CDAC Record Request and Validation

1
CDAC Record Requestand Validation

• Hospital Liaison Meeting
• February, 2007

This material was prepared by Masspro, the
Medicare Quality Improvement Organization for
Massachusetts, under contract with the Centers
for Medicare Medicaid Services (CMS), an agency
of the U.S. Department of Health and Human
Services. The contents presented do not
necessarily represent CMS policy.
8sow-ma-hosp-07-64 Validation-feb
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CDAC Record Request

• Clinical Data Abstraction Center (CDAC)
• Buccaneer Data Services, LLC (BDS)
• 1246 Greensprings Drive
• York, PA 17402
• [phone]
• HPMP Questions Dee Reardon ext 122
• Validation Questions Lesley Rier ext 123

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CDAC Record Request

• Record Request Types
• NPE - National Payment Error (HPMP)
• SI - Surveillance (benchmarks)
• V - Validation
• Premier - 7 additional charts

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CDAC Record Request

• Record Selection
• CMS randomly selects a validation sample of 5
  cases per quarter across topics and pay sources
• Selection occurs around the 20th of the 5th month
  after the end of the quarter (data due 4 months
  15 days following quarter)

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CDAC Record Request

• Hospital Notification
• CMS notifies CDAC of sample selection
• CDAC sends notification via Federal Express to
  the Medical Record Contact at Hospital
• Case Selection Report posted on QualityNet
  Exchange
• Hospitals have 30 days to send record

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CDAC Record Request

• Record Submission
• Copy on white paper
• Include written and electronic information
• Do not use staples, paper clips, or metal clips
• Rubber band each record separately and place
  green coversheet with page count on top
• Do not submit invoices from copying services
• Package appropriately (i.e., weight / tape /
  labeling)

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CDAC Record Request

• Record Reabstraction
• CDAC creates a Gold record by adjudicating the
  medical records
• The completed Gold record is submitted to the
  QIO Clinical Warehouse
• CMS posts validation reports via QualityNet
  Exchange. Hospital users with the QIO Clinical
  Warehouse Feedback Reports role will receive an
  e-mail blast notification stating results have
  been posted

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Validation

• Validation Results
• Hospitals are considered to have passed
  validation if their score is gt 80
• Hospitals with a score gt 80 can not appeal any
  mismatches
• Hospitals with a score lt 80 can appeal all
  mismatches
• Hospitals have 10 business days to appeal

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Validation

• Validation Appeals
• Hospitals must use the Hospital Data Validation
  Appeals Form Part 1 in their appeals
• Supplemental information not originally located
  within the medical record submitted to the CDAC
  is not permitted (e.g., missing pages or reports)
• Hospitals must submit the completed appeals form
  through the Exchange File function of QualityNet
  Exchange
• Education form supplied by the QIO

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Validation
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Validation

• Invalid Record Selection
• Record nor received or received past due date
• Wrong patient
• Wrong dates of stay
• Unmatched admission or discharge date
• Wrong type of admission

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Validation

• Avoid assumptions based on cultural or provider
  habits
• Read data element pages thoroughly
• Review Release Notes in new Spec Manual versions

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Pneumonia

• Initial Blood Culture Time
• 40 - Not Following Guidelines
• Source must be Qualified as draw time
• Time Collected
• Time Drawn
• Time Obtained

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Pneumonia

• Compromised
• 44 - Missed Information
• On Immunosuppressive Therapy in the past three
  months
• HIV / AIDS
• Cystic Fibrosis
• Chemotherapy w/in three months
• Leukemia documented in past three months
• Lymphoma documented in the past three months
• Radiation therapy documented in the past three
  months
• Hospitalized within 14 days.

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Heart Failure

• Discharge Instructions
• 60 of all HF mismatches in 2005
• 21 Medications
• All Med lists which make it into the chart
  within 30 days after discharge
  must match exactly.

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HF Discharge Instructions Meds

• Review all discharge med lists found in chart
• Compare against instruction sheet
• Comparative source
• Not necessary IF
• Practitioner signs instruction sheet
• AND there is no other discharge med list in the
  chart

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HF Discharge Instructions Meds

• Instructions include (at least) NAMES of all meds
• Caveats
• MD list Continue current meds
• Instruction sheet prn meds NOT needed
• of choice meds dont require a name
• Prescriptions are not a med list

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HF Discharge Instructions Meds

• Instruction sheets are assumed to be given to the
  patient
• Educational Material
• Patient provided with educational material
  addressing diet, activity, weight monitoring,
  symptoms to respond to, follow-up appointment and
  the following meds (list names of meds here)

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AMI

• Contraindication to B-Blockers on Arrival
• Whether or not
• the patient received or will receive a
• Beta Blocker

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AMI

• Contraindication to B-Blockers on Arrival
• HR lt 60 off Beta Blockers
• Shock
• Heart Failure
• Allergy
• Heart Block (EKG)
• Other reason documented by practitioner

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AMI

• Contraindication to ASA on Arrival

Whether or not the patient received or will
receive Aspirin
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AMI

• Contraindication to ASA on Arrival
• Allergy
• Coumadin / Warfarin
• Include on temporary hold
• Include noncompliant patients
• Do not include given in ambulance
• Documented reason for not giving ASA
• Include crossed out on discontinued orders
• Active Bleeding

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AMI

• Admission Source
• If SEEN in ED
• the admission source is ED.

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SCIP/SIP
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SCIP/SIP

• High Volume Data Element Mismatches in 2005
• Antibiotic Name 32
• Surgery End Time 25
• Prophylactic Antibiotic 11

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SCIP/SIP

• Data Element Antibiotic Name
• Abstract the first and last dose of each specific
  antibiotic administered from hospital admission
  through the first 48 hours after Surgery End Time
  (72 hours postop for CABG or Other Cardiac
  Surgery)
• Abstract the dose administered prior and closest
  to Surgical Incision Time
• or
• Abstract each antibiotic dose administered from
  hospital admission through the first 48 hours
  after Surgery End Time (72 hours postop for CABG
  or Other Cardiac Surgery)

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SCIP/SIP

• Data Element Surgery End Time
• Using the highest priority available from the
  Suggested Data Sources,
• Anesthesia Record
• Circulation Record
• Nursing Notes
• Operative Report
• Progress Notes

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SCIP/SIP

• Data Element Surgery End Time
• Select the earliest time from the Guidelines for
  Abstraction Inclusion list
• Anesthesia stop / end time Operation closed
• Arrival in the PACU / RR Operating room end,
  finished, or stop time
• Care transfer Operating room exit
• Chest / Abdomen closed Procedure end / stop
• Closure time Room out time
• Discharge to PACU / RR Stop time
• Dressing stop time To PACU / RR
• Dressing time Time incision closed
• End Time Time out
• EOS / end of surgery Time patient taken from
  surgery
• Last stitch in

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SCIP/SIP

• High Risk Data Element Mismatches in 2005
• Infection Prior to Anesthesia 3

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SCIP/SIP

• Data Element Infection Prior to Anesthesia
• Documentation that the patient had an infection
  during this hospitalization prior to the the
  principal procedure
• Documentation of symptoms (e.g., fever, elevated
  white blood cells, etc) should not be considered
  infections unless documented as an infection or
  possible / suspected infection

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SCIP/SIP

• Problem Prone Data Element Mismatches in 2005
• Date of Infection 2/3
• Oral Antibiotic 4/12

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SCIP/SIP

• Data Element Date of Infection
• The date of the first time there is documentation
  that the patient has an infection following the
  principal procedure
• Data Element Oral Antibiotics
• Were the only antibiotic combinations
  administered prior to hospital arrival or more
  than 24 hours prior to incision were either oral
  Neomycin Sulfate Erythromycin Base or oral
  Neomycin Sulfate Metronidazole