DTIC ADA251256: Classification of Champus Professional Services to Ambulatory Patient Groups and Assignment of Resource-Based Relative Values. Champus Professional Services Classification Study (CPSCS).

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by  Defense Technical Information Center

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TRI-SERVICE CHAMPUS STATISTICAL
DATABASE PROJECT
*1 ;(TCSDP)
CLASSIFICATION OF CHAMPUS PROFESSIONAL
SERVICES TO AMBULATORY PATIENT GROUPS AND
ASSIGNMENT OF RESOURCE-BASED RELATIVE VALUES
CHAMPUS PROFESSIONAL SERVICES
DTIC_G1-A SSIFICATION STUDY (CPSCS)
f-
ELECTE
JuS1$W2 VELDA R. AUSTIN, M.S.
A D
Project Director
CPT WAYNE R. WILSON, M.A.
Health Resources Manager
92-14168
HR 92-002 -
_____
92I8
HJANUARY 1992
This document has been appIoved
JA NU A Y 1 9I f
public release and sale its
distribution is unlimited.
UNITED STATES ARMY
HEALTH SERVICES COMMAND
FORT SAM HOUSTON, TEXAS 78234
92 5 28
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Washington D.C. 20301 UNI
1
11. TITLE (Inchude Securty ClaWfication) (U) Classification of CHAMPUS Professional Services
to Ambulatory Patient Groups and Assignment of Resource Based Relative Value
12. PERSONAL AUThOR(S) Velda R. Austin, M.S., CPT Wayne R. Wilson, N.A.
13a. TY Vifa? 9Wport 13b. TIME 6WR % Nov 9 14. R,4W4A)fT f'wi Mofls Day) 15. PAGE COUNT
I FROM
16. SUPPLEMENTARY NOTATION
17. COSATI CODES
Ambulatory Classification, Ambulatory Patient
FIELD GROUP SUB-GROUP
Groups, Resource Based Relative Value Scale
19. ABSTRACT (Contnue on reven if necesry and tdmnAfy by blo number)
This Report presents classification of CHAMPUS professional services data
for Fiscal Year 1989 to Ambulatory Patient Groups (APGs) and assignment of
Resource Based Relative Values (RBRVS) from the Physician's Fee Schedule for
Medicare Patients. CHAMPUS professional services claims data for all three
military service catchment areas were extracted from the Tri-service CHAMPUS
Statistical Database Project files. The study shows that claims data can
effectively be used for research, how encounters can be developed from claims
data, and how APGS and RBRVSs can be applied as a tool for resource alloca
tion. More than sixty-two percent of the variance in resources was accounted
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of resources.
20. DISTRIBUIoN IAVAILABILTY OF ABSTRACT 21. ABSTRACT SECURITY CLASSIFICATION
2s.r -N3UA NMCEL AOSFS FRIEESDPIONNLSIIMBILTEU DIN DIVMIDQUSA ALM E AS RPT. E3 TK USJltS Unclassified
E22b. TELE )H(N&Ek f Are Cod) 22c. OFFIC SYMBO
V ld R5 221-1880 HSHN-A
DO Form 1473, JUN d 0,1m-,el . SECURITY C L nW OM 2 TIU PAGE
Unclassified
TABLE OF CONTENTS
PAGE
DISCLAIMER - i
REPORT DOCUMENTATION (DD Form 1473) - ---------- ii
TABLE OF CONTENTS ------------------ iii
APPENDICES ------------------------ iv
LIST Of TABLES-------------------- v
LIST OF FIGURES --------------------- vi
SUMMARY -v------------------------ Vii
ACKNOWLEDGMENTS-------------------- x
INTRODUCTION--------------------- 1
Purpose---------------------- 1
Background--------------------- 1
Literature Review -i------------------11
Ambulatory Patient Groups --------------- 16
Resource Based Relative Value Scale ---------- 18
Use of Ambulatory Classification Systems -------- 22
OBJECTIVES ----------------------- 24
METHODOLOGY ----------------------- 25
Overview ------------------------ 25
Data ------------------------- 25
Development of Encounter Files ------------- 32
Mapping, or Recoding, of Diagnoses ----------- 34
Mapping, or Recoding, of Procedures ---------- 37
Limitations of the Data ---------------- 38
Data Processing -------------------- 40
RESULTS ------------------------- 43
DISCUSSION ------------------------ 44
Ambulatory Patient Groups --------------- 44
Application of APGs to CHAMPUS PSCS Data -------- 50
Statistical Behavior of APGs -------------- 62
Resource-Based Relative Value System (RBRVS) ------ 66
RBRVS and CHAMPUS Professional Services Data ------ 72
CONCLUSIONS ----------------------- 80
REFERENCES ------------------------ 83
DISTRIbUTION ----------------------- 87
iii
APPENDICES
PAGE
A - Ambulatory Patient Groups ------------- 89
B - Highest Frequency Diagnoses, Encounter File - - - - 101
C - Highest Frequency Procedures and Services,
Encounter Sample File --------------- 105
D - Encounter File Description ------------- 109
E - Diagnosis Translation Table- ------------ 117
F - Procedure Translation Table ------------ 147
G - Translation Table for CPT-4 Visit Codes ------ 153
H - Ambulatory Patient Group Definitions -------- 157
I - Preliminary Ambulatory Patient Group Frequencies - - 161
J - Final Ambulatory Patient Group Frequencies ----- 171
K - Ambulatory Patient Group Statistics After
Consolidation/Packaging, Trimmed Data ------- 181
L - Excerpts from Relative Value Units Table ------ 191
M - Assignment pf Resource-Based Relative Values to
Sample Encounter File Services, By RBRVS Status - - 195
N - Medicare Fee Schedule Procedures Flagged for
Bundling (Status Code "B") ------------- 199
iv
LIST OF TABLES
PAGE
1. Beneficiary Category of Patients by Military
Service of Sponsor ------------------ 28
2. Claims for Payment Under Special Programs, by
Military Service of Sponsor ------------- 39
3. Significant Procedure APG Body Systems -------- 47
4. Ambulatory Patient Groups With Zero Frequencies,
Initial Grouping, CHAMPUS Sample Encounter File - - - 51
5. Ambulatory Patient Groups With Zero Frequencies in
Adjusted CHAMPUS Sample Encounter File ------- 53
6. Highest Frequency APGs After Consolidation and
Ancillary Packaging ----------------- 58
7. Frequency of Ambulatory Patient Group Categories
Before and After Consolidation and Ancillary
Packaging ---------------------- 60
8. Medical APG Consolidation -------------- 61
9. APG Coefficients of Variation, Largest and
Smallest ----------------------- 64
10. Encounter Sample File Statistics ---------- 65
Accesio n For
NTIS CRA&I
DTIC TAB L
U-:.an.mow!-ed L
Justification.
By
Di.t:ibution I
--"--------------
Dist Av a-
v
LIST OF FIGURES
PAGE
1. Age of CHAMPUS Professional Services Beneficiaries - - - 27
2. Gender of CHAMPUS Professional Services Beneficiaries- - 27
3. Diagnosis Categories of Professional Services
Patients, Encounter Sample File ------------ 30
4. Procedure Categories of Most Frequently Coded
Procedures, Encounter Sample File ----------- 31
5. APG Category Frequencies Prior to Consolidation
and Ancillary Packaging ---------------- 55
vi
SUMMARY
Professional services claims constitute the bulk of the Tri-
service CHAMPUS Statistical Database Project (TCSDP) data.
Because of spiraling costs within Department of Defense (DOD)
health services, and particularly within the Civilian Health and
Medical Program of the Uniformed Services (CHAMPUS), better
methods are required to assess current resource allocations as
compared to service requirements.
Classification of ambulatory care data to Ambulatory Patient
Groups (APGs) provides this tool, and indeed has been accom-
plished in the Professional Services Classification Study (PSCS).
This case-level classification system provides information to
analysts and policy makers that will enable them to make better
decisions based on resources available and medical services re-
quirements.
Encounter files were developed from the claims data so that
APG classification could be accomplished. Encounters were built
by joining or separating claims by "care begin date". The re-
sulting encounter enables APGs to be assigned and consolidation
or ancillary packaging of procedures to be flagged. This is
possible because the services provided on a single day are aggre-
gated on the Encounter record, enabling the APG grouper software
to evaluate one service against another in terms of most impor-
tant or resource intensive.
Resource Based Relative Values from the fee schedule for
physician's services were also assigned for each procedure code.
vii