Reporting Practices: Local and National

Getting Started

Local Level Reports

Documenting National Level Reports (Including FI)

CHS FI Reports

Data Validation: Reporting Solutions

Validation Solution for 2003

Validation Solution for 2004 and Beyond

Additional Reports

Getting Started

Section Five provides detailed documentation on the meaning and use of local and national level reports-information that is vital if consistent reporting and clear business rules are to be maintained. By design, these reports embrace different data elements. Regrettably, for Statistical officers needing to reconcile CHS data in the NPIRS System with local data, these differences cause difficulties for unduplicating encounters and for reporting key aspects of CHS data.

Armed with a greater overall understanding of local and national level reports, the CHS Data Quality Work Group can now suggest alternative reporting strategies that will meet the needs for validation of the CHS data held in the repositories.

Local Level Reports

Appendix 5-A [06/09-PDF-39KB]

• DSR-Document Status Report: Indicates the status of a document for a requested period of time. The report shows whether documents are paid, open, or cancelled. CHS offers the option to report on all documents that are open, closed, or a combination of the two (logic pending).

• CER-Expenditure Report: A financial report detailing expenditures by patient, community of residence, age group, totals only, or tribe for a specified period of time (logic pending).

• PSR-Document Summary Report: A report detailing the financial activity on purchase orders during a given period of time (logic pending).

• DSRF-Document Status Report by Fiscal Year: Lists the current status of purchase orders (e.g. paid, canceled, etc.) for a fiscal year (report and logic pending).

• HOSP-Hospital Log: Hospital log (report and logic pending).

• MEDI-Medical Data Reports: A report that prints a CPT/Revenue code summary or CPT codes by vendor (report and logic pending).

• OPTC-Optional Comments Report: A local report that prints the optional comments entered by data entry staff; the report is meaningful only to the local facility (report and logic pending).

• SCCR-Service Class Reports: Prints the service class codes by the fiscal year of the issue date or by vendor, in either a summary report or detail report (report and logic pending).

• THRD-CHS Third Party Payment: (report and logic pending)

• VRPT-Vendor Reports: There are four types of reports that may be printed:
  • QVEN-Quarterly Vendor Report: For each vendor providing service in the date range entered, information displayed includes the order number, order date, contract, and amounts obligated, paid, and adjusted-should be run quarterly (report and logic pending).

  • VFP-Vendor File: Prints the entire contents of the vendor file (report and logic pending).

  • VPS-Vendor by Physician Specialty/Date: Displays the physician specialty, the last date a purchase order was issued for the vendor, and the name of the vendor. The report provides a list of possible service providers for unusual needs or current information on vendor use for specialties for CHS personnel (report and logic pending).

  • UR-Vendor Usage Report: Provides lists that can be attached to letters to vendors on open documents claims submission (report and logic pending).

Documenting National Level Reports (Including FI)

NPIRS Reports The NPIRS CHS reports include only non-duplicate, workload reportable records. The logic for determining if a record is workload reportable is described below.

CHS Outpatient

The workload reportable logic for CHS outpatient records varies based on the source of the data, as shown in the table below.

Data Element	CHS Outpatient Workload Reportable Values
	PCC	CHS638 & CHS FI
Provider Type	N/A for PCC as NPIRS currently does not receive Provider Type in the PCC export	01 (Hospital - GM&S) 05 (Physician) 06 (Optometrist) 07 (Dentist) 12 (Pharmacy) 16 (All Other) 17 (Chiropractor) 18 (NHSC - PNP [National Health Service Corps]) 19 (NHSC - CNW [National Health Service Corps])
Service Type	C (Contract)	N/A for CHS638 and CHS FI
Service Category	A (Ambulatory) S (Day Surgery) O (Observation)	N/A for CHS638 and CHS FI

CHS Inpatient

The workload reportable logic for CHS inpatient records varies on the source of the data, as shown in the table below.

Data Element	CHS Outpatient Workload Reportable Values
	PCC	CHS638 & CHS FI
Provider Type	N/A for PCC as NPIRS currently does not receive Provider Type in the PCC export	01 (Hospital - GM&S) 03 (Hospital - Psychiatric) 04 (Nursing Home)
Service Type	C (Contract)	N/A for CHS638 and CHS FI
Service Category	H (Hospitalization)	N/A for CHS638 and CHS FI

NPIRS CHS

Current NPIRS CHS reports are defined below. See Appendix 5-B for a sample of each report, the report logic, and any correspondence relating to potential problems areas with the report.

Appendix 5-B [06/09-PDF-1.2MB]

• 3A CHS Outpatient: This report is grouped by Area and Facility and displays the number of workload reportable CHS outpatient records for a specified fiscal year and is sorted by primary diagnosis, patient gender, and by patient age groups. The primary diagnosis is based on APC recodes, rather than the ICD9 code. The APC recodes are grouped and totaled by APC Recode Class. For example, APC Recode 067, Infective Disease, belongs to APC Recode Class, Infectious and Parasitic Diseases, which includes APC recodes 001 - 067.

• 3I CHS Inpatient: This report is grouped by Area and Facility and displays the number of workload reportable CHS hospital discharges for a specified fiscal year. It sorts the discharges by their primary diagnosis and by patient age groups, and also provides the total number of hospital days, average length of stay, and total cost. The primary diagnosis is based on inpatient recode, rather than the ICD9 code. The inpatient recodes are grouped and totaled by Inpatient Recode Class. For example, inpatient recode, Streptococ Sore Throat, belongs to Inpatient Recode Class, Infectious and Parasitic Diseases, which includes inpatient recodes 002 - 046.

• 3H CHS Inpatient: This report is grouped by Area and Service Unit and displays the number of workload reportable CHS hospital discharges for a specified fiscal year where the primary diagnosis was an injury. It sorts these discharges by their causes of the injury and by patient age groups. For each cause of injury, the total number of discharges is displayed, along with the total number of hospital days. The causes of injury are grouped by the first three digits of the cause of injury code. For example, causes of injury E878.1 and E878.8 are included in the grouping of E878. For each injury grouping, the total number of hospital discharges and the average length of stay (vs. total number of hospital days) are displayed.

• 3G CHS Outpatient: This report is grouped by Area, Service Unit, and Facility and displays the number of workload reportable CHS outpatient records for a specified fiscal year and is sorted by provider type. NOTE: Since the current PCC export does not send provider type, PCC records are excluded from this report. This means that if NPIRS received a record from the CHS FI or CHS638, which was subsequently overwritten by a PCC record, the record would be excluded from this report.

• 3G CHS Inpatient: This report is grouped by Area, Service Unit, and Facility and displays the number of workload reportable CHS hospital discharges for a specified fiscal year and is sorted by provider type (labeled as Hospital Type on the report). For each provider type, the total number of discharges, total number of hospital days, and the computed average length of stay are displayed. NOTE: Since the current PCC export does not send provider type, PCC records are excluded from this report. This means that if NPIRS received a record from the CHS FI or CHS638, which was subsequently overwritten by a PCC record, the record would be excluded from this report.

• OR67: This report is grouped by Area and Facility and displays the number of workload reportable CHS outpatient records for a specified fiscal year and is sorted by primary care provider. A record's value for primary provider is looked up on a table to determine if the provider is considered a workload reportable primary care provider. NOTE: Since the current CHS638 and CHS FI exports do not send primary provider, those records are excluded from this report. This means that if NPIRS received a record from PCC, which was subsequently overwritten by a CHS638 or CHS FI record, the record would be excluded from this report.

CHS FI Reports

The CHS FI reports described below are primarily provided to the IHS Headquarters, Area Offices, or Service Units, with the exception of the Detail of Remittance report, which is sent directly to providers.

• Explanation of Benefits Report (EOBR): Contains line-level detail of claim and payment data. EOBRs are sorted in purchase/delivery order number by fiscal year for each authorizing facility as specified by IHS. A summary page is also available. The EOBR is a critical report to IHS; see Appendix 5-C for a sample of the report and the report logic.

  Appendix 5-C [06/09-PDF-143KB]

• Annual Audit: Audit of financial statements in accordance with generally accepted accounting standards.

• Federal Manager's Financial Integrity Act (FMFIA): The risk assessment encompasses two general work processes- (1) claims processing and payment operations, (2) and health information and reimbursement.

• IRS 1099 Report: Required data necessary to report 1099s to the IRS.

• Medical and Dental Standard Set Reports: Inter-related set of fourteen reports that summarize utilization, billed charges, and paid amounts by a number of different criteria. The report is produced at the National, Area, and Service Unit levels and organizes data into seven broad categories. The information is reported separately for claims with varying degrees of alternate resource impact so that cost, utilization, and provider trends can be more accurately identified.

• Medicare Fee Schedule Reports: Lists the HCPCS code and Medicare rate by carrier and locality.

• Dental Claims Lag Study Report: Lag factors (multipliers) are used to estimate database at 100% completeness for twelve quarters (36 month time period).

• Medical Claims Lag Study Report: Lag factors (multipliers) are used to estimate database at 100% completeness for twelve quarters (36 month time period).

• Detail of Remittance Report: The DRG and Outlier fields contain data only if the claim is for inpatient facility charges from a provider with a Medicare pricing methodology contract. Additional lines will print if the payee has a balance due on the accounts receivable file.

• Patient Alternate Resource Status Report: Report data is patient specific. Notes include coverage limitations specific to patient or policy. Sorted by IHS facility and alphabetic by last name of patient.

• Medical Statistical Data Files: Separated by Area, file includes year-to-date transactions for hospital inpatient discharges, and outpatient visits as defined by IHS. All paid and final reject claims are included.

• Monthly Contractor Status Report: Includes Contractor Workload, Timeliness Report, and Monthly Summary of Provider Problems. The Contractor Workload includes two reports-(1) Timeliness of Processing Comparison Report, which reflects the percentage of clean claims paid within 21 days, and (2) FY Statistics Report which compiles statistical data based on claims activity.

• Contractor Accuracy Report (attachment to the Contractor Status Report): Sample basis of quality checks on Data Entry, Claims Processing, Alternate Resources, Provider Payment, Pends and Adjustments. Other errors discovered in post payment HRNs, PDOs, and suffixes will also be displayed.

• Prompt Payment Report: Claim detail of interest payments, sorted by Area and Service Unit.

• Monthly Claims Activity Reports-Completed Claims Activity: A detail listing of all patient and non-patient claims processed during the month. Report is sorted by Area/SU and POFY. Data elements consist of, but not limited to, PO#, SCC/OCC, Date Paid and Amount, Document Reference Code, etc.

• Claims Activity Summary Report: The report provide fiscal year-to-date totals within each fiscal year; also included are total dollars and total days so average cost of hospital stay or physician visit may be calculated.

• Pended Claims Activity Report: These claim detail reports are sorted by fiscal year, by Purchase/Delivery Order (PDO) number within that fiscal year, and by authorizing facility. Medical PDO are separated from Dental PDO.

• National Pend Summary: There are two parts to this report-(1) an Area Summary by Fiscal year and pend action required, and (2) a further breakdown of the types and number of pends with pend aging information.

• Catastrophic Claims Activity Report: By authorizing facility and patient specified, the report will detail a cumulative report of all payments-combining PDO's-made for an episode of care.

• Contract Expiration Report: List by contract number those that will expire within 90 days.

• Contract Implementation Effectiveness Reports-Detail and Summary: The summary report provides information about the change in payment method due to the implementation of contracts or rate quotes for two or more years of data.

• Contract Monitoring Paid Claims Report: Provides claim-level detail of purchase orders processed and paid for the current month/quarter activity.

• Contract Monitoring Pended Claims Report: Provides claim-level detail of dollars obligated for purchase orders pending in the FI system at the end of the current month/quarter.

• Contract Monitoring Reject Claims Report: Provides claim-level detail of purchase orders processed and rejected; includes interim and final rejects by a specific provider.

• Contract Monitoring Summary Report: Summary report of the purchase order activity represented by claims paid, processed, and dollars paid under the contract; includes number of purchase orders and dollars obligated without a claim.

• Contractor Payment Adjustment Report: Report of specific payment errors, adjustments, and unsuccessful recover efforts followed by the explanation.

• Dental Claims Pend/Problem Summary Report: Report of all dental claims in process, but not completed, listed by pend code with date of claim pended and pend reason.

• DRG Comparison Report: Measures differences between DRG amount and actual allowed amount. The report includes admission and discharge dates, PDO, DRG, outlier number, DRG payment amount, pass-through amount, coordination of benefits indicator, and actual claim type of payment method.

• Health Record Number (HRN), Location, and Tribe Defaults Used Report: Default value codes are assigned to erroneous data fields, including Tribe, health record number, or residency codes. HCSC (BCBSNM) flags these incorrect records and produces a report listing of incorrect record types on statistical tape.

• Investigational Procedures Review Report: Based on research done using the Medical Coverage Issues Manual provided by HCFA, edits are based on types of service and investigational procedures and summarized by reason the claim was identified as investigational by Area and Service Unit.

• Prospective Payment System (PPS) Report: Unit of payment identified as the preset rate per case or type of discharge; categories of discharge by DRG are based on patient's diagnosis, age, sex, treatment procedures, and discharge status.

• Provider Cost Effectiveness Report: The report includes savings associated with the allowable amount payable under a contract versus what was billed by the provider. Separate section includes savings associated with open-market claims.

• Provider Pend Report: Lists the claims pended for a specific provider for the date the report is generated and the reason each claim is pended.

• Rate Quote Summary: Lists the providers identified as Rate Quote in the order of best discount or what would save IHS/CHS the most.

• Dental Claims Summary Report: Full Pay means the claim was paid at 100% of IHS liability, and Part Pay means the claim was paid at less than 100% of IHS liability. Final Rejects are reported as final. Interim Rejects usually reprocess with additional information.

• Provider Contracts by Area (Contracts in Effect): Sorted by contract number and Area, the report lists every provider with a contract in effect on the requested date.

• Third Party Report: ICD9 diagnosis codes for external cause of injury, "E" codes, i.e., motor vehicle accidents, etc.

• DRG Validation Report: Lists by Area and Service Unit for the quarter and year to date. Includes total number of DRG claims processed, total paid, number of claims reviewed, FI DRG allowed amount, number of claims with coding errors, and potential or actual savings.

• Medical Inflation Report: Includes current billed charges, total units, billed charges per unit, and annualized data.

• Office of Management and Budget (OMB) Report: Provides information on the dollar amount paid, claims and adjustments made, and interest payments made on number of claims by Area and Service Unit.
• Dental Statistical Data Files: Separated by Area, file includes year-to-date transactions for Dental Procedure Codes as defined by IHS. All paid and final reject claims are included.

• Quality of Care Report: Detail list, by Service Unit, of patients identified with potential quality of care issue. The list includes the PO, Provider Name, Date of Service, and Narrative of issue.

• Trend Report: Contents are determined by the procedures and issues being trended. Basic data elements include total number of all claims, total number of claims associated with the selected issue, the time element and percentage calculations.
• Vendor List Report: Report of providers; may be sorted by provider name or zip code.

• Preferred Provider Ranking Report (RQM): Ranks inpatient facilities and professional providers from lowest-cost provider to highest. Four categories of ranking reports: Inpatient Facility, Outpatient Facility, Professional Provider, and Hospital Privilege.

• Dental Fee Profile Report (Dental Usual and Customary Report): Lists each dental procedure by the American Dental Association (ADA) code. For each procedure, all providers are listed with the charge for the procedure and the number of times code was billed. A mean, 50th, 70th, and 90th percentile are calculated.

• Practice Variation Report: Documents potentially inappropriate, unnecessary, or excessive health care services and total potential savings associated with such medical care. National, Area, and Service Unit summaries.

• Quality Indicator Report: Set of thirteen different reports that identify such items as percentage of payments made to contracted providers, percentage of billed charges paid by alternate resources, number and type of outstanding pended claims, inflation rates, high volume providers, and Area Directors Performance Monitoring Reports.

• Provider Medicare Payment DRG Disclosure Report: Includes provider-specific information regarding potential DRG payments. A total DRG payment is calculated for each DRG number. The report includes operating and capital components of the DRG payment and pass through payments and the hospital's Medicare Outpatient Interim Rate, which is a percentage derived from the hospital's ratio of cost to charges.

• Weekly Pended Claims Activity Report:All pended claims; non-patient specific.

• Ad Hoc Reports:Contents is based on requestor needs. Classified into two types: (1) specific studies focus on one specific issue, and (2) special studies are multidimensional analyses on many issues.

Data Validation: Reporting Solutions

Compare and Contrast

Currently, the reports available in NPIRS are used for a different purpose than the reports available at the local facility level and at the CHS FI. NPIRS reports are based on a database that has been unduplicated in a manner that, essentially, allows only one claim per patient encounter, whereas multiple claims per encounter may be reported at the local facility level.

NPIRS reports are used to report workload-a number of non-duplicate, workload reportable encounters occurring at each facility. Conversely, the local facility reports are primarily designed to track and to report the cost of the encounters. If a patient's encounter involved multiple claims paid to multiple providers, the information is maintained at the local facility level and is therefore not unduplicated. The CHS FI EOBR report is based on paid claims, but may include claims that were not sent to NPIRS since the CHS FI uses IHS-developed logic for excluding records that are sent to NPIRS. In addition, the reports at the local and CHS FI level contain information that currently is not sent to NPIRS, such as service class codes, CPT codes, and revenue codes.

Put side by side, the reporting systems can be likened to comparing apples and oranges: Validating CHS information at the local and CHS FI level with information at the NPIRS level is very difficult, if not impossible, given the disparities between the reporting systems.

Validation Solution for 2003

1. At a specified date, the CHS FI would send an export of data to NPIRS in the current format that contains three years' of CHS data (i.e. 2003, 2002, 2001), possibly removing some of the filters it normally applies to the NPIRS data.

2. NPIRS would then load this data after all other data has been loaded, which-in the case of duplicate records-would ensure the CHS FI record is that last record received.

3. The CHS FI would create a separate export in a different format and that would include additional data elements, like the service class codes. The same filters removed from the NPIRS export would also be removed from this export; the two exports would then have the same number of records.

Having this additional information would enable the local facilities to validate their data with the CHS FI's data and with the NPIRS data. The ORYX group, led by Mike Gomez, would process and report on the second FI export.

For the tribal sites not using the CHS FI, CHS data validation can be accomplished through ORYX and NPIRS. A re-export of the CHS638 files containing three years of CHS data would be sent to NPIRS for processing after all other normal export files have been processed. The ORYX group would also receive the same export but with the service class codes added. Comparing these two exports will provide authoritative data validation.

Validation Solution for 2004 and Beyond

Additional Reports

The CHS Data Quality Workgroup does not currently advocate additional reports or to change existing reports at either the local facility level or at the CHS FI