Uncharted Territory: Exploring the content and characteristics of Medicare ED claims

1. Uncharted Territory:Exploring the content andcharacteristics of Medicare ED claims Neal Traven, PhD AHQA Technical Conference New Orleans LA March 12, 2004

2. Acknowledgments and thanks to� Qualis Health ED Project colleagues: Sen Dimas, BS; Karen Benson-Huck, ARNP, PhD; Fred Drennan, MD, MHA CMS Central Office: Mary Beth Ribar (GTL), Steven Blackwell, Aaron Goldfarb, Judy Goldfarb, John Hebb, Jackie Kennedy Sullivan TEP members, consultants

3. ED Continuity of Care Project Contract awarded October 2002 Purpose: �to assess use(s) of emergency department (ED) administrative data and to develop ED quality indicators� Technical Expert Panel for clinical guidance To assess the utility of ED claims, we must learn what is in ED claims

4. What are ED claims? Part A Rolled into Inpatient if admitted within 72 hours Outpatient claim if beneficiary not admitted Part B Physician services, procedures Either/both Part A and Part B (?) Labs, imaging, etc. May depend on hospital corporate structure

5. Data request decision-making What information can be obtained from ED administrative data? What are potential sources of variation in ED claims datasets? Should we look for ED visits rolled into Inpatient admissions? How many requests can we make? How large are the analytic datasets?

6. Ad hoc data request Institutional outpatient records, CY 2001 Six states -- AK, CO, MS, NH, WA, WI Beneficiary 5% sample (last two digits of HIC = 05, 20, 45, 70, 95) Select on specified Revenue Center codes 045X (emergency room services) 0981 (professional services in ED) Return all Revenue Center records of selected encounters

7. Records returned 38770 Base records 1 record per encounter Service dates, bene demographics, UPINs, ICD codes (diagnosis, procedure), FI, total charge and payment 285475 Revenue Center records Multiple records per encounter One record for each Revenue Center within encounter Revenue Center code, HCPCS, APC Linkage to Base record via uniqueid

8. Encounters and beneficiariesby state

9. Encounters per beneficiaryby state and age

10. Proportion of beneficiaries withED-only visits, by state and age

11. Commonly-reported�principal� diagnosis groups Symptoms/signs/ill-defined (780 - 799) 25.7% Injury and poisoning (800 - 999) 22.2% Musculoskeletal/connective tissue (710 - 739) 9.5% Respiratory system (460 - 519) 8.8% Circulatory system (390 - 459) 7.7% Digestive system (520 - 579) 5.8% Genitourinary system (580 - 629) 4.3% Nervous system/sense organs (320 - 389) 3.4% Mental disorders (290 - 319) 3.3% (all other groups) 9.3%

12. Revenue Center code characteristics Code �0001� = �Total charges� appears once in every encounter Multiple Revenue Center codes / encounter Range = 2 - 45 Median = 5 Mean = 7.36 State-specific means range from 6.50 (MS) to 7.74 (NH)

13. Important or commonRevenue Center Groups Encounters Revenue Center Group Percent Times Laboratory (030X) 51.6% 5.06 Ambulance services (054X) 1.6% 2.44 Observation (076X) 3.9% 1.28 Radiology diagnosis (032X) 44.8% 1.27 Pharmacy (025X) 41.4% 1.23 Medical-surgical supplies (027X) 35.3% 1.23 Computed tomography (035X) 9.3% 1.23 ED services (045X) 99.9% 1.22 Electrocardiogram (073X) 26.7% 1.15

15. Phase Two ED Quality Performance Measures Project Identify preliminary QPMs reflecting ER care intrinsic clinical validity evidence-based, when possible cost-effective to measure aligned with other CMS/JCAHO priorities National call for measures Engage stakeholders and TEP Abstraction of ED records