Statistical Aspects

of Physician

Payment Systems

A Report of the National

Committee on Vital and

Health Statistics

Findings and conclusions concerning

current and anticipated needs of users of

data from the patient-physician encounter in

the ambulatory care setting are summarized

in this report. The report emphasizes the

increasing plurality of data uses and of sites

of care in the ambulatory arena and

underscores the value of standard

definitions to facilitate comparison of

different data bases across systems and to

achieve as much uniformity as possible at

the national level.

Documents and Committee Reports

Series 4, No. 24

DHHS Publication No. (PHS) 87–1 461

U.S. Department of Health and Human

Services

Public Health Service

National Center for Health Statistics

Hyattsville, Md.

January 1987
Copyright information

All material appearing in this report is in the public domain and may be

reproduced or copied without permission; citation as to source, however, is

appreciated.

Suggeatad Citetiin

National Center for Health Statistics: Statistical aspects of physician payment

systems. Vita/ and Health Statistics. Series 4, No. 24. DHHS Pub. No. (PHS)

87-1461. Public Health Service. Washington. U.S. Government Printing Office,

Jan. 1987.

Library of (kngraae Cateloging4n-Publication Data

Statistical aspects of physician payment systems.

(Series 4, Documents and committee reports : no. 24)

(DHHS publication ; no. (PHS) 87-1461)

Prepared by the Subcommittee on Statistical Aspects of Physician Payment

Systems.

Supt. of Dots. no.: HE20.6209:4/24

1. Ambulatory medical cere-Utilization-Reporling-United States.

2. Medical record linkeg~United States 1.United States. National Committee

on Vital and Health Statistics. Il. United States. National Committee on Vital and

Health Statistics. Subcommittee on Statistical Aspects of Physician Payment

Systems. Ill. National Center for Health Statistics (U.S.) IV. Series: Vital and

health statistics. Series 4, Documents and committee reports ; no. 24.

V. Series: DHHS publication ; no. (PHS) 87-1461. [DNLM: 1. Ambulatory

Car%conomics-UniWd States. 2. Insurance, Health, Reimbursement—

United states. W2AN148vd no. 24]

HA37.U1 693 no. 24 362.1 ‘0723 S 86-600375

[RA408.5] [362.1 ’72]

ISBN 0-6406-0357+

For sale by the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402
National Center for Health Statistics

Manning Feinleib, M.D., Dr.P.H., Director

Robert A. Israel, Deputy Director

Jacob J. Feldman, Ph.D., Associate Director for Analysis and

Epidemiology

George A. Schnack, Associate Director for Data Processing and

Services

Alvan O. Zarate, Ph. D., Assistant Director for International

Statistics

Peter L. Hurley, Acting Associate Director for Interview and

Examination Statistics

Stephen E. Nieberding, Associate Director for Management

Gail F. Fisher, Ph.D., Associate Director for Program Planning,

Evaluation, and Coordination

Monroe G. Sirken, Ph. D., Associate Director for Research and

Methodology

Peter L. Hurley, Associate Director for Vital and Health Care

Statistics
Preface

This report is the culmination of 2 years of work by

the National Committee on Vital and Health Statistics

(NCVHS) Subcommittee on Statistical Aspects of Physician

Payment Systems and its predecessor work group. The NCVHS

is a legislatively mandated advisory committee to the Secretary

of the Department of Health and Human Services. The report

was approved by the full NCVHS at its meeting on June 6,

1986, and was submitted to the Assistant Secretary for Health

in July 1986.
National Committee on Vital and

Health Statistics

CHAIRMAN

Ronald G. Bkmkenbaker, M.D. (1987)

Vice President for Medical Affairs

St. Vincent Hospital and Health Care Center

2001 West 86th Street

Indianapolis, Indiana 46260

EXECUTIVE SECRETARY

Gail F. Fisher, Ph.D.

Associate Director for Program Planning, Evaluation,

and Coordination

National Center for Health Statistics

3700 East-West Highway

Hyattsville, Maryland 20782

Robert E. Windom, M.D.

Assistant Secretary for Health

Room 7 16G, Hubert H. Humphrey Building

200 Independence Avenue, SW.

Washington, D.C. 20201

Manning Feinleib, M.D., Dr.P.H.

Ex Officio

Director, National Center for Health Statistics

3700 East-West Highway

Hyattsville, Maryland 20782

Membership

Elizabeth L. Barrett-Connor, M.D. (1987)

Department of Community and Family Medicine

School of Medicine, University of California

at San Diego, M-007

La Jolla, California 92093

William R. Felts, Jr., M.D: (1987)

Professor of Medicine

George Washington Univ. Medical Center

2150 Pennsylvania Ave., NW., Rm. 405-C

Washington, D.C. 20037

Ms. Mary Anne Freedman (1989)

Director, Division of Public Health Statistics

Vermont Department of Health

P.O. Box 70

Burlington, Vermont 05402

Lawrence W. Green, Dr.P.H. (1987)

Director, Center for Health Promotion Research

and Development

Univ. of Texas Health Science Center

Houston, Texas 77225

Jerome H. Grossman, M.D. (1988)

Chairman and Chief Executive Oftlcer

New England Medical Center, Inc.

Boston, Massachusetts 02111

Mr. James K. Hutchison (1989)

Chief Actuary

The Blue Cross/Blue Shield Association

676 North St. Clair Street

Chicago, Illinois 60611

Carmault B. Jackson, Jr., M.D. (1987)

Medical Advisory Services

16902 Hidden Timber Wood

San Antonio, Texas 78248

William H. Kirby, Jr., M.D. (1989)

401 Walpole Court

Timonium, Maryland 21093

George C. Myers, Ph.D. (1988)

Center for Demographic Studies

Duke University

2117 Campus Drive

Durham, North Carolina 27706

Lloyd F. Novick, M.D., M.P.H. (1988)

Director, Center for Community Services

New York State Health Department

Governor Nelson Rockefeller Empire State Plaza

Coming Tower Building, Room 1492

Albany, New York 12237

John D. Reid, Ph.D. (1989)

Graduate Professor of Sociology

Howard University

Mailing Address:

Versailles Plaza

2400 Queens Chapel Road, Apt. #105

Hyattsville, Maryland 20782

iv
William J. ScanIon, Ph.D. (1988)

Co-Director

Center for Health Policy Studies

Dept. of Community/Family Medicine

Georgetown Univ. School of Medicine

2233 Wisconsin Avenue

Washington, D.C. 20007

Fernando M. Trevino, Ph.D. (1988)

Associate Professor

Dept. of Preventive Medicine and Community Health

The Univ. of Texas Medical Branch

Galveston, Texas 77550

Karel M. Weigel, R.R.A. (1989)

Coordinator, Records Unit

Dept. of Medical Statistics and Epidemiology

Mdyo Clinic

200 SW. First Street

Rochester, Minnesota 55905

Members retired June 1986

Robert H. Barnes, M.D. (1986)

Chairman

1014 East Blaine Street

Seattle, Washington 98102

Mr. Theodore Allison (1986)

Vice President

Government and Industry Relations

Metropolitan Life Insurance Company

One Madison Avenue

New York, New York 10010

Mr. Walter P. Bailey (1986)

Chief, Office of Cooperative Health and Demography

State Budget and Control Board

Rempert C. Dennis Bldg., Room 337

1000 Assembly Street

Columbia, South Carolina 29201

Suzanne S. Harris, Ph.D. (1986)

Deputy Assistant Secretary for Food and

Consumer Services

USDA Administration Building, 207W

Washington, D.C. 20250

Grayson B. Miller, Jr., M.D. (1986)

Division of Epidemiology

Virginia Department of Health

109 Governor Street

Richmond, Virginia 23219

Subcommittee on

StatisticalAspects of

Physician Payment

Systems

Members

WNiam R. Felts, Jr., M.D., Chairman

Theodore Allison

Carmault B. Jackson, Jr., M.D.

Staff

Marjorie S. Greenberg

OffIce of Program Planning, Evaluation and Coordination

National Center for Health Statistics

3700 East-West Highway

Hyattsville, Maryland 20782

Alan Bradt

Bureau of Data Management and Strategy

Health Care Financing Administration

Meadows East Building

6325 Security Boulevard

Baltimore, Maryland 21207
Contents

—.

I-’reface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

NationalCommitteeonVitalandHealth Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Subcommittee on Statistical As~ctsof Physician Payment Systems . . . . . . . . . . . . . . . . . . . . . . . . . .

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Activities of the Work group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Activities of the Subcommittee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

General tindings and conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Appendixes

I. UniformAmbulatoryMedicalCareMinimumDataSet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

II. Minutes ofthe NCVHS Subcommittee on Statistical Aspects ofPhysician Payment Systems . . . . . . . . . . . .

III, Placeofservicedesignations(FiguresII-VI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

IV, Data flow fortraditional fee-for-semice physicim ~imbumement (Hgu~VII) . . . . . . . . . . . . . . . . . .

...

111

iv

v

1

2

3

4

5

11

13

14

29

33

vii
Statistical Aspects of

Physician Payment

Systems

Introduction

A number of forces are currently converging to increase

interest in ambulatory care data and stimulate reevaluation

of the Uniform Ambulatory Medical Care Minimum Data

Set, The changing patterns for delivering and financing patient

care are all having an impact on the ambulatory care arena.

Procedures p~viously performed exclusively within hospitals

increasingly are now takhg place on an ambulatory or outpatient basis. The technological advancements and changes in

insurance coverage which have made these shifts possible

have stimulated the growth of various alternate care sites,

such as free-standing surgical centers and urgicenters, as well

as the expansion of existing hospital outpatient services. The

public and private commitment in this decade to health promotion and disease prevention has been reflected in a growing

interest in primary care and self-help involving ambulatory

care services. The emphasisin care for our aging population

is alsoon independentlivingandambulatorycare.

The Medicare Prospective Payment System (PPS), enacted

for hospitalsin 1983,has put increasedpressureon institutions

to reduce inpatient stays and costs per case. Under PPS and

other cost containment measures, efforts to shift care to outpatient, and potentially less costly, sites are likely to continue.

Recent national statistics show that for the first time since

1965 hospital care expenditures have declined as a share of

total health care dollars, from 41.9 percent in 1983 to 40.8

percent in 1984. For Medicare, this shift from inpatient to

outpatient care has significant fiscal implications, because

the trust fund for hospital care is financed exclusively through

Social Security taxes, whereas physician services are financed

through a combination of beneficiary premiums and general

revenues and involve considerably more beneficiary cost sharing. Adequate and comparable statistical data will be necessary

to track and assess these possible shifts.

The emerging interest in ambulatory care services has

coincided with the growing focus on reimbursement for physician services. The legislation enacting PPS required the Department of Health and Human Services (DHHS) to study and

report on the advisability and feasibility of covering inpatient

physician services within the hospital’s prospective payment

rate. Because physician services, inpatient and outpatient,

now generally are reimbursed by Medicare on a fee-for-service

basis, and because an episode of care frequently includes

both types of physician services, the broadening of concern

to the full spectmm of physician services has followed naturally. Current approaches being considered by the Department

for reimbursing physician inpatient services all have ‘implications for ambulatory care services as well.

1
Background

Recognizing the numerous statistical issues involved in

current and future policy choices for delivering and reimbursing

physician services, the National Committee on Vital and Health

Statistics (NCVHS) formed a work group in May 1984 to

gather further information and to make recommendations to

the full Committee. Originally charged to examine statistical

aspects of a pre-payment system for physician services, at

its first meeting the work group expanded its investigation

to encompass the adequacy of any data systems related to

the provision of physician services, whether designed for reimbursement, planning, or research. It was decided to give particular attention to services rendered in ambulatory care settings

and to the information needed about these services. The ultimate goals of the work group’s inquity were to encourage

comparability and standardization; to enhance the multiple

utility of data bases; to assure that data requirements by thirdparty payers and others were justified; and to prevent unnecessary duplications. Underlying the effort was the conviction

that in times of decreasing resources, high quality statistics

become increasingly important in making optimal allocation

decisions. The work group was also aware that there would

be growing pressure on the analysis of ambulatory care data

and that development of standard definitions, adoption of

those standards, and training in their application would be

necessary first steps toward turning that data into useful

information.

The NCVHS had contributed to the standardization of

hospital data through the development of the Uniform Hospital

Discharge Data Set (UHDDS) in the early 1970’s and the

recent reassessment of the UHDDS in 1984. The UHDDS

has been approved for use in Department of Health and Human

Services (DHHS) programs since 1974 and is widely accepted

and implemented in the public and private sectors.

Developments in standardization of ambulatory care data

have been considerably slower, even though ambulatory care

is the largest component of the health care system in this

country, accounting for approximately 1 billion contacts with

medical doctors per year. Traditionally, ambulatory care records have been far less standardized than records of hospital

care, and patient complaints and episodes of care have been

less clearly defined and documented. There has been no parallel

in the ambulatory care field to the private sector development

of abstracting services for inpatient care, although computer

applications to physician offices have proliferated in recent

years.

Following the lead of the UHDDS, a Uniform Ambulatory

Medical Care Minimum Data Set was developed by the

NCVHS in the mid- 1970’s and revised in 1980 (see appendix I). Reflecting the state of the art at that time, the focus

was on defining what information should be entered inpatients’

ambulatory medical care records rather than on what information should be abstracted from existing records.

Although the NCVHS submitted the revised version of

the ambulatory data set to the Secreta~ of DHHS in 1981,

no official action has been taken in response to this transmittal.

Although the data set has received wide distribution, it is

not known to be in current use in its entirety in any programs

of the Department. In 1983, the DHHS Health Information

Policy Council (HIPC) gave reexamination of the data set

a lesser priority than the review of the UHDDS and the LongTerm Care Minimum Data Set.
Activities of the work group

The work group formed by the full Committee met on

three occasions between June and October 1984 to obtain

information on current and proposed Departmental data activities and to identify issues that would merit further NCVHS

study and assessment. Because physician payment systems

are a major source of data on ambulatory services, and Medicare requirements often influence activities in the private sector, detailed information was sought and obtained on the data

requirements related to Medicare reimbursement for physician

services. The work group received extensive background on

the Medicare data requirements, the data bases maintained

by HCFA at the national level, and studies underway to assess

physician reimbursement methods.

The review of data requirements, data bases, studies,

and data sets by the work group focused on the following

five areas: patient identification, physician identification, place

of service designation, diagnostic information, and procedure

coding systems. Many of the issues explored, although specific

to Medicare, represented generic concerns that had surfaced

during the earlier minimum data set development.

The work group concluded that the evolving activities

related to changes in methods for physician reimbursement,

particularly in the ambulatory care setting, are likely to have

signitlcant implications for each of these data areas and for

the comparability of data through time and across health care

settings. Continuing liaison among the Health Care Financing

Administration (HCFA), the National Center for Health Statistics (NCHS), and the NCVHS concerning the data systems

to support these activities was considered desirable, at least

until the systems have been fully defined. Therefore, the

work group recommended to the NCVHS at its meeting in

December 1984 that a subcommittee be established to provide

this liaison and address the following tasks as its charge:

. Determine more clearly the specific needs of users of

data from patient-physician encounters in the ambulatory

care setting.

● Develop a schematic overview of the flow of data from

various ambulatory settings into the multiple data bases.

. Define better the different sites of care in the ambulatory

setting and the types of services delivered so that understanding of data requirements can be improved.

The results of these tasks were to be input into the possible

review and revision of the Uniform Ambulatory Medical Care

Minimum Data Set.

The National Committee accepted the recommendations

of the work group and designated a Subcommittee on Statistical

Aspects of Physician Payment Systems, consisting of William

R. Felts, Jr., M.D., Chairman, Professor of Medicine at

George Washington University Medical Cente~ Theodore A1lison, Vice President for Government and Industry Relations,

Metropolitan Life Insurance Company; and Carrnault B.

Jackson, Jr., M.D., Medical Advisor for Baptist Memorial

Hospital System in San Antonio, Texas. Staff from NCHS

and HCFA were requested and assigned to work with the

Subcommittee.
Activities of the Subcommittee

The Subcommittee held four meetings to hear testimony

on June 19, September 10, October 15, 1985, and January

14, 1986 (see minutes in appendix II), in order to pursue

further the work group goals and to address the specific tasks

included in its charge. Following the extensive information

received from the Medicare program during the work group

meetings, the Subcommittee continued to be updated on MedL

care activities and sought to obtain comparable information

from other public and private insurers. The latter provided

an overview of the ambulatory care data requirements and

the flow of data for the patient-physician encounter in their

respective programs or organizations, discussed uses of data

and data problems, and described any work currently underway

to resolve data inadequacies and improve data quality. Researchers and planners who use data from the patient-physician

encounters also contributed to the discussions. Dr. Felts and

Dr. Jackson, both of whom have had extensive involvement

with provider data systems and strong afilliations with national

professional organizations, offered the additional perspective

of practicing physicians. A representative of the American

Medical Association and other observers representing professional associations also attended the sessions.

The purpose of these meetings was to:

. Gather information related to the Subcommittee’s charge.

. Anticipate changes in physician payment systems that

may require collection and analysis of additional items

of data.

. Examine the possible impact of these changes and additions on availability, quality, and comparability of data.

. Analyze the applications of data for trend analysis, research, and program administration.

The meetings also served to bring together interested organizations in the public and private sectors to share mutual concerns

and seek common solutions.

The organizations, grouped by type, that have made presentations to the Subcommittee and the primary focus of their

remarks follow:

Organization Primary focus

Public insurers and data users

Civilian Health and Medical ● Program requirements

Program of the Uniformed . Ambulatory care data needs

Services (CHAMPUS),

Department of Defense

Centera for Disease Control

Department of the Army,

Department of Defense

Medicare Program, HCFA

National Center for Health

Statistics

Medicaid Program, HCFA

Pennsylvania Department of

Public Welfare

Peer Review Organization

Program, HCFA

Veterans Administration

. Ambulatory care data needs for

epidemiologic surveillance

. Ambulatory Care Data

Base Project

● Claims processing

● Statistical system

. National Ambulato~ Medical

Care Survey

● Ambulatory Visit Groups

. National Medicaid repotting

system

● State Medicaid program data

requirements

. Data needs and plans

● Program requirements

● Ambulatory care data needs

Commercial insurers

Metropolitan Life Insurance ● Claims processing

Company . Uses of claims data

Prudential Life Insurance ● Medicare and Medicaid carrier

Company dafa requirements

. Uses of claims data

Blue Cross Blue Shield

Blue Cross and Blue Shield ● Data needs

Association ● Uses of claims data

National Capital Area Blue ● Claims processing

Crose Blue Shield . Uses of claims data

Health Maintenance Organizations

Group Health Association of . Current data requirements of

America different HMO model types

● Data needs

Health planners

United Hospital Fund . Collection and use of hospital

outpatient data

Self-insured employar

Honeywell, Inc. ● Data needs of employers and

business coalitions

● Uses of data

The Subcommittee also requested the views and perspectives of

the House and Senate Subcommittees on Health but was unable

to arrange a mutually convenient meeting time. Information on

activities was sent to the House subcommittee, at the latter’s

request.
General findings and

conclusions

Several themes emerged from the numerous presentations

heard by the Subcommittee:

. All presenters recognized the increasing need for ambulatory care data,

After two decades of focusing almost exclusively

on the utilization and cost of inpatient care, public and

private insurers are beginning to turn their attention to

outpatient services. The Medicare Program has given considerable priority to the development of the data system

for Part B, which reimburses for physician services, durable medical equipment, and laboratory services. The

Part B Medicare Data System (BMAD) includes beneficiary, provider, procedure, and prevailing charge files.

The Subcommittee believes that this data base represents

the most important step at the national level to standardize

and use aggregate data on physician services for policy

evaluation, The Peer Review Organizations (PRO’s),

while currently reviewing hospital care for Medicare and

Medicaid beneficiaries, strongly recognize the need to

examine pre-care and after-care in the ambulatory care

setting. Commercial insurers and Blue Cross Blue Shield

plans are following the lead of the Medicare Program

in addressing data needs from the patient-physician encounter. A self-insured corporation reported increased interest in examining ambulatory care data, noting that its

expenditures for ambulatory care have shifted from 30

percent of total dollars spent to 55 percent in the past

2 years. The Department of the Army has undertaken

a study in six sites with the purpose of establishing a

major new reporting system for ambulatory services. The

United Hospital Fund has recently completed a study

of hospital-based ambulatory care visits in New York

City, of which there are between 10 and 12million annually. One Medicare carrier has initiated a study, with

HCFA support, of overutilization of physician office visits

by beneficiaries.

In the area of epidemiologic research, both the Centers

for Disease Control and the Department of the Army

emphasized the importance of ambulatory care data.

. Demands upon ambulatory care data systems for more

extensive data elements and more comparative analyses

will continue to increase. Those collecting and analyzing

the chta must exercisecautionthat the qualityand context

of the data merit the interpretationsthat are made. The

community of users must assure accurate, meaningful,

and responsible reporting.

Many presenters predicted that data will be sought

to perform more complex and sophisticated analyses once

the basic systems are in place. Subcommittee members

expressed concern that policymakers may attempt to subject data to uses for which the data were not originally

designed. Examples were cited of release of aggregate

data on physician reimbursement under public programs

in the late 1970’s and more recently on hospital mortality

rates for Medicare patients, each of which resulted in

erroneous and potentially damaging conclusions. Data inaccuracies and inappropriate use of raw data were both

at issue. Relevant public and private sector organizations

must set standards not only for data definitions but also

for data quality, adequate sample sizes, and meaningful

computations. Public organizations collecting potentially

sensitive information may need stricter confidentiality legislation to protect raw data files adequately from misuse.

. There are both many commonalities and some significant

differences in the needs of data users. The data variations

stem primarily from administrative requirements.

First, current ambulatory care data requirements differ

considerably depending on the reimbursement system.

Perceived data needs similarly differ widely among insurers. The fee-for-service environment, whether in the public

or private sector, requires considerably more encotmterlevel data than a cavitation system for payment. Even

within the Health Maintenance Organization (HMO) approach, the particular model of HMO impacts significantly

on the type of data collected. Second, each system has

specific and often unique administrative requirements related to determining eligibility and coverage of services

and coordinating benefits. These are the most variable

items collected by the different data systems but are crucial

for benefit management.

. The data currently collected by public and private insurers

meet most of their current needs for reimbursement but

may be quite inadequate for alternative reimbursement

methods. Third party payers are interested in reviewing

quality of care and in conducting relevant research, but

the basic data needed for processing and paying claims

continue to govern their data requirements. and data are

more limited for other uses.

Making changes and adding items to a claim form

can be very costly to the insurers and providers. The

Pennsylvania State Medicaid program reported that changing invoices costs about a million dollars. The Group

5
Health Association of America reported that the type of

data system used in fee-for-service plans would be onerous

and drive up the costs of an HMO, reducing its competitive

position. At the same time, public programs and employers

are finding the data available from cavitation systems

inadequate to meet their needs.

● Many public programs and private insurers and their trade

organizations currently are undertaking efforts to achieve

greater uniformity within their own data systems.

HCFA reported that in the past 5 years the program

has made two major changes that have enhanced the

uniformity of data collection in the Medicare program.

First, the HCFA Common Procedure Coding System

(HCPCS) was adopted for coding of procedures. Second,

a common claims form, the HCFA 1500, was instituted

for all physician-submitted claims. Further uniformity is

to be achieved as regulations have been published to

require Medicaid State agencies to use both HCPCS and

the 1500 by the end of 1986. The Medicaid program

has also undertaken a tape-to-tape project with the goal

of standardizing unit record data in a common format

across States.

The Group Health Association of America (GHAA)

is developing a summary level database for Health Maintenance Organizations using standardized definitions. This

effort is in partial response to the lack of uniformity

in source documents and definitions used for encounter

level data even within the same HMO system.

The Veterans Administration is in the process of automating its clinical data system and moving toward collection of more detailed information on demographic variables and services rendered on 100 percent of its patients.

The CHAMPUS and DOD programs are also examining

changes in their outpatient data systems.

● Presenters also supported the concept of standard definitions to facilitate comparison of different databases across

systems and to achieve as much uniformity as possible

at the national level. There is particularly wide support

for standardization of coding systems and definitions of

units of patient care. Less support was expressed for

standardized claim forms, although many data collectors

and users recognize their advantages.

The United Hospital Fund reported the difficulty in

collecting data on outpatient department and emergency

room visits in New York City due to inconsistent definitions used by hospitals across the city. A self-insured

corporation actively involved in a business coalition described the significant challenge of developing a standard,

uniform data base from a variety of indemnity carriers,

Blue Cross Blue Shield plans, and HMO programs. The

CHAMPUS program cited as a major problem the incompatibility between data from its system and data from

the military hospital ‘system.For example, the CHAMPUS

program defines a visit as a face-to-face encounter with

a health care professional, whereas the military system

includes telephone contacts as encounters. GHAA noted

similar inconsistencies among HMO’s.

Most presenters concluded that the recent efforts undertaken by HCFA have fostered standardization in the

industry. The commercial insurers and Blue Cross Blue

Shield plans that testified have adopted HCPCS, whereas

most of the other public and private insurers reported currently to be using CPT-4, on which HCPCS is based.

A number of public and private insurers are using the

HCFA 1500 or a variant of this form. The Uniform Claim

Form Task Force, chaired jointly by HCFA and the American Medical Association with representation from the Blue

Cross and Blue Shield Association and the Health Insurance

Association of America, agreed in June 1985 to pursue

greater standardization of the claim form. At the same

time, the Task Force identified approximately 14 additional

new items for consideration, many of which relate to determining eligibility and coordination of benefits.

The Pennsylvania State Medicaid Program reported

considerable resistance in that State to use of the HCFA

1500 and argued strongly for common definitions rather

than common claim forms. The latter, it was noted, can

be very difficult to use, because they contain unnecessary

items for some insurers and the same item can have

multiple definitions depending on the insurer. The HCFA

staff estimated that approximately 75 percent of the States

can use the 1500. Representatives of the National

Medicaid Program and the self-insured corporation both

noted that flexibility and decentralization of public and

private programs are often at odds with uniformity.

It was clear to the Subcommittee that there are significant benefits to achieving as much conformity as possible

but that the variable administrative items must be accommodated by any common form and preclude total

uniformity.

The Department of the Army has pursued encounter

form development, because its needs are performance measurement and epidemiologic research rather than claims payment. Under a pilot study to establish a new ambulatory

care data collection and reporting system, the Department

has developed a series of forms with common administrative

and demographic data but with diagnoses and procedures,

coded in ICD-9-CM and ~-4, respectively, tailored

to particular specialties.

● The increasing demands of employers for data from the

reimbursement systems may force greater standardization

of data.

Insurers reported that employers are becoming very

aggressive with cost containment measures and are providing a major impetus for encouraging use of outpatient

settings, As a result, they are demanding comparable

data, which will permit them to make informed decisions

about carriers and benefh packages as well as to assess

the use and outcome of outpatient services delivered to

their beneficiaries. In addition, the growing number of

business coalitions are interested in sharing data from

many different employers and insurance companies. The

self-insured corporation, in its presentation, confirmed

these needs and demands of employers and business coali6
tions and described two related activities. First, the corporation is developing a competitive medical arrangement

request for proposal, with a management information system requirement, for local divisions to use in soliciting

bids from Preferred Frovider Organizations. Second, the

Minnesota Coalition on Health Care Costs is developing

a uniform data reporting request from the employers to

the HMO’S.

. Even as public and private insurers move toward greater

use of cavitation, some forms of which require considerably less data for reimbursement, management information

from the encounter level will continue to be needed to

assess quality, efficiency, cost, and accessibility of care.

Public and private insurers, the Peer Review Organizations, employers, and business coalitions are all concerned about the current and future availability of data

from HMO’s and similar capitated systems. Presenters

generally concluded that data similar to what is being

col!ected currently from the fee-for-service systems will

be needed but that it will be more difficult to obtain

outside of a billing mechanism, There was general agreement that tying data to reimbursement does improve overall reporting, even though it may influence the way some

data are reported, The representative from the GHAA

acknowledged that Government and employers are demanding more utilization information about their enrollees, but urged development of a data system specific

to HMO’s rather than applying the fee-for-service system

to the HMO environment.

. Although data needs for operational purposes may become

more decentralized under cavitation plans, there remain

needs for data at the national level to evaluate policy

options, recommend program changes, and monitor performance. In a dynamic situation such as currently exists

in the health care arena, data can provide a clue as to

whether specific medical interventions and reimbursement

mechanisms are having a positive, negative, or neutral

impact on the outcome of medical care.

It was suggested that encounter-level data will still

be available at the carrier or local level, but it was clear

that this will not completely substitute for national level

data, In addition to meeting needs for program development and monitoring responsibilities, data of adequate

breadth and coverage are needed to address outcome

issues.

. Some of the needs for policy-relevant information and

health services research can be met by survey data, and

such survey mechanisms must be supported. Current survey data on ambulatory medical care are collected on

an intermittent basis and are quite limited in their coverage

of different types of outpatient facilities.

NCHS reported on the National Ambulatory Medical

Care Survey (NAMCS), which operated continuously as

an annual survey from 1973 until 1981, when it was

placed on a triennial basis due to resource constraints.

After an additional 1-year delay, the NAMCS was most

recently conducted in 1985, collecting information on

approximately 75,000-80,000 encounters from a sample

of 5,000 office-based physicians. Funding is not contained

in the FY 1987 budget for the next cycle of NAMCS,

originally scheduled to be conducted in 1988. Although

NCHS has done research on expanding the suwey beyond

office-based physicians to include hospital-based physicians, funding also has not been obtained for this component. The Centers for Disease Control (CDC) reported

that from their perspective NAMCS is an important national resource and should be maintained at least on its

current triennial basis. The Subcommittee confirmed that

further survey delays will interrupt the ability to evaluate

trends and changes in ambulatory care. The Subcommittee

also noted that the information obtained by surveys differs

from that acquired in remuneration data bases and, therefore, is not redundant but complementary.

HCFA also reported on a number of surveys and

special studies either underway or being planned to help

inform policy decisions. Presenters and Subcommittee

members encouraged these activities to expand the information base concerning dhTerent policy options.

. It is timely to undertake a full review of the adequacy

of the Uniform Ambulatory Medical Care Minimum Data

Set. The current data set defines those items that should

be entered in the records of all ambulatory health care.

A revision should bring the data set into accordance with

the Uniform Hospital Discharge Data Set by also specifying those items that should be abstracted uniformly from

existing records.

The increasing interest in comparable ambulatory care

data bases with standardized definitions, evidenced by

the presentations made before the Subcommittee, supports

the reassessment of the Uniform Ambulatory Medical

Care Minimum Data Set at this time. Significant changes

in the care delivered in ambulatory settings and in the

requirements for data have occumed since the last review

and revision.

Although it was not the charge of the Subcommittee to

undertake a systematic review of the Uniform Ambulatory

Medical Care Minimum Data Set nor to develop a full revision,

the extensive presentations received by the Subcommittee did

address many of the key items in the data set. The Subcommittee’s findings and conclusions related to these items follow:

. Patient identification

Much of the testimony was supportive of a unique

patient identifier across the health care system which

would facilitate managed care and linkage of records.

Subcommittee members recognize both the advisability

of a unique patient identifier and the diftlculty of implementation. Confidentiality and privacy concerns make

this an extremely complicated issue which requires more

deliberation.

All Medicare records contain the same unique identifier for each individual served: the Social Security

Number with an associated beneficiary ID code. Medicaid,

CHAMPUS, and private insurers collect the patient’s name

but do not have unique identifiers for the insured and

7
his or her dependents. Furthermore, other record systems,

such as those used by institutions, frequently use their

own identifiers and do not retain the patient’s Medicare,

Medicaid, or insurance number. The new national

Medicaid reporting system will require all States reporting

on tape to provide a unique recipient ID number. Although

the Social Security Number (SSN) is not mandated, the

program notes that the SSN is a requirement for eligibility

and predicts its eventual availability on the data files.

Unique patient identifiers are desirable to track patients, profile utilization patterns, link episodes of care

in the same setting and across different settings, and

coordinate benefits. The multiple sources of care currently

available to patients increase the importance of this

capability.

. Provider identification

Presentations supported the need for a unique number

that distinguishes the provider from all other providers

and is the same for the provider in all settings where

he maybe in practice. The Subcommittee members concur

with this requirement.

In reimbursing physician services, Medicare identifies

the billing entity, such as a group practice or outpatient

clinic, rather than the individual practitioner providing

the services, except where the practitioner is in solo private

practice where the practitioner is individually identified.

Thus, the same practitioner may bill for services under

several different identifiers, and a single identifier can

represent many different practitioners. This system makes

linkage of an individual’s total practice patterns virtually

impossible, even within the Medicare program. HCFA

is responding to this problem by developing a plan for

a HCFA-assigned number (HAN) which would provide

a unique identifier for each physician rendering services.

The new national Medicaid reporting system contains

a provider file but it was reported that the identifying

information on this file is not considered reliable and

will require a major cleanup. Unique provider ID numbers

are considered particularly problematic in the ambulatory

care setting.

The CHAMPUS program also reported problems with

identifying individual providers. The program would like

to be able to identify specific individual providers by

specialty in its data system. The pilot Ambulatory Reporting System under development by the Department of the

Army does include a unique provider identifier.

● Place of service

The presentations before the Subcommittee frequently

addressed the increasingly different settings for services

developing in the health care system. The Subcommittee

concluded that a consensus group, such as the CPT Editorial Board or the NCVHS, should evaluate the definitions

currently in use for place of service and determine the

extent to which standardization is feasible. Survey

mechanisms, such as the NCHS National Ambulatory

Medical Care Survey, should continue to be supported

to address some of the research questions, with attention

to more specificity of sites.

The distinctions between institutional and ambulatory

care and the definitions for different types of care settings

are frequently unclear. Services provided in a hospital

emergency room or out-patient clinic are often identical

to those provided in inpatient settings. Some free-standing

facilities substitute for acute inpatient care while others

are extensions of private physician offices.

In some cases, the specific place of service must

be designated for reimbursement purposes. More broadly,

reasonable specificity is needed for management and research activities. Place of service designations vary widely

among insurers. Medicare, Medicaid, commercial insurers, and Blue Cross Blue Shield all have their own sets

of definitions (see appendix III). The HCFA 1500 has

16 different place of service codes, but the BMAD instructions condense these down to 10 codes. The Blue Cross

and Blue Shield Association reported 34 different place

of service designations aPlan can use in processing claims,

although the place of service codes most commonly filled

in by the person completing the claim form are more

comparable to those used on the HCFA 1500. A commercial insurer presented 19 facility designations with 3 clinic

modifiers.

CHAMPUS does not currently collect place of encounter, but program officials feel it would be beneficial,

particularly in the area of ambulatory surgery. The

Medicaid program reported that it has always collected

place of service of physician visits but has encountered

a great deal of difficulty with standard definitions across

States and has essentially dropped that requirement.

. Diagnosis

Presenters recognized the value of accurate recording

of patient problems and diagnoses, but reported that this

information is frequently unavailable in ambulatory care

reimbursement systems and often is of questionable quality

where available. The Subcommittee reaffirmed the importance of capturing information on all patient problems

and diagnoses requiring attention at the encounter, so

as to make judgments on medical necessity and appropriateness of services, plan resource allocation, and carry

out other policy analyses. The members concluded that

the development of guidance and instmctions on collecting

and coding diagnoses in the ambulato~ setting should

be a consensus activity, and that the Federal government,

as an interested participant, should be an organizer of

this activity.

The Subcommittee fin-therdetermined:

The International Classification of Diseases and its

clinical modification (currently ICD–9–CM) is widely

used by systems coding diagnoses and should continue

as the standard coding convention for this purpose. There

should be a consensus process for developing interim

codes which can be utilized in a timely manner by individual countries between revisions to identify newly recognized conditions and reflect new knowledge.

Separate information on the patient’s stated reason

for encounter can be useful for planning, administrative,
and research purposes. The ICD should be the basis for

any reason for encounter classification system.

Different definitions currently exist in the inpatient

and outpatient environments for designating the first-listed

diagnosis in a data system as either principal or primary.

The terms are sometimes used interchangeably but in

other cases have very different meanings. The selection

of a particuhm definition generally reflects the purpose

for which the data element will be used. If definitions

are not clear or standardized, there is an impact on data

analyses and trends. This problem is further compounded

by the fact that recording of secondary diagnoses also

varies among data systems. If all relevant diagnoses or

problems are not captured by the data system, it may

not be possible to retrieve the patient’s most serious or

life-threatening condition or to identify comorbidity.

The presentations touched upon a number of important

uses of diagnostic information. Accurate diagnoses or

problem descriptions are essential for assessing the quality

of care delivered, They are needed to determine what

types of health problems are being seen and treated in

the different types of ambulato~ care facilities and for

assessing the appropriateness of the setting used to perform

the services. Information on multiple diagnoses is important for developing severity indexes and assessing the

resource requirements of individual cases. Further, several

proposed reimbursement reforms, such as bundling of

services by episodes of care and prospective payment

based on Ambulatory Visit Groups, a categorization being

developed by the Health System Management Group at

Yale University, would require information on the patient’s diagnosis. Finally, use of ambulatory care records

for epidemiologic surveillance, the unique function of

the Centers for Disease Control, is dependent on the

recording and reporting of diagnoses.

The presentations also revealed current limitations

and problems associated with collection of diagnoses.

Under Medicare accurate designation of principal and

secondary diagnoses with ICD–9-CM codes are a necessity for reimbursing hospital services, whereas procedures,

not diagnostic information, are the basis for reimbursing

physician services. Most Medicare carriers require the

physician or patient submitting a claim to provide a reason

for encounter, nature of impairment, or diagnosis. The

Medicare program also plans to begin requiring carriers

to have the capability to keep diagnosis in their claims

processing system. However, much of the diagnostic information obtained is not considered reliable by HCFA due

to the large number of beneficiary-submitted claims, and

thus, carriers are not required to report the item to the

national level. Even with the new requirements, carriers

probably will only need to retain diagnosis where it is

necessary for specific reimbursement decisions. Over half

of the claims for physician services are for office visits,

and the vast majority of claims are paid without reference

to diagnosis. Given the sheer volume of claims, approximately 260 million in Fiscal Year 1985, the Medicare

program considers it prohibitive to match diagnoses with

procedures on a routine basis.

Diagnosis, coded in ICD-9-CM, is a “desirable”

rather than required data item on the subfile for physician

claims in the new national Medicaid reporting system.

The Veterans Administration (VA) expressed considerable

concern about the accuracy of diagnostic information on

outpatient VA records and noted that this information

is not tracked. The CHAMPUS program reported that

only the “primary diagnosis,” defined as the reason for

outpatient care, is captured by its data system and coded

in ICD–9-CM. The forms include room for additional

diagnoses but these are not transmitted on the tape. Thus

the coded diagnosis does not necessarily correspond to

the most expensive treatment or procedure, and there

is not a diagnosis associated with each procedure. The

presenter stated that this seriously limits information for

utilization review.

The current Medical Summary Reporting System used

by the Department of the Army is based on number and

type of visits and contains no coded diagnostic information. However, the Ambulatory Reporting System being

initiated by the Department on a pilot basis requires a

primary diagnosis, coded in ICD-9-CM, and permits multiple secondary diagnoses. The encounter forms used in

the system contain detailed lists of diagnoses tailored

to particular specialties as an aid to completion.

Private fee-for-service insurers report interest in collecting more specific diagnostic information for professional services but encounter problems similar to the public

programs. The GHAA indicated that very few HMO’s

record or code diagnosis on an encounter form in the

ambulatory setting and that, even on the hospital side,

many HMO’s currently do not analyze diagnosis trends.

Finally, the Subcommittee members received information on the International Classification of Primary Care

(ICPC) through their participation in the NCVHS Subcommittee on Disease Classification and Automated Coding

of Medical Diagnoses. This classification was developed

chiefly for the use of primary care providers, with particular application to ambulatory settings, and is undergoing

a number of field tests.

. Procedures

The testimony reinforced the value of uniform coding

of procedures and the positive impact the HCFA Common

Procedure Coding System (HCPCS) has had on standardization. The Subcommittee reaffirmed the NCVHS position

that strong efforts should be made to develop a single

procedure coding system for inpatient and ambulatory

care in the United States.

The Subcommittee further believes that HCPCS,

which is a live system based on CPT4, should be the

core for a national common procedure code for physician

services. Concerning coding of nonphysician services,

the Subcommittee supports the considerable work carried

out for HCPCS and encourages continuation of this work.
Additional study on implementation of a common coding

system for both physician and nonphysician services

should be undertaken.

The presentations confirmed that information is more

widely available on procedures than on diagnoses in ambulatory care data systems, because procedures are the

basis for reimbursement in the fee-for-senice environment. Accurate recording of procedures serves many of

the same purposes described above for diagnoses, as well

as meeting reimbursement needs. Even when procedures

are recorded, however, a number of coding issues remain.

The differing Medicare reporting requirements for

reimbursing hospital services, on the one hand, and for

reimbursing physician inpatient and outpatient services,

on the other, result in the use of two separate cod]ng

systems for the designation of procedures. Volume 3 of

ICD-9-CM is required-for hospital reporting, whereas

the HCFA Common Procedure Coding System (HCPCS)

is used for coding physician services, regardless of the

site in which they have been provided. In instances where

hospital billing offices also perform billing services for

their staff physicians, both systems must be maintained

for each procedure.

Until the recent implementation of HCPCS, there

were an estimated 120 different systems used in reporting

physician services for Medicare. Public and private insurers, for the most part, reported current use of either HCPCS

or CPT-4 for physician services. If the latter is used,

the insurer independently has extended the coding system

for nonphysician services and to meet other unique requirements. Coordination with HCPCS codes for nonphysician

services has not occurred in these cases. As noted earlier,

Medicaid State Agencies will be shifting to HCPCS by

the end of 1986.
Summary

The Subcommittee has addressed each aspect of its charge,

as follows:

● The Subcommittee hasestablished excellent liaison with

NCHS and HCFA, as well as between the public and

private sectors, In many respects, the NCVHS seems

uniquely qualified to play this role for data issues that

cut across Departmental programs and heavily involve

the private sector.

● Through the series of meetings with representatives from

the public and private sectors, the Subcommittee has made

significant progress in identifying more clearly the specific

needs of users of data from patient-physician encounters

in the ambulato~ care setting.

● The discussions with users have provided input to a

schematic overview of the flow of data from various

ambulatory settings into the various data bases in the

fee-for-service environment (see appendix IV). Because

the data systems differ considerably depending upon the

method of reimbursement, it is difficult to capture the

variations in one schema. However, the diagram does

help to demonstrate some of the data requirements, complexities, and interrelationships.

● Presentations by the various public and private insurers

have described the multiple definitions and distinctions

for ambulatory sites of care. Further work is required

to evaluate the definitions currently in use and determine

the extent to which standardization is feasible. The Subcommittee has recommended that this activity be carried

out by a consensus group, such as the CPT Editorial

Board or the NCVHS, and be supplemented by survey

mechanisms.

● The Subcommittee’s investigation has underscored the

value of a Uniform Ambulatory Medical Care Minimum

Data Set. This report summarizes the Subcommittee’s

findings and conclusions related to specific items in the

data set addressed by the various presentations. Because

some items require further study and others were not

considered, the Subcommittee recommends a thorough

and systematic review of all items in the Uniform Ambulatory Medical Care Minimum Data Set for the purpose

of developing a revised version that meets current needs.

This review and revision process should be carried out

by the National Committee on Vital and Health Statistics

and, concurrently, by an interagency task force established

within the Department. The interagency task force should

also have input to the definition of sites of care. Such

an approach would parallel the process used for the

reexamination of the Uniform Hospital Discharge Data

Set and the Long Term Care Minimum Data Set and

should be coordinated with these two data sets to assure

comprehensiveness, minimize redundancy, and facilitate

episode linkage. Attention should also be given to training

in use of the data set, other approaches for assuring data

quality, and standards for reliable and meaningful

analyses.

11
Appendixes

Contents

I. Uniform Ambulatory Medical Cme Minimum Data Set . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Section l. Summary of recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...13

Patient data items . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...13

Provider data items . . . . ...’. . . . . . . . . . . . . . . . . . . ... .. O.. ++. $OC$O C.. .13

Encounter data items . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...13

II. Minutes of the NCVHS Subcommittee on Statistical Aspects of Phvsician Payment Systems . . . . . . . . . . . . . ]4

June 19,1985 meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Medicare claims processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Medicare statistical system . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Commercial insurance data requirements . . . . . . . . . . . . . . . . . . . . . . .

Ambulatory visit groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Blue Cross and Blue Shield Association (BCBSA) data needs . . . . . . . . . . . .

September 10,1985 meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Health Maintenance Organizations (HMO’s) . . . . . . . . . . . . . . . . . . . . .

Figure I. HMO model types . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Medicare update . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Medicaid data requirements . . . . . . . . . . . . . . . . . . . . . . . . .-e-c

October 15,1985 meeting . . . . . . . . . . . . . . . . . . . . . . . ..O . . . . .

National Medicaid reporting system. . . . . . . . . . . . . . . . . . . . . . . . .

Dataneeds ofa Medicare cqn-ier. . . . . . . . . . . . . . . . . . . . . . . . . .

Data needs of employers and business coalitions . . . . . . . . . . . . . . . . . . .

Data needs of Peer Review Organizations (PRO’s) . . . . . . . , , . . . . . . . . .

Dataneeds ofa Blue Cross Blue Shield plan . . . . . . . . . . . . . . . . . . . .

January 14,1986 meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ambulatory care data needs of Veterans Administration (VA) programs . . . . . . .

Ambulatory care data needs of Civilian Health and Medical Program of the Uniformed

program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ambulato~ care data base project of the Department of the Army . . . . . . . . . .

Collection and use of hospital outpatient data . . . . . . . . . . . . . . . . . . . .

Ambulatory care data needs of Centers for Disease Control (CDC) programs . . . . .

111.Place of service designations (Figures II–VI) . . . . . . . . . . . . . . . . . . . . . .

Figure II. HCFA 1500 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Figure III. Medicare Carriers Manual, Part 3-claims process . . . . . . . . . . . .

Figure IV. Metropolitan Life Insurance Company place of service codes . . . . . . .

Figure V. Blue Cross and Blue Shield Association place of service codes+laim form

Figure VI. Blue Cross and Blue Shield Association place of service codes—processing

IV. Data flow for traditional fee-for-service physician reimbursement (Figure VII) . . . . .

. . . . . . . . . . . . . . 14

. . . . . . . . . . . . . . 14

. . . . . . . . . . . . . . 15

. . . . . . . . . . . . . . 15

. . . . . . . . . . . . . . 16

. . . . . . . . . . . . . . 16

. . . . . . . . . . . . . . 17

. . . . . . . . . . . . . . 17

. . . . . . . . . . . . . . 17

. . . . . . . . . . . . . . 18

. . . . . . . . . . . . . . 19

. . . . . . . . . . . . . . 20

. . . . . . . . . . . . . . 20

. . . . . . . . . . . . . . 21

. . . . . . . . . . . . . . 21

. . . . . . . . . . . . ., 22

. . . . . . . . . . . . . . 22

. . . . . . . . . . . . . . 24

24

ie;ices-(CHAMPUi)” “ “

. . . . . . . . . . . . . . 25

. . . . . . . . . . . . . . 26

. . . . . . . . . . . . . . 26

. . . . . . . . . . . . . . 27

. . . . . . . . . . . . . . 29

. . . . . . . . . . . . . . 29

. . . . . . . . . . . . . . 30

. . . . . . . . . . . . . . 32

. . . . . . . . . . . . . . 32

. . . . . . . . . . . . . . 32

. . . . . . . . . . . . . . 33
Appendix L

Uniform Ambulatory Medical

Care Minimum Data Set

[From lhe Report of the National Commitee on Vital and Health Statlstioa, April 1981]

Section 1. Summary of recommendations

The consultants of the Uniform Ambulatory Medical Care

Minimum Data Set Technical Consultant Panel (TCP), National Committee on Vital and Health Statistics, recommend

that the following items constitute the minimum data set that

should be entered in the records of all ambulatory health

care. When so recorded, routinely and uniformly, the value

of health records to the patient care process, and the potential

of health records as an information source are greatly enhanced.

Patient data items

1. Personal identification

2. Residence

3, Date of birth

4. Sex

5. Race and ethnic background

Provider data items

6. Provider identification

7, Location or address

8, Type of practice

9. Profession

Encounter data items

10. Date and place of encounter

11. Patient’s reason for encounter

12. Diagnostic services

13. Problem, diagnosis, or assessment

14. Therapeutic services

15. Preventive services

16, Disposition

17. Expected principal source of payment

18, Total charges

This content reflects several changes from the previous

data set that the consultants recommend be adopted by the

National Committee on Vital and Health Statistics. These

modifications are proposed in order to accommodate the changing environment of ambulatory care. Specifically:

1, The consultants propose a data set that is patient oriented

as opposed to provider oriented. The structure of the

data set is therefore modified to reflect all the services

provided for the patient during the course of an encounter

as opposed to the services rendered by one provider.

2. In accordance with this concept of a patient-oriented data

set, the consultants recommend an expansion of the scope

of the data set. The definition of encounter is modified

to clarify the role of the provider and so capture a greater

proportion of those services provided by nonphysicians.

The following points concerning the Uniform Ambulatory

Medical Care Minimum Data Set (UAMCMDS) should be

emphasized

1. The items constitute a minimum data set. As such, the

data set was designed to meet common data needs among

multiple user groups, not to meet the total data needs

of any one user group. Providers of ambulatory care

and collectors of ambulato~ care data should feel free

to expand this minimum data set in accordance with their

particular requirements.

2. The data set is recommended for inclusion in health records. Providers of care should record these data in at

least the detail specified using the recommended definitions. Although desirable, all items need not be recorded

in the individual patient health record. Some items, for

example, may be included in registration or billing records. In such instances, however, the capability should

exist to link data from the various record sources. In

addhion, some data items need only be recorded once

and updated when necessary.

3. Neither a survey or other data collection system nor a

data collection “form” is recommended. Data systems

and forms will generally vary according to the data needs

of individual programs. It is recommended, however,

that when UAMCMDS items are included in a data system,

the recommended definitions and minimal classifications

be followed.

The consultants recommend that the Uniform Ambulatory

Medical Care Minimum Data Set be accepted by the U.S.

Department of Health and Human Services, and other Federal

agencies that fund ambulatory health care programs. It is

further recommended that the U.S. Department of Health

and Human Services designate an office to have responsibility

for promulgation of the data set. Such promulgation would

include the adoption of the Uniform Ambulatory Medical

Care Minimum Data Set and its definitions by those Federal

programs requiring reporting of ambulatory care events. This

would encourage uniformity in Federal reporting for the items

described in the minimum data set. The consultants also reiterate previous recommendations of the National Committee on

Vital and Health Statistics that private health care institutions,

professional organizations, and insurance caniers endorse and

agree to use the data set.

13
Appendix IL

Minutes of the NCVHS

Subcommittee on

Statistical

Physician

Aspects of

Payment Systems

June 19, 1985 meeting

The National Committee on Vital and Health Statistics

(NCVHS) Subcommittee on Statistical Aspects of Physician,

Payment Systems held its first meeting on June 19, 1985.

The Subcommittee members had previously held three meetings as a work group between June and October 1984.

Participants were William R. Felts, M. D., Chairman,

and Theodore Allison, NCVHS members; William F. Stewart,

James Delozier, and Marjorie Greenberg, National Center

for Health Statistics (NCHS); Alan Bradt and Jean Harris,

Health Care Financing Administration (HCFA); David Zimmerman and David Rinaldo, Metropolitan Life Insurance

Company; and Steven Culler, Blue Cross and Blue Shield

Association. In addition, approximately 8 persons attended

as observers, including a representative from the Pennsylvania

State Medicaid Program. The third NCVHS member of the

Subcommittee, Carmault B. Jackson, Jr., M.D., was unable

to attend due to illness.

Representatives of the Medicare program, Metropolitan

Life Insurance Company, and the Blue Cross and Blue Shield

Association each provided an overview of ambulatory care

data flow for the patient-physician encounter in their respective

organizations. Current data procedures, requirements, and

problems, as well as anticipated future data needs, were

discussed.

Medicare claims processing

Jean Harris, Division of Carrier Procedures, provided

extensive information on claims processing for Medicare

Part B, which includes physician services, durable medical

equipment, and laboratory services. The program has approximately 30 million beneficiaries. In FY 1985, HCFA anticipates

processing about 260 million claims, each of which will have

two to three services per claim. Due to the size of the system

and the cost of operating it, the program tries to keep data

items to a bare minimum.

Medicare Part B claims can be submitted by either the

patient or physician, which has enormous implications for

the quality of the data. In the past 5 years, the program

has made two major changes that have enhanced the uniformity

of data collection. First, a common claims form, the HCFA

1500, was instituted for all physician-submitted claims. Second, the HCFA Common Procedure Coding System (HCPCS)

was adopted for coding of procedures.

The Medicare program also is actively encouraging submission of claims in electronic medi% currently between 10

and 20 percent of claims are submitted in this form.

Carriers retain data for future use for four purposes:

. To maintain a history of the beneficiary (to check for

duplicate claims and medical necessity).

. To update reasonable charge screens.

● To perform post-payment utilization review.

. To monitor fees of nonparticipating physicians.

Because Medicare is no longer always the primary payer,

it has become necessary to collect more patient information

than in the past for coordination of benefits.

Patient-submitted claims represent a significant problem

for reporting diagnosis or reason for encounter. On these

claims only symptoms or complaints can be requested. Due

to the unreliability of much of the information, carriers do

not routinely enter diagnosis into their data bases, unless

data are submitted in electronic media. Currently HCFA is

considering an instruction to carriers that will require them

to have the capability to keep d]agnosis in their claims processing systems, However, carriers probably will only need to

retain diagnosis for paper claims where it is necessary for

specific reimbursement decisions. Over half of the claims

are for office visits and the vast majority of claims are paid

without reference to diagnosis. Given the volume of claims,

it will probably be prohibitive to match diagnoses with procedures on a routine basis. Mr. Stewart suggested consideration

should be given to collecting the complaint or symptoms,

as well as a diagnosis, on physician-submitted claims.

Availability of diagnostic information will improve with

an increase in physician-submitted claims. About 29 percent

of physicians and suppliers currently are classified as participating physicians in the Medicare program, and in the past year

there has been a dramatic rise in the assignment rate from

53 percent to 68 percent of the claims. In some cases, physicians complete the claims form even when they do not accept

assignment. At the same time, valid questions still can be

raised about the accuracy of some of the diagnostic and,

to a lesser extent, procedure codes received, because coding

usually is performed by office personnel who are not specifically trained in medical coding. When codes are not recorded

and must be entered by the carrier, addhional inaccuracies

can occur. Dr. Felts and others raised questions about the

appropriateness of carriers changing codes for various reasons.

In the area of physician identifiers, most carriers are

14
able to distinguish the individual physician who performed

the service, even when the physician is in a group which

uses a single identifier. However, it is virtually impossible

to pull together all of the services rendered by a given physician

in a variety of practice settings. It would be very costly

and sensitive to give each provider a unique number.

The Uniform Claim Form Task Force met in early June

and agreed to pursue greater standardization of the claim

form (HCFA 1500) by eliminating local variants. The Task

Force is chaired jointly by HCFA and the American Medical

Association and includes representation from Blue Cross and

Blue Shield Association and the Health Insurance Association

of America. The Task Force also reaffirmed the enormous

costs to third-party payers and providers alike of making

changes in the claims form and concurred that we may be

on the verge of significant reimbursement reform for physicians. The latter would provide the next opportunity to make

major changes in the claims form. The Task Force identified

approximately 14 additional new items for consideration; many

relate to determining eligibility and coordination of benefits.

Since the implementation of prospective payment for hospitals in October 1983, HCFA is requiring intermediaries to

send Part A data, which cover hospital services, to the carriers

who process the respective Part B data. In addition to preventing double billing for nonphysician services during a hospitalization, there is also the concept that if a hospital stay or

a portion thereof is denied for reasons of medical necessity,

then perhaps some physician services should also be denied

or their intensity reduced. HCFA is also supporting a number

of research studies involving linked Part A and Part B records.

Medicare statistical system

Alan Bradt, Bureau of Data Management and Strategy,

updated the Subcommittee on Medicare Part B data activities.

There are basically four statistical systems:

. Bill summary record—5 percent sample of beneficiaries.

. Payment record—100 percent of payments.

. BMAD-Part B Medicare Data System, consisting of

four files; it may make the previous two files archaic.

. Peer Review Organization (PRO) data--currently only

Part A data, but the PRO’s may expand to reviewing

Part B services as well.

Details of the different data sets are contained in the minutes

to the work group meeting of June 14, 1984.

Standard data files and reports from the BMAD will be

published and available. The 1984 data currently are being

processed; approximately 95 percent are reporting HCPCS

codes, although some of the codes have been converted from

previous coding systems. No information is available from

health maintenance organizations.

Uses of the statistical files include the following:

● Merging Part A and BMAD data for the report due to

Congress July 1, 1985, on prospective payment for physicians. This report will also look at other possible physician

reimbursement reforms, such as fee schedules, relative

value scales, and cavitation.

. HCPCS maintenance.

. Prevailing charge tables.

. Administrative cost containment analyses.

HCFA is developing an on-line access system which will

greatly facilitate special studies by the different components.

This system will probably not be operational by October 1,

as originally planned.

There was general agreement that the method for communicating to physicians and carriers the rationale behind

deleting old procedure codes and adding new ones to HCPCS

should be improved.

Commercial insurance data requirements

David Zimmerman, Assistant Vice President, described

the data requirements at Metropolitan Life Insurance Company,

which he considered simiIar to other commercial carriers.

Claims are submitted to the insurer by individuals, providers, employers, and electronically through a clearinghouse.

Electronic submissions account for approximately 5 percent

of the claims. The majority of claims come from the individual

or the employer, who often must veritj eligibility. Claims

average three services and two providers per claim.

Basically, the HCFA 1500 satisfies most of the data

requirements. One new item which probably will be needed

is the spouse’s month and day of birth to determine the

primary carrier for chiIdren of two insured parents. The

National Association of Insurance Commissioners has recommended the use of whichever parent’s birthday comes earlier

in the year as an unbiased decision rule. Greater detail on

place of service is also desired by many companies, which

are encouraging people to use outpatient care as much as

possible.

Employers ate becoming very aggressive with cost containment measures and increasingly are making demands for

data, Two factors will force greater standardization of data

collection. First, employers are tending to switch insurance

companies far more frequently than in the past. Second,

business coalitions are interested in sharing data.

Following the lead of Medicare, the commercial insurers

are moving to ICD-9-CM for diagnostic coding and CPT4

for procedure coding. There are no immediate plans to use

HCPCS, but the CPT modifiers eventually will be

accommodated.

David Rinaldo, Statistical Consultant at Metropolitan Life,

reported on typical uses of the claims history data. These

include:

. Reporting to policyholders on service utilization and

expenditures.

. Tracking of savings from cost containment programs.

. Identifying aberrant patterns of practice.

. Identifying efficient patterns of practice.

Mr. Rinaldo suggested that in the future, data needs

will be greater than the items currently contained on health

insurance forms. Specifically, there will be a need to link

treatment and charges data for a series of encounters to

construct a defined episode of care. Questions on whether

15
the condition is chronic or acute, whether this is the first

treatment for the illness, and on referrals would facilitate

this construction. The stimulus for these data will probably

come from employers. Although most of the focus has been

on inpatient costs, there is an increasing interest in the ambulatory arena.

Ms. Harris noted that packaging services is attractive

due to the sheer volume of claims, but that to date efforts

to bundle have had minimal success. It has been estimated

that packaging could reduce the annual number of claims

from 260 million to 150 million. Dr. Felts pointed out that

patient outcome must be considered when looking at episodes

of care and expressed concern about the state-of-the-art for

examining and making judgments on outcomes from different

treatment patterns.

Ambulatory visit groups

Jim Delozier, Ambulato~ Care Statistics Branch, NCHS,

described the research currently being conducted at Yale with

support from HCFA on Ambulatory Visit Groups (AVG’S).

Data from the National Ambulatory Medical Care Survey

(NAMCS) conducted by NCHS are being analyzed to develop

groups with a common pattern of resource use. Patients are

classified primarily by diagnosis, but in some cases the patient’s complaint is also a factor. The goal is to develop

an ambulatory patient classification capable of serving as the

basis for a per case prospective reimbursement system.

It was noted that, whereas certain reimbursement approaches, such as AVG’S, might require data not currently

collected, others such as cavitation would require practically

no data for reimbursement. However, data for utilization review are still necessary in the HMO setting to identify

underutilization.

Blue Cross and Blue Shield Association

(BCBSA) data needs

Steven Culler, Manager of Professional and Institutional

Payments, reported on BCBSA data requirements. The

BCBSA is basically a coordinating agent for 88 independent

plans, providing research, actuarial marketing, and educational

services. Claims processing is performed by the individual

plans, and there is no national aggregation of claims data.

The majority of claims are submitted by participating physicians, and eligibility is usually determined by the plan and

not the employer.

Blue Shield uses a claim form very similar to the HCFA

1500. A collapsed CPT-4 coding system is used for reimbursement purposes. The extent to which the coding system is

collapsed varies among the plans.

Uses of the data include reimbursement, utilization review,

auditing, and antifraud efforts. Hospital records have improved

considerably for all patients since the Prospective Payment

System was implemented for Medicare, and similar improvements are anticipated in ambulatory records as outpatient care

is scrutinized. The emphasis is expected to be on improved

data quality and more analysis rather than major new data

requirements. Mr. Culler concurred with Mr. Rinaldo that

interest in outpatient review is relatively recent but on the

rise. Employers are providing a major impetus for encouraging

use of outpatient settings.

For institutional review, the emphasis is on pre-admission

review rather than post-admission denials. The plans are trying

to identify cost-effective physicians by making comparisons

with comparable peer groups. Mr. Culler acknowledged that

there are problems defining the correct peer groupings and

determining efficiency. Also more profiling of claims data

by physicians will be needed in the outpatient area. In some

cases, profiling of patients is also necessary to identify overutilizers. BCBSA has made some preliminary efforts to develop

visit categories, which would require better collection of the

reason for encounter, but the individual plans have not been

enthusiastic about this approach. Fraud and abuse activities

require evidence from outside the claims form, but there is

tremendous variation in the backup records available in ambulatory settings.

The Subcommittee agreed that it would not be necessary

to meet again July 9 as tentatively scheduled. The next Subcommittee meeting will be September 10. Subsequently, a

meeting was also scheduled for October 15.

Dr. Felts identified the following groups as possible presenters at fim.u-emeetings: other insurers, such as Medicaid,

Kaiser, Worker’s Compensation, Civilian Health and Medical

Program of the Uniformed Services (CHAMPUS), and the

Veterans Administration; State personnel; chairmen of the relevant congressional committees or their staffs; Peer Review

Organizations; Institute of Medicine; employer groups; other

DHHS components; and the research-epidemiology community.

Prepared by: Marjorie S. Greenberg, OPPEC, NCHS.
September 10, 1985 meeting

The National Committee on Vital and Health Statistics

(NCVHS) Subcommittee on Statistical Aspects of Physician

Payment Systems held its second meeting on September 10,

1985.

Participants were William R. Felts, Jr,, M.D., Chairman,

Theodore Allison and Carmault B. Jackson, Jr., M.D.,

NCVHS members; James Delozier, Marjorie Greenberg, and

William F. Stewart, National Center for Health Statistics

(NCHS); Alan Bradt and Bob Silva, Health Care Financing

Administration (HCFA); David Plotnick, Group Health Association of America (GHAA), and Gerald Radke, Pennsylvania Department of Public Welfare.

Dr. Felts opened the meeting by reviewing the ma. v

concerns of the Subcommittee. These concerns include identifying data items that are not collected in a uniform manner

from the patient-physician encounter, anticipating changes in

physician payment systems which may require collection and

analysis of additional items of data, and examining the possible

impact of these changes and additions on comparability of

data and trend analysis.

The first Subcommittee meeting on June 19, 1985, focused

on Medicare and private insurer data requirements. This meeting emphasized data requirements of Health Maintenance Organizations and aState Medicaid program.

Health Maintenance Organizations (HMO’s)

Mr. Plotnick, Director of Research and Development at

GHAA, provided background on his organization and the

types of HMO’s it represents. The GHAA was founded in

1959 as a National Trade Association of prepaid group practice

and staff model HMO’s. The organization currently represents

130 HMO’s, which account for about 12–13 million enrollees

or approximately 75 percent of the Nation’s enrollment in

HMO’s, At present about one quarter of the HMO’s enroll

persons on Medicare but many more are contemplating it

due to the new Tax Equity Fiscal Responsibility Act of 1982

(TEFRA) requirements.

In addition to group and staff model HMO’s, there are

other models, including independent practice associations

(IPA’s) which are represented by a separate organization.

Mr. Plotnick, who is responsible for developing a comparative data base on HMO’s, emphasized that the structure

of an HMO affects the organization’s data collection and

contributes to the lack of uniformity among different types

of HMO’S. The GHAA recently examined the different HMO

reporting requirements through a HCFA grant.

Basically, there are three different HMO models—staff,

group, and IPA--(see figure I), plus mixed models. In each

case the HMO is responsible for marketing the health plan,

collecting premiums, and then contracting with other organizations or hiring providers. The unique aspects of each model

and their impact on data requirements areas follows:

● Staff model-Group Health Association of Washington,

D. C., is an example. Staff are salaried and represent

a fixed cost. No claim forms are generated, and there

is minimal examination of specific units of service or

specific encounters. The HMO contracts for inpatient care

with individual hospitals which prepare the HCFA uniform

bill. Specialty care is provided either on a fee-for-service

or retainer basis.

● Group model—This model is exemplified by the Kaiser

Medical Care Program. The HMO either sets up its own

Staff model

I

HMO

I

Group model I

HMO

I

IPA model HMO

1

1

Hospital

Figure L HMO model types

17
multi-specialty medical group or contracts with an existing

medical group. In the latter case the HMO is dependent

upon the data system used by the group. The HMO generally pays by cavitation, putting the group at risk for

medical services and, in some cases, ancillary and even

hospital services. Again it is not necessary to look at

specific units of service for reimbursement. Some larger

group models own their own hospitals, while others contract for hospital services as in the staff model. Some

specialty services may be purchased.

● IPA model—The IPA model is set up to contract with

a number of providers covering a broad geographic area.

This model may use cavitation or fee for service. Claim

forms are used for each encounter, and thus generally

there is more information than in the other tyo models.

Community hospitals are used, as in the other models,

but there are usually very few referrals for specialty care

outside the IPA.

In recent years many HMO’s are mixing the model types,

and the lines are becoming less clearcut.

The source documents used for encounter data lack uniformity, even within the same HMO system, such as the

decentralized Kaiser Program. Some HMO’s use appointment

books rather than encounter forms, and even the definition

of an encounter may vary. The recommended definition of

an encounter is “a face-to-face contact between an HMO

member and a provider of health care services who exercises

independent judgment in the care and provision of health

service(s) to the member.” However, some HMO’s count

a telephone contact as an encounter, and others may count

a series of services ordered by a physician as separate encounters. HMO’s also differ on whether they can document the

actual number of encounters or types of services provided

by specialty providers.

The reason for the encounter may appear in the medical

record but rarely is recorded on an encounter form. Very

few HMO’s code diagnosis in the ambulatory setting, and

even on the hospital side many HMO’s currently do not analyze

diagnosis trends.

HMO’s routinely track provider productivity, queuing

time and waiting time, Quality of care and underutilization

are monitored more frequently through chart review than

through the data systems. HMO’s will be subject to review

by Peer Review Organizations under procedures currently

being negotiated with HCFA.

Although HMO’s, to the extent that they are community

rated, don’t need group specific experience data for administrative purposes, government and employers are demanding more

utilization information about their enrollees. As these demands

increase and as the HMO indust~ becomes more competitive

in negotiating with providers, HMO’s are under pressure to

develop more sophisticated data systems, to improve coding

of procedures and diagnoses, and to capture more information.

However, it will probably be 5 to 10 years before the

HMO data system capabilities are significantly improved. Even

then, the type of data system used in the fee-for-service environment would be onerous and drive up the costs of an HMO,

reducing its competitive advantage. A system specific to

HMO’s would be preferable. Only one HMO, the Harvard

Community Health Plan, uses an automated medical record,

and this is said to be generally disliked by the physicians.

Currently the IPA’s, which are the fastest growing model

type, have much better utilization data than staff or group

models because payment is usually tied to a claim form.

Since IPA’s have to manage utilization over a whole geographic area to providers who may not be seeing many HMO

patients, the claims are examined fairly carefully. Larger centralized systems established by chains and management companies will naturally have better and more uniform data collection systems.

Although there are data supporting both adverse and favorable selection by HMO enrollees, there are very inadequate

data, in general, on why people choose certain health plans

over others. Another area where more data are needed is

technology utilization. The GHAA recently conducted two

surveys on organ transplants. Perhaps 15 to 20 HMO’s have

their own research departments, and Kaiser Health Plan in

Oregon has its own health services research center. For research projects, these plans typically generate their own data

set, drawing directly from the medical records. The National

Ambulatory Medical Care Survey (NAMCS) conducted by

NCHS, which uses its own data collection form, includes

HMO physicians in its survey of office-based physicians and

is trying to tighten its definitions in this area in the 1985

survey.

In partial response to the overall lack of uniformity in

data collection, GHAA is developing a summary level data

base, using standardized definitions. The data base should

be able to provide numbers of encounters by different types

of providers for the whole industry. Funded by the Henry

J. Kaiser Foundation, the project currently is collecting data

from 14 HMO’s across the country. Eventually HMO’s will

participate on a subscription basis and receive comparative

data by which they can measure their own performance.

Medicare update

Alan Bradt, Bureau of Data Management and Strategy,

reported on Medicare data activities. The issue of a unique

physician supplier identifier is being addressed at an internal

HCFA meeting on September 11. Currently a single physician

can have multiple I.D. numbers within the same carrier service

area, as well as differing numbers in different carrier areas.

The probable approach will be a HCFA-assigned number

(HAN), which would be unique to HCFA and not tie into

any other existing systems. The carrier would use the HAN

to replace any identifiers currently in use.

Coding maintenance is continuing on the HCFA Common

Procedure Coding System (HCPCS). The carriers basically

have converted to HCPCS, but there are communication problems. Not all carriers are using all the codes and not all

codes are being paid properly. Staff will be working on achieving more uniformity in coding applications across the country.

Coding standardization activities underway include the

Mandex contract to develop an index for HCPCS and CPT,

BMAD data analysis to identify trends or patterns of services
which will help standardize coding applications, and validating

and reviewing the two adapters that have been developed

for placing Volume 3 ICD-9-CM and CPT codes into common

DRG’s. Mandex is also conducting the latter effort and is

encouraged by preliminary results.

The 1984 BMAD data are in house, with approximately

50 percent edited and accepted. The data base should be

reudy for HCFA use and analysis by October 1, 1985, and

the on-line system should become available by February or

March 1986. Access to the latter will be menu driven, permitting users to work with manageable data files that meet their

specific needs. All carriers will have converted to HCPCS

by the end of September and corrections of erroneous conversions are moving along slowly.

One BMAD application currently under study by HCFA

is development of national fee schedules. Other groups within

HCFA are examining relative value scales and extension of

DRG’s to cover physician payment. Each of these research

efforts relates to the report to Congress on Physician DRG’s,

which was due July 1, 1985, and is currently undergoing

Departmental clearance.

Finally, HCFA is looking at ways to streamline the

Part B data system to reduce carrier burden and expense.

One approach would be to increase the BMAD submittal

and eliminate other components, such as the payment record.

Medicaid data requirements

Gerald Radke, Deputy Secretary for Medical Assistance

imd Medicaid Director in the Pennsylvania Department of

Public Welfare, reported on Medicaid data requirements from

the perspective of his State. Mr. Radke emphasized that there

is little central direction to the 54 separate Medicaid programs

at the operational level and that, to some extent, each State

makes its own decisions on coverage and reimbursement.

Data requirements are driven by both political considerations, such as sensitivity to public perceptions of fraud and

abuse, and the following administrative-structural problems:

. Since the legal contract is with the provider, not’ the

beneficiary, all the controls are on the provider side.

. Further, because it is an open-ended contract, the controls

are after-the-fact controls which seek to examine medical

necessity, This is the focus of most of the information

collected, although the diagnostic information is not very

good, The most frequent procedure is an office visit.

As the payor of last resort, the Medicaid program

must spend a lot of time making sure it doesn’t pay

bills covered by another payment source. Trauma codes,

in particular, are closely monitored for alternative

compensation.

In addition, there are Federal requirements related to timeliness and accuracy. At the same time, there is pressure at

the State level to reduce administrative costs. Pennsylvania

has reacted to these cross pressures by putting the burden

on the provider to fill out the invoice correctly or have it

returned.

Like most large States, Pennsylvania uses a fee schedule.

Since 1979, the State has been making a concerted effort

to upgrade the schedule, beginning with the primary care

area. As a result, statewide payments to the physician community have doubled over a two-year period.

The Medicaid program currently uses ICD-9 for coding

diagnoses and a variation of CPT-3 for coding procedures,

but will probably convert to HCPCS by July 1986. Mr. Radke

noted that the Medicaid data bases have tremendous potential

for research, but the primary focus must be on collecting

information to administer the respective State Medicaid

program.

Although supporting uniform minimum data sets, Mr.

Radke stated he was strongly against common claim forms.

The latter are very difficult to use, because they contain unnecessary items and the same item can have multiple definitions

depending on the insurer. As a result, it is diff]cult to train

people to fill them out and there are potential problems with

data accuracy. The physicians in Pennsylvania have refused

to use the HCFA 1500 for Medicaid reimbursement, preferring

a simplified State invoice. The 1500 is totally inadequate

for determining coordination of benefits, an important issue

for Medicaid programs. Hospitals may start using the UB82,

even though it is considered inappropriate for DRG’s, but

the UB82 will never be used for outpatient services in Pennsylvania. Every time the State changes invoices it costs the

Medicaid program about $1 million.

Pennsylvania Medicaid is in the process of implementing

a prepaid cavitation project for 100,000 Philadelphians. The

providers will submit encounter forms to a contractor, who

will feed information back to the physicians and the Medicaid

program.

Following the presentations, the Subcommittee reviewed

the agenda for the October 15 meeting, which will begin

with Subcommittee business at 9:00 a.m. It was tentatively

agreed that an additional meeting would be held in January.

Prepared by: Mmjorie S. Greenberg, OPPEC, NCHS.

19
October 15, 1985 meeting

The National Committee on Vital and Health Statistics

(NCVHS) Subcommittee on Statistical Aspects of Physician

Payment Systems held its third meeting on October 15, 1985.

Participants were William R. Felts, Jr., M.D., Chairman,

Theodore Allison and Carmault B. Jackson, Jr., M.D.,

NCVHS members; James Delozier and Marjorie Greenberg,

National Center for Health Statistics (NCHS); Alan Bradt,

Richard Bale, Ph. D., Richard Beisel, Donald Muse, Ph. D.,

and Donald Sikora, Health Care Financing Administration

(HCFA); Thomas J. Beatty and Brenda Freitag, Prudential

Insurance Company of America; Susan McAllister, Honeywell, Inc.; and Barry Wilson, Group Hospitalization and

Medical Services, Inc.

The meeting began with discussion of Subcommittee business, including preparation of the Subcommittee’s report to

the full Committee. Mrs. Greenberg agreed to draft an interim

report for review by Subcommittee members and distribution

to all NCVHS members prior to the November 7–8 NCVHS

meeting. The Subcommittee decided to hold an additional

meeting on January 14, 1986, to hear presentations from

other Federal agencies, such as the Centers for Disease Control,

the Veterans Administration, and the Department of Defense,

and to obtain more information on hospital outpatient data

needs. Subcommittee members and staff will also meet the

following day, January 15, to prepare the Subcommittee’s

final report.

Following Subcommittee business, presentations were

heard on the following topics related to data needs and current

data practices in the ambulatory care arena:

. The new person-based national Medicaid reporting system.

. Data needs of a Medicare carrier.

. Data needs of employers and business coalitions.

. Data needs of Peer Review Organizations.

. Data needs of a Blue Cross Blue Shield plan.

National Medicaid reporting system

Dr. Donald Muse, Director, Division of Medicaid Estimates, Office of Actuary, described the evolution of the national Medicaid reporting system. Between 1965 and 1981,

Medicaid had a paper system based on a 12-page required

form. Beginning in 1981, the form was expanded to 47 pages

and a quality review system was instituted with financial

penalties for noncompliance. More importantly, a tape-to-tape

project was undertaken with the goal of standardizing unit

record data in a common format across States.

The tape project determined that certain variables could

be collected uniformly. As a result, States were given the

option either to continue submitting the aggregate paper report

or to begin submitting unit record data on tape. Thirty States

have chosen the tape option, with eight selected initially to

provide data on FY 1985 payments. Reports will be available

3 months after the close of the fiscal year. Currently the

Medicaid fiscal year reports are based on the dateof-payment rather than the date-of-service. Within a year,

HCFA may require all States to submit Medicaid data on

tape in response to pending Congressional action regarding

special adjustments in Medicare payments to hospitals that

serve large numbers of poor patients. In order to implement

this requirement, it would be necessary to link Medicaid and

Medicare data on hospital services.

The tape system consists of the following three files:

● Paid claims.

. Eligibility.

. Provider.

The paid claims file contains three separate subfiles for

hospital inpatient claims, long-term care institution claims,

and other provider or physician claims. Each subfile has required data elements, desirable data elements, and Statespecific codes. Since the paid claims file and the eligibility

file both are used extensively by the States for payment and

utilization control, the data on these files are considered more

reliable than the data on the provider file. The latter will

require a major clean-up overtime as use of the file increases.

Although the long-term goal is to have the Medicaid

data comparable to Medicare data, the initial objective was

to make the system operational. Thus it was not possible

to achieve standardization for certain elements, such as diagnosis and procedure codes, where widespread variation exists

at the State level. Diagnoses, coded in ICD–9–CM, are “desirable” rather than required data items on all three claim subfiles.

Procedure codes are “desirable” on the inpatient claim subfile

and required on the “other” or physician claim subfile. In

both cases a number of different coding systems are accepted

for procedures, with each State designating which system

it is using. No procedure codes are requested on the long-term

care subfile. In addition, the inpatient subfile includes as

“desirable” a principal procedure category, which is to be

selected from a standard list of very broad surgical categories,

such as “Surgery Cardiovascular System.” If these tiles become

involved with payment mechanisms for Medicaid, as many

expect, significant efforts will be made to increase standardiza20
ticm. However, the Medicaid program has a history of flexibility at the individual State level, which is often at odds with

uniformity.

Other items of interest to the Subcommittee included place

of service and personal identifiers. Dr. Muse noted that the

Medicaid program has always collected place of service of

physician visits but has encountered a great deal of difficulty

with standard definitions across States and has essentially

dropped that requirement. Concerning personal identifiers,

every State reporting on tape must provide a unique recipient

ID number, which will probably be the person’s Social Security

number by the end of the decade. Un;que provider ID numbers

w-econsiderably more problematic, particularly in the ambulatory care setting.

The first priority for data production will be the basic

reporting by service types and types of eligibles. Initial analysis

will probably focus on long-term care data. Eventually, public

use data files should be available, but procedures must be

developed to draw useful samples from the approximately

600 million records submitted per year by the thirty States.

Data needs of a Medicare carrier

Mr. Thomas Beatty, Vice President for Federal Programs,

reviewed Prudential Insurance Company’s experience converting three States and four programs from California Relative

Value (CRV) to the HCFA Common Procedure Coding System

(HCPCS), Prudential is the Medicare (Part B) carrier for New

Jersey, North Carolina, and Georgia as well as the Medicaid

contractor in New Jersey, processing nearly 25 million claims

per year. Prudential is also the Medicare (Part A) fiscal intermediary for approximately 500 providers .’The conversion difficulties Prudential encountered were not with the actual crosswalk between the two coding systems but with the inconsistency in definitions for related data elements across the three

States. These elements included followup days, surgical procedures which required an assistant, method for measuring oxygen, etc. Since the payment safeguards are related to these

elements, Prudential felt it was crucial to standardize them

across the States. After considerable effort, all three States

now are recording the HCPCS elements uniformly, with the

exception of risk on anesthesia. In addition, the dentists participating in the New Jersey Medicaid program did not agree

to the conversion to HCPCS and were permitted to retain

their current coding system. Although the conversion from

CRV to HCPCS was fairly direct, Mr. Beatty expressed limited

confidence in conducting trend analyses using data from the

two coding systems.

Mr. Beatty and Ms. Freitag also described the work Prudential currently is conducting under a 2-year HCFA grant

to examine patient-induced overutilization. Prudential became

interested in this area during the 1970’s after analyzing data

for visits by one patient to numerous physicians or excessive

visits by one patient to one or two physicians. The latter

type of overutilization was labeled “patient-induced and provider-condoned.” The HCFA grant will permit interviews with

over 1200 patients who had 47 or more office visits per

year, and with their physicians. In addition, clinical information on patients with 2546 visits per year will be requested

from their physicians by mail. After all the cases are reviewed,

some patients may be placed on a form of pre-care

authorization.

The review of Medicaid utilization patterns by Prudential

is facilitated by the availability of diagnosis on the automated

record. Mr. Beatty noted that if physicians could access this

information base to review a patient’s previous treatment and

prescriptions, it might be possible to reduce expenses and

increase the quality of patient care.

Prudential discontinued inputting diagnosis on the Medicare Part B records when the Department of Health, Education,

and Welfare decided not to pay for the item and to charge

the carrier with an error if the item were erroneous. Mr.

Beatty stated that it would be helpful to have a diagnosis

on the Part B claim for hospital visits but was less sure

of its value for ambulatory care visits. In particular, he expressed concern about the quality of the information since

the majority of claims are submitted by the patients. Matching

Part A and Part B records is considered a valuable tool.

Prudential estimates that in the State of New Jersey, for

every dollar spent on monitoring, $25 are saved. The ratio

in the South is approximately 1:15.

Data needs of employers and business

coalitions

Susan McAllister, Corporate Manager for Health Data

and Administration, presented an overview of the Honeywell

health benefits program, which encompasses 68,000 employees in 40 different business units and 200,000 dependents.

Honeywell has been self-insured for 13 years and offers 400

different medical plans. It is administered through two indemnity carriers and four Blue Cross Blue Shield plans. One

business unit, located in Phoenix, Arizona, is self-administered. The company is committed to self-insurance but has

more questions about self administration. Although the latter

may reduce the costs of claims processing and produce more

timely data, it requires considerable expertise of staff.

The divergence of plans and a corporate culture which

encourages flexibility and decentralization make it extremely

difficult to develop a standard, uniform data base. Many of

the plans in the field operations with very few employees

are HMO’s. In addition, 75 percent of the employees in the

largest unit, located in Minneapolis, are enrolled in HMO’S.

Honeywell has worked very strongly with the Minnesota

Coalition on Health Care Costs to develop a uniform data

reporting request from the employers to the HMO’S. The

request represents a compromise but should help alleviate

some of the current inadequacies in the HMO data. Ms. McAllister stated that HMO’s are beginning to respond to the pressure from employers to produce utilization data. Inpatient

data will become available first, followed by outpatient data.

The IPA’s currently are in the best position to provide the

data requested.

The indemnity carriers also differ in their ability to produce

data. The private carriers which deal nationally across many

different plans have been much more willing and able to

21
provide adequate data than the local Blue Cross Blue Shield

plans which have a monopoly in their area.

Currently, Honeywell is developing a competitive medical

arrangement request for proposal (RFP), which includes a

management information system requirement. The RFP will

be made available to the local divisions to put out to Preferred

Provider Organizations (PPO’S) forbids or to evaluate offerings

coming to them.

Honeywell also has an arrangement with McGraw HiIlSystemetrics, which is developing a standard data base from

the six different carriers. The data are on a mainframe file

to which Honeywell has online access. One analysis has attempted to attach DRG’s to the inpatient claims data. Interest

in analyzing ambulatory care data is also growing since expenditures for ambulatory care have shifted from 30% of

total dollars spent to 5570in the past two years.

In addition to using data for purchasing decisions, Honeywell is also interested in educating its employees about

their health care. At the same time, the Company must be

sensitive to contldentiality and privacy issues.

Ms. McAllister noted that the imposition of a uniform

bill by the Medicare program has helped foster standardization,

resulting in improved data. State-wide data bases also offer

some promise since many Honeywell divisions outside of

Minneapolis are quite small and cannot, themselves, produce

adequate data on providers. The ability to request profiles

from the Peer Review Organizations at the institutional level

will also be pursued. Ms. McAllister supports strong research

data bases for developing standards and benchmarks of care.

The Minnesota Coalition is interested in acquiring data

on diagnoses and procedures but has not finalized the

taxonomies. Currently Honeywell is dealing with ICD–9 codes

for diagnoses and ICD-9 or CPT4 codes for procedures.

Data needs of Peer Review

Organizations (PRO’s)

Donald Sikora, Chief of the Systems Management Branch,

HCFA, presented a paper on the data needed by the PRO

program to carry out review functions. Mr. Sikora emphasized

that many of the policies concerning physician review and

related data requirements are evolving and subject to change.

Planned uses of the PRO data areas follows:

. Track patient health care histories and build a scenario

of the patient’s multiple encounters with the health care

system.

. Generate statistics on patient care by DRG, geographical

location of service, age, type of care, charges, etc.

. Examine changes in practice patterns and in the health

care delivery system.

Currently, the PRO’s are reviewing hospital care, but

the need to examine pre-care and after-care in the ambulatory

setting is strongly recognized. Plans are underway for eight

m nine PRO’s to review ambulatory care on an experimental

basis. Mr. Sikora presented two record formats for data

collection to facilitate hospital and ambulatory review. The

inpatient PRO record format (FI Unibill), which was promulgated on January 1, 1985, is an outgrowth of the PSRO

Hospital Discharge Data Set (PHDDS). The proposed record

for PRO review of ambulatory services is in the preliminary

discussion phase, and no decisions have been made on coding

systems and how the data will be collected. Mr. Sikora

emphasized that a good ambulatory record would make a

contribution to the health care delivery system.

Review of Health Maintenance Organizations by the

PRO’s is still under consideration. They will probably review

the hospital stays of HMO patients, but review of the total

ambulatory care is questionable. Although the proposed record

formats should allow the PRO to establish whether a patient

was an HMO enrollee, identifying enrollees in PPO’S or

self-insured groups would be more difficult. This limitation

would need to be addressed if a PRO moved into private

review, which is encouraged by the legislation.

Standardizing the definitions for sites of care will also

be necessary for the PRO’s to carry out their responsibility

to deny services or the cost of services, where indicated.

Alan Bradt confirmed that the information Medicare collects

on place of service is adequate for current processing but

probably will not meet future needs or the needs of other

programs.

Data needs of a Blue Cross Blue Shield

plan

Barry Wilson, Vice President for Public Affairs, described

the data flow at the Bhte Cross Blue Shield Plan of the

National Capitol Area. As is the case with all health insurers,

the major focus of the Plan’s data systems is to process and

pay claims rather than perform utilization analyses. The Plan

serves approximately 1.1 million participants, contracting with

35 hospitals, 6000 physicians, 1500 dentists, over 30 home

health care agencies, and a wide range of other types of

institutional and professional providers.

Currently 20 to 25 percent of the physician claims are

submitted electronically, and a number of hospitals submit

tapes for use in processing and payment. The Plan is implementing a new claims processing system which will gradually

replace the multiple electronic and manual systems and will

bring together the Blue Cross and Blue Shield data. The

new system employs ICD-9-CM coding for diagnoses and

HCPCS coding for procedures, but analysis of this data will

still be limited. Because Blue Shield pays on the basis of

procedures and Blue Cross pays for patient days of care,

only three digits of the diagnosis are collected on professional

claims and procedural data are collected only incidentally

on hospital claims. Thus date of service must be used to

match hospital and professional services rather than diagnosis

or procedure codes. Up to 60 percent of the data can be

lost in this kind of matching process. The importance of

collecting more specific diagnostic information for professional

services is recognized in house, but it has had a low priority

in the claims payment process. Recording of place of service

is also limited to three categories needed for payment: inpatient, outpatient, and physician’s office.

The situation is compounded by the UB82 claim form,

22
which all hospitals in the Plan are adopting, and the Interplan

Data Record required by the National Blue Cross and Blue

Shield Association. Neither of these formats breaks out ancillary services in sufficient detail to be useful for studying

utilization, particularly of specific laboratory and radiological

exams and other related services. Finally, patient-physician

encounters outside of the hospital and many other ambulatory

care services are reimbursed only under the major medical

coverage for which claims are submitted by the subscriber

rather than the provider. Early next year the Plan intends

to accept physician-submitted claims for all outpatient services,

including office visits, which should improve the quality

of data received and the ability to construct patient care

histories. Within the Plan there is no difficulty identifying

individual participants because the patient name and birth

date are available, upon enrollment and on each claim.

Mr. Wilson noted that even within the current constraints,

the Plan is able to conduct a number of analyses with the

data base derived from the paid claims file. These analyses

are used to redesign benefit structures and to consider implementation of cost containment features, such as preadmission authorization and second surgical opinions. The

data are also used in the aggregate to identify potentially

aberrant patterns of practice which then must be investigated

on a manual basis. At the same time the Plan has conducted

demonstration or pilot programs to acquire the data needed

to evaluate health care services, such as home care and

hospices, in terms of their appropriateness for coverage. The

Plan’s data support a 5-percent savings from pre-admission

authorization, but there is less evidence of cost savings from

second surgical opinion programs.

Analysis of data on trends and practice patterns is complemented by a strong educational approach. The Plan believes

that the key to quality, cost effective care is obtaining professional consensus for given protocols and then developing

the benefits structure to support these protocols. This approach

is in the embryonic stage, but is viewed as promising by

the medical community as well as the Plan. Good quality

data are useful both in developing the protocols and in tracking

compliance with them.

Prepared by: Mmjorie S. Greenberg, OPPEC, NCHS.

23
January 14, 1986 meeting

The National Committee on Vital and Health Statistics

(NCVHS) Subcommittee on Statistical Aspects of Physician

Payment Systems held its fourth meeting on January 14, 1986.

Participants were William R. Felts, Jr., M.D., Chairman,

Theodore Allison and Carmault B. Jackson, Jr., M.D.,

NCVHS members; James Delozier, Gail F. Fisher, Ph. D.,

and Mmjorie Greenberg, National Center for Health Statistics

(NCHS); Alan Bradt, Health Care Financing Administration

(HCFA); Major Stuart Baker and Colonel Donald Rosenberg,

M.D., Department of the Army; Kenneth Zimmerman, Civilian Health and Medical Program of the Uniformed Services

(CHAMPUS); Emily Goodwin, United Hospital Fund of New

York; Michael M. Lawson, Veterans Administration (VA),

and John Llvengood, M.D., Centers for Disease Control

(CDC).

The meeting began with an update on HCFA and NCHS

data activities relevant to the Subcommittee’s work. Alan

Bradt reported on the following HCFA issues:

●

●

●

●

Staff are researching current proposals for physician payment reform but are awaiting further congressional guidance. The Harvard AMA study on relative value scales

was funded, and projects on vouchers and carrier cavitation are among those under consideration.

The Medicare data bases are being strengthened, with

1984 calendar year data in house and instructions for

submittal of 1985 data under development. The contractor

currently is testing the on-line system and training for

the system will begin in February.

Regulations have been published requiring Medicaid State

agencies to use the HCFA 1500 and the HCFA Common

Procedure Coding System (HCPCS) by the end of 1986.

Work continues on the HCFA assigned number (HAN)

which will provide a unique identifier for each physician

rendering services. The associated data base will indicate

the physician’s specialty and related credentials and demographic variables. A staff paper on the HAN will be

available for administrative consideration by the end of

February, and a decision is expected by the end of the

year. Implementation would proceed state by state and

take approximately a year to a year and a half to complete.

Dr. Felts asked about the impact on data if the cavitation

approach predominates in the Medicare program. It was noted

that incentives inherent in cavitation may lead to underutilization, and to assure quality of care may require different approaches to data collection and analysis. Mr. Bradt stated

that data similar to what is currently being collected will

still be needed, but that it will be more difficult to obtain

outside of the billing mechanism. Dr. Jackson suggested that

more data will reside at the carrier and local level but agreed

that data at the national level for policy decisions may suffer.

Mr. Bradt also observed that reliability of data is more questionable when the data are not tied to a billing mechanism.

Jim Delozier reported that data collection for the 1985

National Ambulatory Medical Care Survey (NAMCS) conducted by NCHS is being completed and that data from

the survey should be available by the end of 1986. The

1985 NAMCS collected information on approximately 75,000

to 80,000 encounters from a sample of 5,000 physicians.

Funding in FY 1987 for the next cycle of NAMCS, scheduled

to be conducted in 1988, currently is in doubt. Although

NCHS has done research on expanding the survey beyond

office-based physicians to include hospital-based physicians,

funding for this component also has not been obtained. Dr.

Felts noted that trend data from the 1981 and 1985 NAMCS

should be of interest, because the Medicare prospective payment system was instituted between the two time periods.

Mr. Delozier agreed but pointed out that expected source

of payment, indicating Medicare or Medicaid status, will

be available only for the 1985 survey.

Following the NCHS and HCFA updates, presentations

were received on the following topics:

●

●

●

●

●

Ambulatory care data needs of Veterans Administration

(VA) programs.

Ambulato~ care data needs of Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)

program.

Ambulatory care data base project of the Department

of the Army.

Collection and use of hospital outpatient data.

Ambulatory care data needs of Centers for Disease Control

(CDC) programs.

Ambulatory care data needs of Veterans

Administration (VA) programs

Mr. Michael Lawson, Director of the Medical Administration Service, and members of his staff described ambulatory

care data requirements of the VA programs. The VA delivers

ambulato~ care through the following two distinct approaches:

24
Two hundred and twenty-six outpatient VA clinics associated with 172 hospitals and accounting for 17 million

outpatient visits per year.

Direct contract with Private Providers, resulting in approximately $250 million in expenditures per yea-. Eligibility

for contract care is much more restricted than for clinic

care and usually must be authorized in advance by the

VA. There is a $75/month limitation, although this can

be exceeded after approval of a treatment plan.

The data systems supporting the two approaches are totally

independent and currently are not compatible. The outpatient

clinics use a manual system and collect only two items on

100 percent of the visits in order to perform work load analysis—the patient’s eligibility category and whether or not the

visit is scheduled, is for a compensation claim, or is to apply

for medical care. More detailed information on demographic

variables and services rendered is collected on a 20 percent

sample and on special categories of patients. The VA is in

the process of automating the clinic data system and moving

towards collection of all items on 100percent of the patients.

There is no mechanism at this time within the clinic

system for identifying and tracking any services by an individual provider. Mr. Lawson has considerable concern about

the accuracy of diagnostic information on outpatient VA

records, and this information also is not tracked. Concerns

tibout resource allocation are creating pressures to code ambulatory surgeries, but questions also exist about the accuracy

of this data. General categories of surgery may be used

as Qcompromise,

The data system for contract care is a fee system which

basically enrolls vendors, receives and keypunches bills, and

makes payments. Providers include on their usual bill a brief

description of the reason for encounter and the service

rendered, but no medical coding of diagnoses or procedures

is performed or retained by the data system. Clerks manually

check the condition treated on the bill against the veteran’s

eligibility for treatment. Although the VA fully recognizes

the limitation of this data system, there is reluctance to burden

the fee-basis physicians with additional data requirements.

Ambulatory care data needs of CWilian

Health and Medical Program of the Uniformed

Services (CHAMPUS) program

Mr. Kenneth Zimmerman, Health Care Data Analyst in

the CHAMPUS Statistics Branch, provided an overview of

the CHAMPUS program and ambulatory care data requirements, The mission of CHAMPUS is to augment the military

direct health care system for the approximately 6.5 million

dependents of active duty members, retirees, and their dependents, whenever care cannot be provided by a military

hospital. The actual users of CHAMPUS in a given year

comprise fewer than 20 percent of the eligible population,

or 1,1 million people worldwide.

Approximately 875,000 of the CHAMPUS users receive

some reimbursed care in the ambulatory setting, accounting

for 4.5 million visits in Fiscal Year 1984, and 85 percent

of the claims. Outpatient expenditures are approximately

16 percent of the total CHAMPUS budget of $1.4 billion

or about $225 million. Although the majority of resources

and cost controls are on the inpatient side, utilization and

expenditures are increasing in the ambulatory sector.

The program is set up very similarly to a Blue Cross

Blue Shield high option plan. Five fiscal intermediaries are

under contract with CHAMPUS to process claims for the

beneficiaries, which are submitted on one of several forms.

About 65 percent of the billing comes in on the CHAMPUS

500 form, with another 15 percent submitted on the HCFA

1500 (CHAMPUS 501) form. Outpatient claims are also submitted on the UB 82. The fiscal intermedhries are responsible

for coordinating benefits, since CHAMPUS is always the

secondary payer, except to Medicaid. Charges are profiled

and paid on a “usual, customary, and reasonable” basis at

the 80th percentile for outpatient services. Payment tapes,

containing some of the data items abstracted from the claims

form, are submitted to CHAMPUS. Mr. Zimmerman reviewed

the specific items of interest to the Subcommittee:

●

●

●

●

●

Patient identification---considerable information is required to determine eligibility, including the sponsor’s

social security number. The patient’s name is collected

but no unique number is assigned.

Provider identi&ation-The IRS tax number is used for

identifying the provider. Since there are some inconsistencies and duplications across fiscal intermediaries, the program is trying to move towards a central provider data

base to be updated and maintained by the intermediaries.

Problems will still exist with multiple providers within

a group or clinic sharing the same ID number. The program

would like to be able to identify in the data system specific

individual providers by specialty, particularly in the psychiatric area.

Diagnoses-Only the “primary diagnosis,” defined as the

reason for outpatient care, is captured by the data system

and coded in ICD-9-CM. The forms include room for

additional diagnoses but these are not transmitted on the

tape. Thus the coded diagnosis does not necessarily correspond to the most expensive treatment or procedure, and

there is not a diagnosis associated with each procedure.

This seriously limits information for utilization review.

Procedures-Coding of procedures is by CPT4 with several hundred additional CHAMPUS-assigned codes for

nonphysician services and mental health services. The

latter codes have not been coordinated with the HCFA

Common Procedure Coding System (HCPCS). If other

coding systems are submitted by providers, the fiscal

intermediaries must convert to CPT-4 and CHAMPUS

codes.

Encounter data—The data system captures date of encounter, but when there are multiple encounters for the

same procedure, only the number of times the procedure

is billed on the claim is recorded, not the specific dates

of care. Place of encounter is not collected, but program

officials feel it would be beneficial, particularly in the

area of ambulatory surgery.

25
A limited data audit function currently exists at

CHAMPUS, but the program is hoping to implement a data

integrity study, which will be the first in-depth examination

of data quality and accuracy.

Utilization review is confined at this point primarily to

mental health care. A small Office of Program Integrity does

selected reviews of suspected provider fraud and abuse.

Because the CHAMPUS budget has risen from under

$1 billion in Fiscal Year 1981 to over $1.4 billion at the

present time, there is a great deal of pressure to implement

cost-efficient payment mechanisms which take advantage of

competitive forces in the marketplace. A number of Health

Maintenance Organization (HMO) and Preferred Provider Organization (PPO) demonstrations currently are underway. Mr.

Zimmerman noted that it will be important in these arrangements to define clearly the essential set of data items required.

A major data problem for CHAMPUS is the incompatibility between the CHAMPUS data system and the military

hospital data system. Definitions are not standardized, for

example, on patient units of care. Whereas the CHAMPUS

program defines a visit as a face-to-face encounter with a

health care professional, the military system includes telephone

contacts as encounters. Also, although a patient may receive

only a portion of his care under CHAMPUS, the program

does not have ready access to the data for the care provided

in the military health system.

The CHAMPUS program developed a strategic information plan almost a year ago to revise totally the way data

are summarized from a claims-based approach to an encounterbased system. This plan is on hold pending other decisions

on fi.uure CHAMPUS directions for reimbursing inpatient

and outpatient care.

Ambulatory care data base project of the

Department of the Army

Major Stuart Baker and Colonel Donald Rosenberg presented a briefing on the Army Medical Department (AMEDD)

Performance Measurement Study, which is now a Department

of Defense, Tri-Service initiative. The AMEDD Performance

Study was initiated in 1983 in response to a need for better

epidemiologic and performance information (particularly in

the outpatient environment) in the Army Medical Department

(AMEDD) Health Care Delivery system. The Army already

had a specific inpatient reporting system which collected discharge data largely consistent with the data elements represented in the Uniform Hospital Discharge Data Set.

The contribution of the AMEDD Performance Measurement Study to the inpatient system has been to examine the

application of the Diagnosis Related Group (DRG) classification to the military beneficiary population in an attempt to

explain variations in practice patterns and hospital performance. On the ambulatory side, the purpose is to establish

a major new data collection and reporting system to replace

the current Medical Summary Reporting System which, like

the VA system, is based on the number and type of visits

(e.g., cardiology, OB, etc. ) and cannot describe the nature

or complexity of the ambulatory practice and services from

a diagnostic, procedural or demographic perspective. Both

the inpatient and outpatient components of the study are being

coordinated with the current work on DRG’s and Ambulatory

Visit Group (AVG) research, which is ongoing in the Health

System Management Group (HSMG) at Yale University’s

School of Organization and Management. From an ambulatory

perspective, one of the main purposes in maintaining a collaborative relationship with HSMG was to insure compatibility

with the newly proposed AVG “GROUPER.”

The Ambulatory Reporting System was designed to address three responsibilities—measuring performance, gathering occupational health medical information, and meeting

epidemiologic data requirements. The system currently is being

used by six sites within the Army Medical Department. The

scope of the study extends the collection and management

of the ambulatory data through October 1987.

The system included a patient registration process, patient

encounter (visit) forms, and a provider registration process.

The patient is identified by the social security number of

the sponsor and a two-digit prefix referred to as the Family

Member Prefix. A unique number has been developed to

identify each provider. These two elements are the “keys”

to the database.

The system employs microcomputers, mark sense forms,

and scanners to update the data base. Each remote site can

produce data locally or address the main data base at Fort

Detrick, where the central data base is maintained. Encounter

forms were developed by panels of physicians on a consensus

basis for nearly three dozen specialties. The forms include

common administrative and demographic data as well as diagnoses and procedures tailored to the particular specialty. Diagnoses are coded in ICD–9–CM and procedures in CYf-4.

Both coding conventions have been “extended” to describe

provider-demanded uniqueness. The form requires a primary

diagnosis, which is the primary reason for the visit, and permits

multiple secondary diagnoses.

Physician acceptance of the reporting system has varied.

Some who were initially resistant are recognizing the potential

of the data for special studies and practice profiling, The

major complaint is that it takes about a minute to complete

the encounter form for every patient.

The future of the reporting system after the demonstration

ends has not been decided. Consideration is being given

to promulgating it throughout the Department of the Army,

which has some 400 separate reporting outpatient facilities

or clinics (not hospital-based) accounting for the majority

of the 24 million outpatients treated annually by the AMEDD.

Interest also exists in implementation across the three services.

Collection and use of hospital

outpatient data

Emily Goodwin described an ambulatory care data project

carried out in 1983–84 by the United Hospital Fund, which

provides philanthropic support to the voluntary hospitals in

New York City. The project centered on patient origin information from hospital-based ambulatory care visits. There are

between 10 and 12 million outpatient department and

26
emergency room visits annually in New York City, and many

hospitals have attributed their poor financial condition to the

provision of these services. Success with a patient-origin study

on inpatient care in 1978 provided the impetus for this

undertaking.

Overall goals of the study were to allow public policy

decisianmaking to be based on information, to provide new

hospital management planning tools, to improve and provide

for consistent information practices at the hospitals, and to

provide opportunities for health services research.

The first step was a data capacity study, which revealed

a number of inconsistencies across hospitals, including the

definition of a visit. Because the Fund had to rely on voluntary

hospital cooperation and could not reimburse the clinics for

submitting data, the original goals of obtaining a year’s worth

of data from all 83 voluntary and municipal proprietary hospitals in machine-readable form had to be modified. The final

study focused on the second quarters of 1983 and 1984, with

all hospitals participating in the 1984 data collection. Specific

data problems and issues were as follows:

The study’s intention to collect a unique patient identifier

within each hospital and a primary payer patient ID number

for linkage across hospitals did not prove feasible due

to confidentiality concerns.

Separate hierarchical classification schemes had to be developed to accommodate the detail submitted on payment

source and clinic type. The scheme for the latter was

quite complex but turned out to be more of an administrative categorization than a reflection of medical specialization, as originally desired.

The Fund experienced tremendous problems getting hospitals to follow simple formats and coding instructions.

Reliance on the hospitals’ outpatient billing system for

in-scope visits created some difficulties. For example,

same-day admissions were not contained in this system,

whereas ancillary service visits were included.

Recording of primary diagnosis, or the reason the patient

presented for the visit, was subject to considerable clerical

error, After correcting the most obvious problems, the

data appeared consistent with other information.

The volume of data—approximately 1.6 million outpatient

department visits and 650,000 emergency room visits—

initially proved overwhelming for analysis. Development

of special condensed and summarized files alleviated this

problem.

The Fund concluded that the information collected was

reasonably accurate and had considerable value for planning

purposes. If the study were repeated, the Fund would definitely

consider sampling visits so that more detail could be collected.

Patient ID continues to be of interest, as are procedures.

Mrs. Goodwin endorsed the need for standard definitions

but noted that voluntary compliance has limitations, and the

existence of clout usually improves reporting.

Ambulatory care data needs of Centers

for Disease Control (CDC) programs

Dr. John Livengood provided the Centers for Disease

Control’s perspective as a user of ambulatory care data. The

unique function of CDC is epidemiologic surveillance, which

requires a systematic approach to collection, analysis, and

interpretation of health data. This process must be closely

integrated with the dissemination of knowledge to the people

who need to know, which is linked to CDC’S primary focus

on prevention.

Although an explicit purpose of a surveillance system

is to detect and control epidemics, in Dr. Llvengood’s experience this is seldom accomplished through routine data reporting. Ambulatory records, however, have the potential of

identifying an epidemic several weeks before it shows up

in mortality records. Ambulatory surveillance data also can

be used to test hypotheses about modes of transmission of

illness, to report trends in illness, to evaluate control measures

and public health interventions, to monitor changes in infectious agents, and to detect changes in the pattern of general

health practice.

Increased attention to the ambulato~ care setting reflects

a growing interest in describing the total effect of illness,

not only on costs but on overall quality of life. Dramatic

shifts of care to the ambulatory setting have also increased

the importance of data from this sector.

Sources of data used by CDC include vital statistics,

hospital discharge surveys, physician visit surveys, and surveys

of the general population, such as the National Health and

Nutrition Examination Surveys. Dr. Llvengood noted that

the National Ambulatory Medical Care Survey conducted

by NCHS is an important national resource and should be

maintained at least on its current triennial basis. The CDC’S

most basic surveillance is through the Notifiable Disease

Reports, which are designed to trigger a local response and

subsequently are transmitted to CDC on a State-by-State

basis. These reports suffer from underreporting but do permit

detection of trends.

Three other data sources that CDC uses are the National

Drug and Therapeutic Index (NDTI), the Ambulatory Sentinel

Practice Network (ASPN), and the National Electronic Injury

Surveillance System (NEISS). The NDTI has been operated

by IMS America since 1960 and collects utilization data

from office-based physicians with an emphasis on prescription

drugs. The ASPN began in 1981 and is a voluntary system

of office-based family practice physicians which focuses on

specific conditions over a defined time period. The NEISS

is a stratified random sample of hospital emergency rooms,

initiated in 1972, and providing particularly valuable information on involvement of consumer products in injuries.

Dr. Livengood also described the Behavioral Risk Factor

Telephone Surveys, which are being conducted by more than

23 States with CDC involvement.

27
Major problems with the data sources include lack of

timeliness, limitations in scope, concerns about data validity,

and insufficient detail atthe geographic and condition level.

Dr. Livengood noted a number of areas where additional

outpatient data would be desirable, including diabetes and

hypertension control, technology assessment, and use of selftesting devices. An ideal list of data items would contain

information on patient disability, occupation, risk factors,

circumstances of injury, product involvement, and onset and

duration of illness, as well as the more standard items.

For data improvement, Dr. Livengood would support

procedures for validation of diagnosis and development of

an algorithm for the underlying cause of visit. Better methods

for tracking patients and following back on patients are also

needed.

Dr. Felts concluded the meeting by noting that the numerous presentations heard by the Subcommittee demonstrate

both the commonalities and differences in user data needs.

They all support, however, the essential need for information

regardless of the reimbursement approach adopted by public

and private programs. These needs include monitoring the

system and maldng judgments about adequacy of utilization

and medical necessity. Maintaining comparability of data

sets will bean ongoing challenge.

Prepared by: Marjorie S. Greenberg, OPPEC, NCHS.

28
Appendix Ill.

Place of service designations

(Figures H/l)

FNurG Il. HCFA 1500

BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT

ANO PRIVATE HEALTH PROGRAMS, SEE SEPARATE

INSTRUCTIONS ISSUED BY APPLICABLE PROGRAM.

REFERS TO GOVERNMENT PROGRAMS ONLY

MEDICARE AND CHAMPUS PAYMENTS A patienf’a signature

requests that payment be made and authorizes release of medical

information necessary to pay the claim. If item 9 is completed, the

patient’s signature authorizes releasing of the information to the insurer

or agency shown. In Medicare assigned or CHAMPUS participation

cases, the physician agrees to accept the charge detemrmalion of the

Medicare carrier or CHAMPUS fiscal intermediary as the full charge,

and the petient is responsible only for the deductible, coinsurance.

and noncovered services. Coinsurance and the deductible are based

upon the cherge determination of the Medicare carrier or CHAMPUS

fiscal intermediary if this is less than the charge submitted. CHAMPUS

is not a health insurance program and rendera payment for health benefits provided through membership and affiliation with the Uniformed

services. Information on the patient’s sponsor should be provided in

those items captioned “lnsurecK i.e.. items 3, 6, 7, 6, 9 and 11.

BLACK LUNG ANO FECA CLAIMS The provider agrees to accept the

amount paid by the Government as payment in full. See Black

Lung FECA instructions regarding required procedure and diagnosis

coding systems.

SIGNATUREOF PHYSICIANOR SUPPLIER (MEDICARE, CHAMPUS,FECA AND BLACK LUNG)

I cerfify that the services shown on this form were medically indicated although mcidantal perl of a covered physician’s service, 3) they must

and necessary for the health of the patient and were personally be of kinds commonly furnished in physician’s offices, and 4) the

rendered by me or were rendered incident to my professional service services of nonphysicians must be included on the physician’s bills.

by my employee under immediate personal supewiaion. except as

otherwise expressly permitted by Medicare or CHAMPUS regulations. For CHAMPUS claims. I further certify that neither I nor any employee

For sewtces to be considered a ‘incident” to a physician’s professional

who rendered the serwces are employees or membets of the Uniformed

services (refer to 5 USC 5536). For Black Lung clalms, I further certify

service, 1) they must be rendered under the physician’s immediate that the services periormed were for a Black Lung related disorder.

personal supervision by hisr’her employee, 2) they must be an integral,

No Part B Medicare benefits may be paid unless this form is recewed as required by existing law and regulations (20 CFR 422 510)

NOTICE: Any one who misrepresents or Ialslfies essential reformation to recaive payment from Federal funds requested by this form

may upon conviction be subject to fine and imprisonment under applicable Federal laws.

NOTICE TO PATlENT ABOUT THE COLLECTION ANO USE OF MEDICARE. CHAMPUS. FECA. AND BLACK LUNG INFORMATION

We are authorized by HCFA, CHAMPUS and OWCP to aak you for

information needed in the administration of fhe Meelcare. CHAMPUS.

FECA, and BLACK LUNG programs. Authority to collect information

is in section 205(a). 1672 and 1875 of the Social Security Act as

amended and 44 USC 3101, 41 CFR 101 et seq and 10 USC 1079

and 1066.5 USC 6101 et seq: and 30 USC 901 et seq.

The mformafion we obtain to complete claims under these programs

IS used 10 identity you and to determine your eligibllify. It is also used

to decide if the services and supplies you received are covered by

these programs and to insure thaf proper payment is made.

The Information may also be given to other providers of services,

carriers, intermediaries, medical review boards and other organizations or Federal agences as necessa~ to admmtister these programs.

For example. it may be necessary to disclose mformatlon about the

benefits you have used to a hosp!tal or doctor.

With the one exception discussed below. there are no penaltes under

these programs for refusing to supply information However, failure

to furnish information regarding the medical sewices rendered or the

amount charged would prevent payment of claims under these programs. FaJure to furnish any other information. such as name or claim

number, would delay payment of the claim

It is mandalo~ that you tell us if you are being treated for a work related injury so we can determine whether, workers’ compensation will

pay for treatment. Section 1877 (a) (3) of the Social Security Act provides criminal penalties for withholding this in formahon

MEDICAID PAYMENTS(PROVIDER CERTIFICATION)

I hereby agree to keep such records as are necessary to disclose fully

fhe extent of services provided to individuals under the State’s Title

SIGNATURE OF PHYSICIAN (OR SUPPLIER)’ I certify that the

XIX plan and to furnish information regarding any payments claimed

services listed above were medically ind)cated and necessa~ to the

for providing such aetvicee as the State Agency or Oept. of Health and

health of this patient and were personally rendered by me or my

Human Services may request I further agree to accept, as payment in

employee under my personal direction.

full, the amount paid by the Medicaid program for those claims NOTICE: This is to certify that the foregoing information is true.

submitted for payment under that program, with the exception of accurate and complete.

authorized deductibles and coinsurance.

I understand that payment and satisfaction of this claim will be from Federal and State funds, and that any false claims, statements, or

documents, or concealment of a material fact, may be prosecuted under applicable Federal or State laws.

PLACE OF SERVICE CODES: TYPE OF SERVICE CODES:

1- (IH) - Inpatient Hospital 1 - Medical Care

2- (OH) - Outpatient Hospital 2 - Surgery

3- (o) - Doctor’s Office

4- (H)

3 - Consultation

- Patient’s Home

5-

4 - Diagnostic X-Ray

- Day Care Facility (PSY)

6-

5 - Diagnostic Laboratory

- Night Care Facility (PSY) 6 - Radiation Therapy

7- (NH) - Nursing Home 7 - Anesthesia

6- (SNF) - Skilled Nursing Facility

9- - Ambulance

6 - Assistance at Surgery

O - (OL) - Other Locations

9 - Other Medical Service

A - (IL) - independent Laboratory

O - Blood or Packed Red Cells

A - Used DME

B - (ASC) - Ambulatory Surgical Center

C - (FITC) - Residential Treatment Center

F - Ambulatory Surgical Center

H - Hospice

O - (STF) - Specialized Treatment Facility

E - (COR) - Comprehenswe Outpatient

L - Renal Supplies tn the Home

M - Alternate Paymenl

Rehabilitation Factlity for Maintenance Dtalysls

F - (KDC) - Independent Kidney Disease N - Kidney Donor

Treatment Center V - Pneumococcal Vaccine

Y - Second Opinion on Electwe Surgery

Z - Third Opinion on Electwe Surgery

29
Figure Ill. Medicare Carriers Manual, Part 3-clsims process

13710 (cont.) REPORTS AND STATISTICS 03-85

Field Position Number of Item Description Comment

Number Columns

4. 10 (1) HCPCS Indicate the procedure code 1) HCPCS

Indicator reported as follows: codes include:

1 = HCPCS All CPT-4

codes,

HCFA

national

2 = Other codes and

local codes

(WXYZ)

assigned by

you.

2) Other

codes

include: any

code

used

before conversion to

HCPCS.

5. 11-12 (2) Modifier Show HCPCS 2-digit modifiers received on the

claim. If multiple

modifiers are reported,

show 99. If no modifier

was used Ieave blank. Also

~w any modifier you add

for administrative purposes.

If you have not converted

to HCPCS, show the %pecial

action code” or other code

used to modify the procedure

code. Provide documentation

of these special codes.

6. 13 (1) Place of This field denotes the

Service place of service. Use

the following codes:

‘~1”= Office

“2” = Home

‘!3” = Inpatient Hospital

114!1= SNF

These codes

are consistent

with the codes

and definition used for

the Payment

Record,

s 13030.4

13-398

30

Rev. 1084
03-85 REPORTS AND STATISTICS 13710 (cont.)

Field Position Number of Item Description Comment

Number Columns

(6. cont.) “5” = Outpatient Hospital

“6” = Independent Laboratory

“7” = Other

118!!= Independent Kidney

Disease Treat ment

Center

“9” = Ambulatory Surgery

Center

‘~H1t= Hospice

7. 14 (1)

8. 15-20 (6)

Qpe of This field represents the

Service type of service. Use the

following codes:

“1” = Medical Care

“2’! = Surgery

“3” = Consultation

“4” = Diagnostic X-Ray

~151~= Diagnostic

Laboratory

‘?6tf= Radiation Therapy

“7’?= Anesthesia

“8” = Assistance at Surgery

‘!9” = Other Medical Service

“O” = Whole Blood or Packed

Red Cells

“A” = Used DME

“F” = Ambulatory Surgical

Center (Facility

Usage)

‘?L’t= Renal supplier in the

home

‘WI”= Monthly Cavitation Payment

(Dialysis)

‘~N”= Kidney Donor

T = Pneumococcal Vaccine

“Y” = Second Opinion on

Elective Surgery

Z“ = Third Opinion on Elective

Surgery

These codes

are consistent

with the codes

and definition

used for the

Payment

Record,

S1303.4.

Frequency Show the total number of times

that this procedure code/modifier,

occurred within “this locality,

specialty, T/S, P/S sequence and

was recorded in History. This

Rev. 1084 13-399

31
Figure IV. MetropoMsn Life Insursnce Compsny placeof service

Co&!s

Typa of Facility

01- Hospital (Rsgular-f3eneral)

02- Clinic

03- Paychiatnc Hospital

04- Christian Science Hospital

05- osteopathic Hospital

06- Nursing Home

07- Extendad Care Facility

03- sanitarium

09- School Custodial/Developmental

10- School-Teaching

11- Health Resort

12- Ambulatory Surgicenter

13- Drug/Alcohol Rehabilitation Center

14- Home Health Agency

15- Infirmary

16- Veterana Administration

17- Medical Rehabilitation Facility

18- Hospice (terminally ill)

19- Sirfhing Cantera

Clinic Modifiera

1- Hemodialysis Treatment Center

2- Hemophilia Treatment Canter

3- Freestanding Emergency Treatment Center

~um‘~~~= ;~~ue *M A-w pkitxt of

Senrics

[Placa of sarvicscedesfilledin bypersonccmplafingclaim form]

Plac8 of service code=

1 - (IH) - Inpatient Hospital

2 - (OH) - Outpatient Hospital

3- (0) - Doctor’s Office

4 - (H) - Patient’s Home

5- - Day Care Facility (PSY)

6- Night Care Facility - (PSY)

7 - (NH) : Nursing Home

- (SNF) - Skilled Nursing FaciMy

:- Ambulance

0 - (OL) = Other Locations

A - (IL) - Independent Laboratory

Other Medical Surgical Facility

; ~ (RTC) = Residential Treatment Center

- (STF) - Specialized Treatment Facility

NOTES This &Me is on the back of claim form.

The number and fist may vary fmm plan to plan but this is the moat emmnen list uaad by

We Shafd p!arm

Figuremt31M.t313ar&f3hM3 Shiskl AssocMh pkiceof

-

[Pfssa of semica filled in by gwson prwaasing the claim at fhs PM]

Description

1. Hospital, inpatient

2. Hospital-affiliated hospice

3. Rehabilitation hospital, inpatient

4. Hospital, outpatient

5. Hoapifal-baaed ambulatory surgical facilii

6. Hospital, outpatient hospice services

7. Rehabilitation hospital, outpatient

8. Provider’s office (includes Professional Other Provider)

9. Hospice services rendered in the prwider’s office

10. Patient’s home

11. Hospice services rendered in the patient’s home

12. Psychiatric facilii, inpatiinf

13. Psychiatric facilii, outpatient

14. Psychiatric day-care facifii

15. Psychiatric night-care facifity

16. & 17. Residential substance abuse treatment

facility (includes A!cohotism Treatment

Facilii and Drug Abuse Treatment Facility)

18. & 19. Outpatient substance abuse treatment

facilii (includes Alcoholism Treatment

Facility and Drug Abuse Treatment Facility)

20. Independent clinical laboratory

21. Numlng home

22. Skilled nursing faciiity/exfendad care facility

23. Ambulancq ground

24, Ambulancq air

25. Ambulancq sea

26. Ofher unlisted licensed facilii (Facilii Ofher Provider)

27. Hemophilia treatment canter

28. Freestanding ambulatory mediial facility

29. Freestanding dialysis facility

30. Freestanding ambulatory surgical facility

31. Freestanding alternate birthing canter

32. Freestanding cardiac rehabilitation facility

33. Freestanding hospice facility

34. Pharmacy

NOTES Moat plans enfy mcettl the detailed servioa sits fw National Aexunts.

fnfomsatkm pmv”@ cm tie dmgnda and pmcadure Ox#as alfcw pfan parsonnal to

determine tfw app+epdate place of service frem the claim form.

The actualbeationof fhawvice sitecannotb3 determined for every claim.

U.S. GWERNNENT PRINTINGOFFICE:1987- 181- 33 q 40022

32
Appendix IV.

Data flow for traditional

fee-for-service physician

reimbursement

(Figure VII)

FigureW. Dataflow fortfadwal fee-for-servicephyaklan raifnburaefnent

‘~Patient-physician encounter

Preparation of claim

or encounter form

v

i

(usually with symptoms (If hospital outpatient site of

or diagnosis describad service, procedures described

by ICD-94M codee, by vol. 3 of ICD.9-CM codes

and services [procedures] for institutional reimbursement)

by CPT4 codes)

i J i i I i i 11

Blue Cross/

Commercial

Medicare Madicera

State

Employers Blue Shield part B Chamrxm intarmadisry

insurer(e) aganc”ms

etc.

plan carrier [for cmtpatiant

Part B procssebg)

>

‘-~

-

- ----- ~ ,f’’:’s -

3Resaarch

v

H.C.F.A.

“B-MAD’

U.S.A.

detsfils

Congrass

Policy

H.C.F.A. & D.H.H.S.

Functions

. . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Statistical : Adminiatretiva :

Menegfmat end

.

Policy

1 ) L- ~1 ~, ~.earth

...........................................

Note: The schemetic doss not reflect the dsts flow for cepitation end HMO physicien reimbursement. Oate collection and date flow for cavitation

systems, such sa come parts of DOO, VA, CHAMPUS, and other public or private sector organizatiena, ara Iimitad to sdminktrative naads

with local application, ratention, and distribution.

33
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