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

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 [email protected]

» Individualized assistance

CMS

˗ http://www.cms.gov/MedicaidDataSourcesGenInfo/07

_MAXGeneralInformation.asp (see presentation URL

list)

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