Selective Review of Variables and Research Issues Review of Varia… · » Home and Community Based Services » Included in monthly waiver type/ID variable, greater eligibility group
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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: 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
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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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