY17 Tmt DMIS ID 0109 0067 0047 0014 0073 0104 0095 0125 0108 0052 0029 0124 0607 0079 0086 Tmt DMIS ID Name SAMMC WRNMMC EISENHOWER TRAVIS KEESLER BEAUFORT WRIGHT-PATT MADIGAN WM BEAUMONT TRIPLER SAN DIEGO PORTSMOUTH LANDSTUHL NELLIS KELLER Bed Days 94,716 58,946 20,702 20,519 6,990 1,415 8,189 45,770 25,827 50,045 59,425 49,718 14,166 8,760 1,833 MS-DRG RWP 31,690.05 16,626.60 5,185.02 6,457.51 3,139.56 268.83 3,605.23 13,598.65 8,547.79 11,014.73 16,983.89 13,358.45 3,997.32 3,396.83 773.11 Dispositions ALOS CMI Rank 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 24,549 13,359 4,372 5,721 2,940 260 3,653 13,827 8,791 11,596 18,018 14,715 4,731 4,161 972 3.86 1.29 4.41 1.24 4.74 1.19 3.59 1.13 2.38 1.07 5.44 1.03 2.24 0.99 3.31 0.98 2.94 0.97 4.32 0.95 3.30 0.94 3.38 0.91 2.99 0.84 2.11 0.82 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

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

35. Questions vpav@kennellinc.com 35