FY 2010 encounter data validation study final report for Georgia Families care management organizations [Dec. 2010]

State of Georgia
Department of Community Health
FY 2010 ENCOUNTER DATA VALIDATION STUDY FINAL REPORT
for
Georgia Families Care Management Organizations
December 2010
3133 East Camelback Road, Suite 300 Phoenix, AZ 85016 Phone 602.264.6382 Fax 602.241.0757

CONTENTS
1. Executive Summary ........................................................................................................................ 1-1 Methods ............................................................................................................................................1-1 Key Findings .....................................................................................................................................1-2 Analyses of Electronic Encounters .................................................................................................1-2 Medical Record Review Findings ...................................................................................................1-2 Conclusions and Recommendations ................................................................................................1-3 Conclusions ....................................................................................................................................1-3 Recommendations .......................................................................................................................... 1-3
2. Overview and Methodology ........................................................................................................... 2-1 Overview ...........................................................................................................................................2-1 Methodology .....................................................................................................................................2-1 Analyses of Electronic Encounters .................................................................................................2-1 Medical Record Review..................................................................................................................2-3 Study Limitations ............................................................................................................................2-6
3. Results ............................................................................................................................................ 3-1 Analyses of Electronic Encounters ...................................................................................................3-1 Utilization Statistics.........................................................................................................................3-1 Encounter Field Completeness and Reasonableness....................................................................3-4 Age/Gender-Appropriateness of Diagnoses and Procedures.........................................................3-5 Timeliness of Encounter Data Processing......................................................................................3-6 Medical Record Review ....................................................................................................................3-8 Completeness ................................................................................................................................. 3-9 Encounter Data Accuracy.............................................................................................................3-13 EPSDT Component Completion ...................................................................................................3-14
4. Discussion ....................................................................................................................................... 4-1 Discussion and Conclusions .............................................................................................................4-1 Analyses of Electronic Encounter Data Findings............................................................................4-1 Medical Record Review Findings ...................................................................................................4-1 Recommendations ............................................................................................................................4-2
Appendix A. Data Abstraction Tool ................................................................................................. A-1
Appendix B. Methodology Specifications Tables .......................................................................... B-1
Appendix C. Detailed Results Tables and Notes ........................................................................... C-1
Appendix D. AMERIGROUP Summary of Findings........................................................................ D-1
Appendix E. Peach State Summary of Findings ............................................................................ E-1
Appendix F. WellCare Summary of Findings ..................................................................................F-1

Encounter Data Validation Study Final Report State of Georgia

Page i GA2009-10_EDV_FinalRpt_F1_1210

1. Executive Summary

The Georgia Department of Community Health (DCH) contracted with Health Services Advisory Group, Inc. (HSAG), to conduct an encounter data validation (EDV) study during fiscal year 2010, which evaluated the completeness and accuracy of encounter data submitted by the three care management organizations (CMOs): AMERIGROUP Community Care, Peach State Health Plan, and WellCare of Georgia, Inc. This report presents the study findings and provides an assessment of the quality of Georgia's electronic encounter data.
Methods
The EDV study was composed of two analytic components: an analysis of electronic encounter data and medical record review.
The first component examined the quality of encounters submitted to DCH with dates of service on or between January 1, 2008, and December 31, 2008. This component sought to answer the following questions:
Were required electronic encounter data fields populated with values? If populated, were required electronic encounter data fields properly formatted and did they
contain reasonable values? Were age-appropriate and gender-appropriate diagnosis and procedure codes submitted
correctly based on a member's age and gender? Were encounters submitted timely and consistently throughout the review period (i.e., January
1, 2008December 31, 2008)?
The second component of the EDV study assessed the completeness and accuracy of Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) professional encounters through medical record review. Three questions were examined:
To what extent were administrative encounters for EPSDT services submitted completely? To what extent were administrative encounters for EPSDT services coded accurately? To what extent were required EPSDT visit components documented in the medical record?
Using random sampling, HSAG selected 411 EPSDT professional encounters from each participating CMO for the medical record review, for a total sample of 1,233 EPSDT visits. Each CMO received a sample list containing the selected members' names and the providers associated with the selected EPSDT visits. The CMOs had the responsibility to procure the medical records for the selected members and identified providers for dates of service in calendar year (CY) 2008.
Upon receiving the medical records from the CMOs, HSAG coders used an electronic abstraction tool to evaluate the sample EPSDT visits. During the review, HSAG coders evaluated the records to determine whether the sampled EPSDT visits were supported by documentation in the medical record. In addition to validating the date of service, diagnosis code, and procedure code for each

Encounter Data Validation Study Final Report State of Georgia

Page 1-1 GA2009-10_EDV_FinalRpt_F1_1210

EXECUTIVE SUMMARY
visit, HSAG reviewers also evaluated whether the provider performed and documented the required EPSDT visit components (e.g., initial/interval history, physical exam, developmental/behavioral surveillance), based on the 2008 Bright Futures Periodicity Schedule. Once HSAG evaluated the sampled EPSDT visits, one additional EPSDT visit per member was randomly selected from the medical record for evaluation. If there was no additional EPSDT visit within the medical record, a physician office visit within the study period was selected.
Key Findings
Highlights of the major findings from the EDV study are presented below.
Analyses of Electronic Encounters
The majority of the critical electronic encounter data fields (13 of 17) were found to contain accurate and reasonable values in more than 95 percent of the professional and institutional encounters. The results for the remaining four critical data fields showed no discernible patterns, suggesting opportunities for improvement.
At least 95 percent of the professional and institutional encounters were submitted with agespecific and gender-specific diagnosis or procedure codes that were appropriate based on the member's age and/or gender.
The CMOs submitted their encounters consistently and timely to DCH. Statewide, 55.8 percent of professional encounters, 60.1 percent of institutional encounters, and 70.6 percent of pharmacy encounters were submitted and processed in Georgia's encounter data system within 90 days of their dates of service.
Despite variations in the volume of the CMOs' monthly encounter data submissions, Georgia Families members received comparable numbers of services from each CMO during CY 2008.
Medical Record Review Findings
Encounters contained in Georgia's electronic encounter data were generally supported by members' medical records (i.e., there was agreement between the encounter data and the medical record). Statewide, 93.9 percent of the dates of service from the electronic encounter data, 86.7 percent of diagnosis codes, and 78.5 percent of procedure codes had supporting evidence in the corresponding medical records.
Although most of the encounters in the electronic encounter data were supported by the members' medical records, not all services documented in the medical records were found in the electronic encounter data. Statewide, 20.5 percent of the dates of service, 49.3 percent of the diagnosis codes, and 40.1 percent of the procedure codes that were documented in the members' medical records were omitted from the electronic encounter data (i.e., encounter data omission).
Omissions identified in the medical record (services located in the encounter data but not supported in the medical record) and omissions in the encounter data (services located in the medical record but not in the encounter data) illustrate discrepancies in the completeness of Georgia's encounter data.

Encounter Data Validation Study Final Report State of Georgia

Page 1-2 GA2009-10_EDV_FinalRpt_F1_1210

EXECUTIVE SUMMARY
While providers documented many of the required EPSDT components in the medical records, only 10.6 percent of the EPSDT visits had all of the age-required components completed and documented during the selected visit.
Conclusions and Recommendations
Conclusions
Findings from the analyses of electronic encounters suggested that the overall quality of the encounter data submitted by the Georgia Families' CMOs was relatively complete and accurate. The CMOs also submitted their encounters in a timely and generally consistent manner. Results from the medical record review indicated that while electronic encounter data were generally supported by medical record documentation, not all services documented in the members' medical records were found in the electronic encounter data. This finding represents an opportunity for improvement in the accuracy and completeness of Georgia's encounter data. With regard to EPSDT component completion, the study findings presented some opportunities for improvement since few medical records contained documentation of all required EPSDT services.
Recommendations
Based on the study findings, HSAG recommends the following:
DCH should continue its current process and approach to ensuring high-quality encounter data submission, including the monthly reconciliation of raw encounter files and establishment of encounter data quality standards.
DCH may want to consider requiring the CMOs to develop an encounter-related education program and subsequent audit for their providers.
DCH should work with the CMOs to investigate incomplete encounter data submissions based on medical record review results and develop strategies to improve rates, including the expansion of current performance measures and standards.
The CMOs should examine reasons behind the low EPSDT component completion rates and develop a performance improvement plan to address any identified barriers. Plan strategies should include educational outreach to providers.

Encounter Data Validation Study Final Report State of Georgia

Page 1-3 GA2009-10_EDV_FinalRpt_F1_1210

2. Overview and Methodology

Overview
Accurate and complete electronic encounter data are important to the success of the Georgia Families Medicaid managed care program. DCH relies on encounter data submissions to monitor and improve the quality of care, establish performance measures, generate accurate reports, and set valid capitation rates. The completeness and accuracy of these data are essential to the overall management and oversight of its managed care program.
DCH contracted with HSAG to conduct the EDV study. The EDV study assessed the completeness and accuracy of Georgia's Medicaid encounter data for CY 2008 and focused on Georgia Families' members enrolled in the following CMOs:
AMERIGROUP Community Care (AMERIGROUP) Peach State Health Plan (Peach State) WellCare of Georgia, Inc. (WellCare)
Methodology
Following the CMS validating encounter data protocol2-1, the EDV study used two approaches when evaluating the quality of Georgia Families' encounter data. These approaches included:
An analysis of electronic encounter data from Georgia's encounter data system. A medical record review of the accuracy and completeness of EPSDT service encounters.
Analyses of Electronic Encounters
The analyses of electronic encounters examined the extent to which the CMOs submitted encounters with complete and valid values to the State. Since the quality of encounter data is affected by many variables, HSAG's review involved multiple evaluation methods. These methods evaluated the extent to which:
1. Important encounter data fields contained complete and/or valid values. 2. The use of diagnosis and procedure codes was appropriate, given members' age and/or gender. 3. Encounters were submitted on a timely basis. 4. The volume of submitted encounters was reasonable.

2-1 Department of Health and Human Services, Centers for Medicare & Medicaid Services. Validating encounter data: A
protocol for use in conducting Medicaid external quality review activities. Protocols for External Quality Review of Medicaid Managed Care Organizations and Prepaid Inpatient Health Plans. Final Protocol, Version 1.0, May 1, 2002.

Encounter Data Validation Study Final Report State of Georgia

Page 2-1 GA2009-10_EDV_FinalRpt_F1_1210

OVERVIEW AND METHODOLOGY

DCH's data vendor extracted the data needed to complete these analyses based on data requirements prepared by HSAG. In September 2009, the data vendor extracted professional, institutional, and pharmacy encounters with dates of service during CY 20082-2, and also provided other supporting data files related to members and providers associated with these encounters.
Data Field Completeness and Reasonableness
HSAG's initial evaluation focused on evaluating key data fields contained in Georgia's encounter data system, including member ID, provider ID, date of service, primary diagnosis, and member gender. Since these fields are required in the CMOs' submission of encounter data, HSAG analysts examined the percentage of professional and institutional encounters that contained values in these data fields (percentage present). HSAG analysts then assessed whether the submitted values were in the correct format and contained expected values (percentage valid values). For example, an encounter where the member ID field was populated with a value of "0000000" would be considered to have a value present and in correct format, but not with a valid value. Table B-1 in Appendix B shows the acceptable ranges or values for the data fields included in this study.
Age/Gender Appropriateness of Diagnoses and Procedures
Incomplete and/or invalid encounter data may also exist when the diagnosis or procedure code submitted is not appropriate for the age or gender of the member. A male member, for example, should not have an encounter for a pregnancy. Similarly, some procedure codes are age-specific. As an example, providers should use the codes of 99381 or 99391 for comprehensive, preventive medical checkups for infants younger than 1 year. HSAG analysts reviewed numerous diagnosis and procedure codes and evaluated the percentage of encounters in which a less-appropriate code was used given a member's age and/or gender. Table B-2 in Appendix B shows the age and gender requirements for the diagnosis or procedure codes used in this analysis.
Encounter Data Submission Timeliness
Another aspect of incomplete data involves situations in which encounters are not submitted to the State within a reasonable time after a provider conducts the service. To evaluate how timely the CMOs submitted encounters to the State, HSAG analysts calculated the number of days between the date of service and processing dates within Georgia's encounter data system. HSAG analysts categorized the timeliness of encounter submissions into six groups:
Fewer than 30 days 3060 days 6190 days

2-2 Professional encounters selected for analysis included those with a date of service during CY 2008 and the following place-of-service codes: 11-Office, 12-Home, 20-Urgent Care Facility, 21-Inpatient Hospital, 22-Outpatient Hospital, 23-ER-Hospital, 24-Ambulatory Surgical Center, 41-Ambulance, 50-Federally Qualified Health Center, 53-Community Mental Health Center, 71-Public Health Clinic, 72-Rural Health Clinic, and 81-Independent Laboratory. Institutional encounters selected for analysis included those with a date of service during CY 2008 and the following type-of-bill codes: 11X-Inpatient Hospital, 13X-Outpatient Hospital, 2XX-Skilled Nursing Facility, 7XX-Clinic, and 8XX-Special Facility. All pharmacy encounters during CY 2008 were included in the analyses. See Table B-3 and Table B-4 in Appendix B for additional information.

Encounter Data Validation Study Final Report State of Georgia

Page 2-2 GA2009-10_EDV_FinalRpt_F1_1210

OVERVIEW AND METHODOLOGY
91120 days 121180 days More than 180 days
Utilization Statistics
The volume of encounters submitted by a CMO throughout the year also provides useful information on the completeness of Georgia's encounter data. This evaluation examined the average number of encounters per member per year, by CMO and by encounter type (i.e., professional, institutional, and pharmacy encounters). HSAG analysts also evaluated monthly variation in the submission of encounter data for professional, institutional, and pharmacy encounters in order to identify any gaps in data submission.
Medical Record Review
The review of members' medical records offers another method to examine the completeness and accuracy of Georgia's Medicaid encounter data. For this study, HSAG collected and reviewed Georgia Families members' medical records to assess the quality of EPSDT encounter data. Based on the medical records collected for this review, HSAG examined the extent to which services documented in the medical record were not present in the electronic encounter data (known as encounter data omissions) as well as the extent to which services documented in the electronic encounter data were not present in members' corresponding medical records (known as medical record omissions). HSAG also evaluated the accuracy of diagnosis and procedure codes submitted to Georgia's encounter data system based on documentation contained in members' medical records. The information that follows outlines the methods used to conduct this analysis.
Study Population
The study population for the medical record review analysis consisted of Georgia Families members who:
1. Were younger than 21 years of age as of December 31, 2008. 2. Were enrolled in a CMO as of December 31, 2008. 3. Had at least one EPSDT visit2-3 during the study period (January 1, 2008, through December 31,
2008). 4. Were continuously enrolled in the same CMO during the study period (January 1, 2008, through
December 31, 2008) with no more than a one-month enrollment gap.

2-3 In collaboration with DCH, HSAG identified EPSDT visits based on specific procedure codes (i.e., 9938199385, 99391 99395) and provider type (i.e., physicians, provider type = "200").

Encounter Data Validation Study Final Report State of Georgia

Page 2-3 GA2009-10_EDV_FinalRpt_F1_1210

OVERVIEW AND METHODOLOGY

Sampling
Using the professional encounter data file prepared by DCH's data vendor, HSAG identified all Georgia Families members who met the study population requirements. For each CMO, HSAG analysts used random sampling to select 411 members for medical record review. For each sampled member, HSAG randomly selected one EPSDT visit that took place during CY 2008.2-4 Each sampled EPSDT visit represented services performed by a single provider on a specific date of service for a specific member.
Data Collection
To ensure the consistent collection of medical records across the CMOs, HSAG prepared a study introduction letter early in the process. This letter highlighted the study methodology, study population requirements, study period, and the suggested components of members' medical records to be submitted (e.g., progress notes, EPSDT visit forms, growth charts, history, and physicals). HSAG then conducted individual conference calls with each CMO to answer any outstanding questions from the data collection liaison. Finally, HSAG forwarded the sample list with member and provider information to each CMO for processing. Upon receipt of the sample from HSAG, the CMOs worked with their providers to obtain members' complete medical records covering services provided during CY 2008. Only the member's medical record for the provider identified in the sample was required for submission; medical records from other physicians visited by the member during the year were not requested.
Abstraction
Upon receiving the medical records from the CMOs, HSAG coders abstracted information from the charts to evaluate the completeness and accuracy of encounter data elements. First, HSAG coders verified whether dates of service found in the electronic encounter data were found in the members' medical records. If so, the date of service was determined to be valid; if not, the date of service was listed as a medical record omission. HSAG coders also compared the electronic encounter data and the medical record to validate corresponding diagnosis codes and procedure codes associated with the dates of service. All findings were entered into an electronic medical record abstraction tool to ensure data integrity.
Additionally, for each verified date of service in the sample list, HSAG evaluated whether the member's medical record contained documentation of the following EPSDT visit components2-5:
Initial/interval history Physical exam Developmental/behavioral surveillance

2-4 HSAG found that in rare instances, providers submitted more than one EPSDT encounter for a member on the same date of service. To ensure that the medical record review included all services provided on the same date of service, encounters with the same date of service and provider were consolidated into one visit for sampling purposes. The number of sample cases was 411 for each CMO, for a total of 1,233 sample cases. HSAG estimated that this sample size would provide 95 percent confidence that the sample results would be within 5 percent of the variance from the true population results.
2-5 In collaboration with DCH, HSAG selected these components based on the 2008 Bright Futures Periodicity Schedule.

Encounter Data Validation Study Final Report State of Georgia

Page 2-4 GA2009-10_EDV_FinalRpt_F1_1210

OVERVIEW AND METHODOLOGY
Health education and/or anticipatory guidance Measurement of height, weight, head circumference, and body mass index (BMI)2-6 Vision assessment Hearing assessment Dental inspection/referral (ages 12 months through 20 years) Immunization status addressed
Among the remaining visits documented in the medical record during CY 2008, HSAG randomly selected one additional EPSDT visit. If an additional EPSDT visit was not identified, HSAG selected an additional physician office visit. HSAG then evaluated whether the additional date of service documented in the member's medical record was found in the electronic encounter data. If so, the date of service was determined to be valid; if not, the date of service was listed as an encounter data omission. Again, HSAG coders compared the medical record and electronic encounter data to validate corresponding diagnosis codes and procedure codes associated with the dates of service.
Analyses and Study Indicators
Once data collection was completed, HSAG analysts exported the abstraction data from the electronic tool into analytic files for analysis. HSAG developed five study indicators to report the medical record review results.
1. Medical record agreement rate--the percentage of sampled dates of service identified in the electronic encounter data that were also found in members' medical records. This rate was also calculated for diagnosis and procedure codes.
2. Medical record omission rate--the percentage of sampled dates of service identified in the electronic encounter data that were not found in members' medical records. This rate was also calculated for diagnosis and procedure codes.
3. Encounter data omission rates--the percentage of dates of service from members' medical records that were not found in the electronic encounter data. This rate was also calculated for diagnosis and procedure codes.
4. Accuracy rates of coding--the percentage of diagnosis codes associated with validated dates of service from the electronic encounter data that were correctly coded based on members' medical records. This rate was also calculated for procedure codes.
5. Required EPSDT component completion rate--the percentage of sample EPSDT visits, based on dates of service identified in the electronic encounter data, where all of the required EPSDT components were documented in members' medical records.

2-6 Head circumference was only for members who were 24 months old or younger. Body mass index was only for members who were 24 months old or older.

Encounter Data Validation Study Final Report State of Georgia

Page 2-5 GA2009-10_EDV_FinalRpt_F1_1210

OVERVIEW AND METHODOLOGY
Study Limitations
When evaluating the findings presented in this report, it is important to understand the following limitations associated with this study:
1. The findings from this study are associated with CY 2008 encounters; as such, the results may not reflect the current quality of DCH's encounter data. In fact, during the analyses of electronic encounters, HSAG identified data issues that have since been resolved based on discussions in June 2010 with DCH and another DCH contractor (Myers and Stauffer). The data files prepared for this study appear to have been extracted before DCH addressed and resolved these data quality issues in coordination with Myers and Stauffer's activities.
2. Successful evaluation of members' medical records depends on the ability to locate and collect complete and accurate medical records. Therefore, validation results could have been affected to the extent that the medical records reviewed were incomplete (e.g., missing pages).
3. Since the EPSDT component completion analysis relied solely on the documentation contained in members' medical records, results are dependent on the overall quality of a physician's medical record. For example, a physician may have performed a vision assessment but did not document it in the member's medical record. As such, HSAG would have counted that EPSDT component as a negative finding. This study was unable to distinguish cases in which a service was not performed versus a service that was performed, but not documented in the medical record.

Encounter Data Validation Study Final Report State of Georgia

Page 2-6 GA2009-10_EDV_FinalRpt_F1_1210

3. Results

This section describes the major findings from the EDV study. Detailed results including the numbers and percentages related to each figure are located in Appendix C. CMO-specific results and information are available in Appendices D, E, and F.

Analyses of Electronic Encounters
The analyses of electronic encounters examined the extent to which the CMOs submitted encounters to the State with complete and valid values. For CY 2008, DCH received close to 20 million encounters from the three CMOs. This includes more than 9 million professional encounters, more than 1.4 million institutional encounters, and more than 9 million pharmacy encounters. Figure 3-1 presents the distribution of electronic encounters included in the analyses by CMO and encounter type.
Figure 3-1--Frequency of Encounters by CMO and Encounter Type
100%

80% 49.8%
60%

48.7%

57.3%

40% 26.3%
20% 23.9%
0% Professional (n=9,267,026)

32.2%
19.0% Institutional (n=1,420,619)

26.9%
15.8%
Pharmacy (n=9,067,164)

AMERIGROUP Peach State WellCare

Source: Table C-1--Encounters Included in the Administrative Analyses, Appendix C Note: WellCare's membership was approximately two times the size of Peach State's and AMERIGROUP's. As such, it is expected that its overall number of encounters would be higher than the other CMOs.

Utilization Statistics
The review of utilization statistics provides valuable insight into the completeness of Georgia's electronic encounter data by measuring the volume of electronic encounter data submissions. Table 3-1 provides a general overview of the average utilization per member in CY 2008. As noted earlier, the Georgia Families program had nearly 20 million encounters in CY 2008. Medicaid members had

Encounter Data Validation Study Final Report State of Georgia

Page 3-1 GA2009-10_EDV_FinalRpt_F1_1210

RESULTS

an average of 20.8 encounters during this time period. Individual CMO rates exhibited minimal differences ranging from 18.8 encounters per member to 22.7 encounters per member.

Table 3-1--Encounter Data Overview

Statewide Total AMERIGROUP

Peach State

WellCare

Average number of members1 Total member months2
Total number of encounters Total encounters PMPY3

949,116 11,389,386 19,754,809
20.8

202,171 2,426,047 3,914,453
19.4

283,333 3,399,998 5,328,388
18.8

463,639 5,563,666 10,511,968
22.7

1 The average number of members was calculated by dividing the total number of member months by 12. This calculation is the basis for reporting per member per year (PMPY) rates.
2 The total number of member months from each CMO will not sum to those in the Statewide Total column because enrollment segments for some members overlapped with different CMOs.
3 The total encounters per member per year (PMPY) rate was calculated by dividing the total number of encounters by the average number of members.

As indicated earlier, the highest volume of encounters was associated with professional and pharmacy services; this pattern was consistent across all CMOs (Figure 3-2). However, while the distribution of encounters per member per year (PMPY) was similar across CMOs for institutional encounters, there was considerably more variation among the CMOs for professional and pharmacy encounters. The largest difference in utilization was noted among pharmacy encounters where the number of prescriptions PMPY ranged from 7.1 prescriptions PMPY to 11.2 prescriptions PMPY.

Figure 3-2--CMO Variations in Encounters Per Member Per Year

12

10

8

6

4

2

0 Professional Encounters

Institutional Encounters

Pharmacy Encounters

Statewide AMERIGROUP Peach State WellCare
Source: Table C-2--Utilization of Services, Appendix C
Figure 3-3 and Figure 3-4 illustrate the distribution of professional and institutional encounters by place of service and bill type. Among professional encounters, office and facility-based visits (63.9 percent and 22.2 percent, respectively) represented the largest proportion of encounters (Figure

Encounter Data Validation Study Final Report State of Georgia

Page 3-2 GA2009-10_EDV_FinalRpt_F1_1210

RESULTS
3-3). For institutional encounters, outpatient hospitals accounted for 85.6 percent of the encounters in CY 2008 (Figure 3-4).
Figure 3-3--Distribution of Professional Encounters Based on Place of Service

Source: Table C-3--Utilization of Services by Place of Services (for Professional Encounters) or Type of Bill (for Institutional Encounters), Appendix C ^ Includes professional visits provided at urgent care facilities, inpatient hospitals, outpatient hospitals, emergency room at
the hospital, and ambulatory surgical centers. + Includes professional visits provided at Federally Qualified Health Centers, community mental health centers, public
health clinics, and rural health clinics.
Figure 3-4--Distribution of Institutional Encounters Based on Type of Bill

Source: Table C-3--Utilization of Services by Place of Services (for Professional Encounters) or Type of Bill (for Institutional Encounters), Appendix C
^ Includes rural health clinics, hospital-based clinics, independent renal dialysis centers, freestanding clinics, clinics at outpatient rehabilitation facilities, and community mental health centers.

Encounter Data Validation Study Final Report State of Georgia

Page 3-3 GA2009-10_EDV_FinalRpt_F1_1210

RESULTS

Encounter Field Completeness and Reasonableness
To determine the completeness and reasonableness of Georgia's electronic encounter data, HSAG's analysts examined the percentage of key data fields that contained data and were populated with expected values. Overall, all seven required data fields (Member ID, Provider ID, Service From Date, Service To Date, Primary Diagnosis, Procedure Code, and Paid Date) exhibited a high level of completeness, with nearly 100 percent of encounters containing information (See Table C-4 in Appendix C). Figure 3-5 shows that the CMOs submitted reasonable values in the seven required professional encounter data fields. Except for the provider ID field, more than 95 percent of the submitted professional encounter data contained valid data. For the provider ID field, 86.6 percent of the encounters contained valid values. Performance was consistent across CMOs. For additional information on optional data fields such as additional diagnoses, see Appendix C, Table C-4.

Figure 3-5--Percentage of Professional Encounters Containing Valid Values in Select Data Fields
100%

95%

90%

85%

80%

75%
Member ID (99.2%)

Provider ID (86.6%)

Service From Service To Date

Date (98.7%)

(98.7%)

Primary Diagnosis (99.9%)

Procedure Code (>99.9%)

Paid Date (99.9%)

AMERIGROUP

Peach State

WellCare

Source: Table C-4--Summary of Professional Encounter File Completeness, Appendix C Note: Statewide percentage is reported in the parentheses for each data field.

Similar to professional encounters, almost all of the submitted institutional encounters contained information in the 10 required institutional encounter data fields (i.e., Member ID, Provider ID, Discharge Date, Admit Date, Paid Date, Service From Date, Service To Date, Primary Diagnosis, Procedure Code, and Revenue Center Code). See Table C-5 in Appendix C for detailed information. Additionally, all CMOs submitted reasonable values with valid formats in seven of the 10 required institutional encounter data fields. All data fields except for Provider ID, Admit Date, and Procedure Code had more than 95 percent of the fields populated with valid data. Figure 3-6 shows that statewide rates for the Provider ID, Admit Date, and Procedure Code fields ranged from 37.4 percent (Procedure Code) to 89.7 percent (Admit Date). For additional information on optional data fields such as additional diagnoses, see Appendix C, Table C-5.

Encounter Data Validation Study Final Report State of Georgia

Page 3-4 GA2009-10_EDV_FinalRpt_F1_1210

RESULTS

Figure 3-6--Percentage of Institutional Encounters Containing Valid Values in Select Data Fields 100%

80%

60%

40%

20%

0% Provider ID (82.5%)

Admit Date (89.7%)

Procedure Code (37.4%)

AMERIGROUP

Peach State

WellCare

Source: Table C-5--Summary of Institutional Encounter File Completeness, Appendix C Note: Statewide percentage is reported in the parentheses for each data field.

Age/Gender-Appropriateness of Diagnoses and Procedures
Another method for evaluating the reasonableness of submitted electronic encounter data is by investigating the age/gender-appropriateness of diagnosis and procedure codes. Figure 3-7 highlights the overall findings from HSAG's review of age/gender-appropriateness. In general, 95 percent or more of all professional and institutional encounters with age-specific and genderspecific diagnosis or procedure codes were appropriate according to the patient's age or gender.

Encounter Data Validation Study Final Report State of Georgia

Page 3-5 GA2009-10_EDV_FinalRpt_F1_1210

Figure 3-7--Percentage of Professional and Institutional Encounters with Age/Gender-Appropriate Diagnoses or Services

RESULTS

100%

95%

90%

85%

80%

75% Diagnoses

Services

Age-Appropriate

Diagnoses

Services

Gender-Appropriate

Professional Encounters Institutional Encounters

Source: Table C-6--Age- and Gender-Appropriate Professional Encounters, Appendix C Table C-7--Age- and Gender-Appropriate Institutional Encounters, Appendix C

Timeliness of Encounter Data Processing
Encounters that are complete and accurate but are not submitted timely to the State create challenges to monitoring programs and evaluating CMOs' performance. Figure 3-8 shows that statewide, 55.8 percent of professional encounters, 60.1 percent of institutional encounters, and 70.6 percent of pharmacy encounters were processed into Georgia's encounter data system within 90 days from the date of service. Across the three encounter types, considerable variation was noted among the CMOs, with differences ranging from 25.8 percentage points for professional encounters to 44.1 percentage points for pharmacy encounters.

Encounter Data Validation Study Final Report State of Georgia

Page 3-6 GA2009-10_EDV_FinalRpt_F1_1210

RESULTS

Figure 3-8--Percentage of Encounters Processed in Georgia's Encounter Data System within 90 Days from the Date of Service
100%

80%

60%

40%

20%

0% Professional

Institutional

Pharmacy

Statewide AMERIGROUP Peach State WellCare

Source: Table C-8--Timeliness of Encounter Data Processing (Statewide), Appendix C Table C-9--Comparison of CMO Performance on Encounter Data Processing Timeliness, Appendix C

Further examination of the volume of encounters submitted by month provides additional insight into potential problems with the completeness of data. Figure 3-9 shows that for professional and institutional encounters, minimal variation in encounter data volume was noted at the statewide level during CY 2008. This monthly variation falls within an acceptable range. The drop in the volume of institutional encounters for May 2008 was due to the missing CMO identifiers in these encounters. If the CMO identifiers had been available, the volume for May 2008 would be comparable to that of April 2008. HSAG discussed this topic with DCH and found that this issue was likely related to how the institutional data were prepared for the study and was not reflective of the actual encounter data present in Georgia's encounter data system.
The monthly variation for pharmacy encounters was more notable than for the professional and institutional encounters. This may be related to two of the CMOs that exhibited more fluctuations in their pharmacy encounter volume between the first and second quarters of CY 2008.

Encounter Data Validation Study Final Report State of Georgia

Page 3-7 GA2009-10_EDV_FinalRpt_F1_1210

RESULTS

Figure 3-9--Monthly Variations of Statewide Encounters by Type 1,200,000

1,000,000

800,000

600,000

400,000
Volume (in thousands)
200,000

0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Professional

Institutional

Pharmacy

Source: Table C-10--Statewide Monthly Encounter Data Volume by Encounter Type, Appendix C

Medical Record Review
Although administrative analyses may provide insights on the state of encounter data quality in Georgia's encounter data system, medical record review remains the only method for a true and comprehensive assessment of encounter data completeness and accuracy. To accomplish the medical record review component of the study, HSAG used the professional encounter data file prepared by Georgia's data vendor and identified all Georgia Families members who met the study population requirements. For each CMO, HSAG analysts used random sampling to select 411 members for medical record review. Then, for each sampled member, HSAG randomly selected one EPSDT visit that took place during CY 2008. Each sampled EPSDT visit represented services performed by a single provider on a specific date of service for a specific member.
HSAG forwarded the sample list with member and provider information to each CMO for processing. Upon receipt of the sample, the CMOs worked with their providers to obtain a member's complete medical record that covered services provided during CY 2008. Only the member's medical record for the provider identified in the sample was required for submission; medical records from other providers visited by the member during the year were not requested. The CMOs requested all medical record components (e.g., progress notes, EPSDT visit forms, growth charts, history, and physicals) from the provider. The entire CY 2008 medical record was collected, thus giving the HSAG coders full access to select a second visit if available.

Encounter Data Validation Study Final Report State of Georgia

Page 3-8 GA2009-10_EDV_FinalRpt_F1_1210

RESULTS

Out of the original sample of 1,233 cases, 1,221 records were submitted by the CMOs for medical record review. Of the 12 records not submitted by the CMOs:
Six were not submitted due to provider refusal to release the records. Four were not submitted due to the provider being unable to locate the record. Two were not submitted due to the provider documenting on the procurement tracking form that
the member did not access care even though an electronic encounter was submitted.
All 12 cases remained in the analysis, since the encounter was submitted by the provider and the member met the eligibility requirements. (See Table C-11 in Appendix C.)

Completeness
HSAG evaluated encounter data completeness by identifying differences between the electronic encounter data and the members' medical records. Medical record omission and encounter data omission represent two aspects of encounter data completeness. Medical record omissions occurred when an encounter data element (i.e., date of service, diagnosis code, or procedure code) was not supported by documentation in a member's medical record. Medical record omissions suggest opportunities for improvement within the provider's internal processes, such as billing processes and record documentation by the providers. As determined during this review, the most common reasons for medical record omissions were:
The provider did not document the services performed in the medical record despite submitting a claim/encounter.
There was a data entry error for one or more elements (e.g., date of service). The medical record could not be located. The provider did not perform the service.
Encounter data omissions occurred when an encounter data element (i.e., date of service, diagnosis, or procedure) was found in a member's medical record, but was not listed in the electronic encounter data. The most common reasons for encounter data omissions were:
The provider's billing office made a coding error. DCH's encounter data systems contained certain restrictions related to encounter submission
requirements that affected the processing of some encounters (e.g., number of diagnosis or procedure code fields, requirements regarding resubmission of denied or rejected encounters). Different provider IDs were used when submitting the encounters. There was a lag between the time when the service was performed by the provider and the encounter was submitted to the CMOs and/or DCH.
After the coders validated the selected EPSDT date of service they randomly selected one additional EPSDT visit from the submitted medical record. If the HSAG coders did not find an additional EPSDT visit in the medical record, they selected any physician office visit. The coders used the electronic abstraction tool to check whether the documented date of service was also in the State's electronic encounter data file. They then coded the procedures and diagnoses based on the

Encounter Data Validation Study Final Report State of Georgia

Page 3-9 GA2009-10_EDV_FinalRpt_F1_1210

RESULTS

documentation in the medical record and evaluated whether the diagnoses and procedures documented for this selected date of service were submitted completely and accurately to the State's encounter data. Additional selected services from the members' medical records were evaluated against members' eligibility; services rendered when a member was ineligible for Medicaid were excluded from the analysis.
Date of Service Omission Rates
Figure 3-10 shows that statewide, 6.1 percent of the selected dates of service in the electronic encounter data were not found in members' medical records (i.e., medical record omission). Additionally, 20.5 percent of the dates of service identified in the medical records were not found in the electronic encounter data (i.e., encounter data omission). CMO-specific findings did not show any major variation for either the medical record or encounter data omission rates.
Figure 3-10--Medical Record and Encounter Data Omission Rates (Date of Service)

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Statewide

AMERIGROUP

Peach State

WellCare

Medical Record Omission

Encounter Data Omission

Source: Table C-12--Date of Service Medical Record Agreement and Omission Rates, Appendix C Table C-13--Date of Service Encounter Data Omission Rates, Appendix C

Diagnosis Code (ICD-9-CM) Omission Rates
Figure 3-11 shows that 13.3 percent of the selected diagnosis codes in the electronic encounter data were not found in members' medical records (i.e., medical record omission). Individual CMO rates indicated some variation with rates ranging from 8.6 percent (Peach State) to 15.8 percent (WellCare). Diagnosis codes most frequently identified in the electronic encounter data but not found in members' medical records included:

Encounter Data Validation Study Final Report State of Georgia

Page 3-10 GA2009-10_EDV_FinalRpt_F1_1210

RESULTS

V72.0 (examination of eye and vision). V72.19 (other examination of ears and hearing). V82.5 (screening for chemical poisoning and other contamination).
Figure 3-11--Medical Record and Encounter Data Omission Rates (Diagnosis Codes)

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Statewide

AMERIGROUP

Peach State

WellCare

Medical Record Omission

Encounter Data Omission

Source: Table C-14--Diagnosis Code Medical Record Omission and Encounter Data Omission Rates, Appendix C
Figure 3-11 also shows that the encounter data omission rates for diagnosis codes were much higher than the medical record omission rates for diagnosis codes. Overall, about half of the diagnosis codes (49.3 percent) identified in the medical records were not present in the electronic encounter data, with individual CMO rates ranging from 35.9 percent to 64.3 percent. These findings may have resulted from DCH billing guidelines in place during the measurement period. The diagnosis codes most frequently found in members' medical records but omitted from the electronic encounter data included:
V20.2 (routine infant or child health check).3-1 V05.3 (need for prophylactic vaccination and inoculation against viral hepatitis). V03.82 (need for prophylactic vaccination and inoculation against streptococcus pneumonia). V06.1 (need for prophylactic vaccination for diphtheria, tetanus, and pertussis [DTP/TDaP]). V05.4 (need for prophylactic vaccination and inoculation against varicella).

3-1 Based on HSAG's review of members' medical records, the diagnosis code V20.2 and V70.0 were used interchangeably. This practice is in agreement with DCH policy and procedures.

Encounter Data Validation Study Final Report State of Georgia

Page 3-11 GA2009-10_EDV_FinalRpt_F1_1210

RESULTS

These findings suggested that while data elements identified in the electronic encounter data were generally supported by members' medical records, the electronic encounter data were missing information on nearly half of the diagnosis codes documented in members' medical records. These findings may have been related to DCH policy and procedures that did not require providers to submit multiple diagnosis codes for vaccine administration.
Procedure Code (CPT-4) Omission Rates
Figure 3-12 shows that statewide, 21.5 percent of the selected procedure codes in the electronic encounter data were not found in members' medical records (i.e., medical record omission). Individual CMO rates indicated some variation with rates, ranging from 19.5 percent (WellCare) to 22.6 percent (Peach State). Procedure codes most frequently identified in the electronic encounter data but not found in members' medical records included:
99212 (evaluation/management, established outpatient, 10 minutes). 96110 (developmental testing, limited). 90633 (hepatitis A, adolescent). 99393 (established patient visits, late childhood years 5-11).
Figure 3-12--Medical Record and Encounter Data Omission Rates (Procedure Codes)

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Statewide

AMERIGROUP

Peach State

WellCare

Medical Record Omission

Encounter Data Omission

Source: Table C-15--Procedure Code Medical Record Omission and Encounter Data Omission Rates, Appendix C

Although somewhat lower than exhibited for diagnosis codes, the encounter data omission rates for procedure codes were still higher than the medical record omission rates for procedure codes.

Encounter Data Validation Study Final Report State of Georgia

Page 3-12 GA2009-10_EDV_FinalRpt_F1_1210

RESULTS
Figure 3-12 shows that statewide, 40.1 percent of the procedure codes identified in the medical records were not present in the electronic encounter data. Encounter data omission rates were similar across the CMOs. The procedure codes most frequently found in members' medical records but omitted from the electronic encounter data included:
90472 (vaccine administration code without counseling > 8 years). 90471 (vaccine administration code without counseling < 8 years). 90473 (administrative services associated with intranasal vaccine).
These findings suggested that while encounter data elements identified in the electronic encounter data were generally supported by members' medical records, the electronic encounter data were missing information on 40.1 percent of the procedure codes documented in members' medical records. However, these rates may have been affected by DCH billing policy and procedures since these codes do not represent billable services.
Encounter Data Accuracy
For encounter data accuracy, HSAG considered the encounter data elements (i.e., diagnosis code and procedure code) correct if documentation in the medical record supported the codes contained in the electronic encounter data. During the medical record review, HSAG coders evaluated diagnosis and procedure codes from the electronic encounter data and identified discrepancies based on documentation in the members' medical records. The three most common reasons for errors in coding were:
Documentation in the medical record did not support the code. There were specificity errors for diagnosis codes. Procedure codes submitted for the selected date of service reflected a higher or lower level of
service than the services documented in the medical record.
Specificity errors occur when a provider submits an encounter that has a diagnosis code without the required fourth or fifth digit. For example, a diagnosis code of 410 (heart attack) should include fifth-digit specificity, such as 410.01, to indicate which part of the heart was affected and if the heart attack was the first episode. Providers can prevent specificity errors with updated claims processing software. Health plans and states can prevent specificity errors by requiring providers to submit claims using full specificity, when necessary.
Overall, HSAG found that when the diagnosis and procedure codes were present in both the electronic encounter data and medical record, the submitted codes were accurate. Figure 3-13 shows that the accuracy rates for both diagnosis and procedure codes were above 90 percent.

Encounter Data Validation Study Final Report State of Georgia

Page 3-13 GA2009-10_EDV_FinalRpt_F1_1210

RESULTS

100%

Figure 3-13--Diagnosis and Procedure Accuracy Rates

90%

80%

70%

60%

50% Statewide

AMERIGROUP

Peach State

WellCare

Diagnosis Accuracy Procedure Accuracy

Source: Table C-16--Diagnosis Coding Accuracy Rates and Types of Error, Appendix C Table C-17--Procedure Coding Accuracy Rates and Types of Error, Appendix C

For diagnosis coding, the majority of errors were associated with discrepancies between submitted codes and national coding standards rather than specificity errors. In general, accuracy errors resulted from inadequate documentation in the medical record to support a given diagnosis code.
For procedure coding, 54 percent of the identified errors resulted from providers submitting a higher level procedure code for services performed than was supported and documented in the medical records. While these findings suggested some degree of "up-coding" on the part of physicians, the impact was relatively small.
EPSDT Component Completion
In order for providers to submit an encounter with a DCH-approved EPSDT procedure code (i.e., 9938199385 or 9939199395), they must perform all required EPSDT components and document the services in the medical record. Figure 3-14 shows that 10.6 percent of the EPSDT visits evaluated had all required components documented in the members' medical records. Although several individual EPSDT components exhibited very high completion rates (i.e., Initial/Interval History, Physical Examination, and Developmental/Behavioral Surveillance), four had rates below 50 percent. These lower rates, compared to the rates for the other individual EPSDT components, may be due to the requirement that the provider plot the measurements on a height and weight

Encounter Data Validation Study Final Report State of Georgia

Page 3-14 GA2009-10_EDV_FinalRpt_F1_1210

RESULTS
growth chart for a positive response on the documentation of height and weight. This requirement also applied to the documentation of head circumference and body mass index.
Figure 3-14--Statewide EPSDT Component Completion Rates

Source: Table C-18--Statewide EPSDT Component Completion Rates, Appendix C
The Bright Futures guidelines required EPSDT providers to document several EPSDT components (e.g., height, weight, head circumference, and body mass index) on a growth chart. Since its implementation on July 1, 2008, the statewide EPSDT component completion rate has improved from 8.6 percent to 12 percent.3-2 Following implementation, notable increases in the documentation of height, weight, and head circumference were identified. Although the increases were not substantial, this finding reflected providers' increased adherence to the Bright Future guidelines.

3-2 Findings of the comparison of the statewide EPSDT Component Completion Rates before and after the Bright Future Guidelines implementation are found in Table C-19 in Appendix C.

Encounter Data Validation Study Final Report State of Georgia

Page 3-15 GA2009-10_EDV_FinalRpt_F1_1210

4. Discussion

Discussion and Conclusions
Analyses of Electronic Encounter Data Findings
Based on the analyses of electronic encounter data, HSAG found that most encounters submitted to Georgia's encounter data system contained reasonable and accurate values in critical fields. While some fields exhibited minor data issues in four critical data fields (e.g., provider ID), 13 of the 17 critical data fields contained accurate and reasonable values in more than 95 percent of the professional encounters and institutional encounters. Additionally, at least 95 percent of the professional and institutional encounters with age/gender-specific diagnosis or procedure codes were appropriately coded according to the patient's age and/or gender.
CMOs also submitted their encounters timely and consistently to DCH. Although there is no specific timeliness requirement for encounter data submissions4-1, 55.8 percent of professional encounters, 60.1 percent of institutional encounters, and 70.6 percent of pharmacy encounters were processed in the State's encounter data system within 90 days of the dates of service. Additionally, the distribution of encounter submissions on a monthly basis was in alignment with general expectations for the time period.
Medical Record Review Findings
Based on the cases sampled for medical record review, HSAG found that the encounters submitted to DCH were generally supported by documentation in members' medical records. Statewide, 93.9 percent of the dates of service identified in the electronic encounter data were found in the medical record. Overall, 86.7 percent of diagnosis codes and 78.5 percent of procedure codes identified in the electronic encounter data were found in members' medical records. These findings suggested a moderately high level of completeness among key encounter data fields when compared to members' medical records.
Although encounters submitted by the providers to DCH generally had supporting documentation in the medical records, not all services documented in the medical records were submitted to DCH (encounter data omission). For instance, 20.5 percent of the dates of service documented in the members' medical records were absent from the electronic encounter data. There is an opportunity to improve the completeness of DCH's electronic encounter data by increasing the percentage of diagnosis and procedure codes submitted to the electronic encounter data system to better align with what is found in the medical records.

4-1 Based on a review of the Georgia Families CMO Encounter Data Submission Policies and Procedures document (revised March 2, 2009), timeliness requirements were applied to the resubmission of rejected encounters. There was no explicit timeliness requirement for initial encounter submission.

Encounter Data Validation Study Final Report State of Georgia

Page 4-1 GA2009-10_EDV_FinalRpt_F1_1210

DISCUSSION
The results from the medical record omission and encounter data omission analyses illustrate some discrepancies in the completeness of Georgia's electronic data. Although the discrepancies were not extensive, the results suggested that in CY 2008, some services performed were not incorporated into Georgia's encounter data system. A review of the Georgia Families requirements for encounter data submission suggested that although the CMOs were expected to submit encounters denied or unpaid by their systems, they were not required to submit certain denied claims (e.g., those with missing/incomplete data, duplicate procedures on same date of service, and ineligibility of the member). The policies also did not require the CMOs to correct and resubmit denied encounters that received a rejection or denied disposition in the encounter rejection reports. As such, it is possible that some of the omissions noted in this analysis resulted from the CMOs' different practices in submitting encounters that were unpaid or denied by their own systems.
HSAG found that the diagnosis and procedure codes submitted to Georgia's encounter data system were generally accurate. Overall, 92.3 percent of diagnosis codes and 96.1 percent of procedure codes identified in the electronic encounter data were supported by medical record documentation. However, these rates may have been affected by DCH billing policy and procedures. These overall findings showed that less than 10 percent of the diagnosis and procedure codes in Georgia's electronic encounter data were inaccurate. The majority of diagnosis-related errors involved discrepancies in the use of certain codes compared to national coding standards instead of specificity errors. More than half of the incorrect procedure codes involved submitting a higherlevel service code than was supported in the members' medical records.
Finally, HSAG found that Georgia providers documented many of the required EPSDT components in medical records, with initial/interval history, physical examination, and developmental/behavioral surveillance exhibiting very high completion rates. Nonetheless, only 10.6 percent of the EPSDT visits had all the age-appropriate components documented. The least-documented components included body mass index, head circumference, and height and weight. With the implementation of the Bright Futures guidelines, the statewide EPSDT component completion rates increased 3.4 percentage points compared to prior time period. However, these results still indicated considerable room for improvement.
Recommendations
Based on the analyses of electronic encounters, the overall quality of the encounter data submitted by Georgia Families' CMOs was considered complete and accurate. These encounters were also submitted in a timely manner. While HSAG identified a few data concerns, these issues appear to have been the product of the data extraction process used by DCH's data vendor in preparing the data files for this study. More importantly, based on encounter data quality activities undertaken by DCH since 2009, the data issues identified in this study no longer appear to be reflective of the current quality of encounter data.
Results from the medical record review suggested that while submitted encounters (including diagnosis and procedure codes) were generally supported by members' medical records, opportunities for improvement were noted for the submission of complete and accurate encounters to DCH. Additional opportunities for improvement were noted in the documentation of EPSDT

Encounter Data Validation Study Final Report State of Georgia

Page 4-2 GA2009-10_EDV_FinalRpt_F1_1210

DISCUSSION
visits, since only 10.6 percent of EPSDT visits contained documentation that all the required components were completed. Based on these findings, HSAG recommends the following:
DCH should continue its efforts to monitor encounter data submissions and address any identified data issues with CMO encounter file submissions. The few data concerns that emerged from the analyses of encounter data may be related to factors such as possible errors in the data file extracted by the vendor and used for this study, incorrect or infrequent updates of data files within the MMIS system, inconsistent updates and populations of data values across different files within the MMIS, inconsistent implementation of system edits on submitted encounters, and incomplete or inconsistent encounter submission by the CMOs on required fields. In evaluating the nature of these issues, HSAG reviewed several encounter data quality reports compiled by Myers and Stauffer for the State of Georgia. Based on its review and on discussions with DCH and Myers and Stauffer, HSAG found that many of the data issues identified in this study have since been addressed through the State's ongoing efforts to improve the overall quality of submitted encounters. Since January 2009, DCH and its contractor, Myers and Stauffer, have consistently worked with the CMOs to ensure that submitted encounters are complete and accurate. More specifically, DCH requires CMOs to have at least 99 percent of their cumulative encounters submitted monthly to the Medicaid Management Information System. Myers and Stauffer also provide monthly raw encounter data files to the CMOs for review and reconciliation. Recognizing that the current approach appears to provide an effective and efficient process to monitor encounter data quality and identify data issues, HSAG recommends that DCH continue its current process and approach to ensuring high-quality encounter data submission.
DCH should consider requiring the CMOs to audit provider encounter submissions for completeness and accuracy. DCH should share the EDV findings with the CMOs and require them to develop periodic provider education and training regarding encounter data submission, documentation, and coding practices. These activities should include a review of the EPSDT requirements, especially for new providers contracted with the CMOs. In addition, HSAG recommends that the CMOs consider performing periodic reviews of submitted claims to verify appropriate coding. DCH should consider requiring the CMOs to report this information as part of the Georgia Families contract to maintain good encounter data quality.
DCH should work with the CMOs to explore the reasons for incomplete encounter data
submissions based on medical record review results and develop strategies to improve rates. Since maintaining good encounter data quality is a responsibility involving multiple organizational entities--including the State, the CMOs, and the providers--HSAG recommends that DCH work with the CMOs to explore the reasons for relatively high encounter data omission rates. DCH should ensure that there are no system issues that impact the acceptance of encounter data submitted by the CMOs. DCH may also want to consider revisiting the impact of not requiring the CMOs to submit encounters denied for missing/incomplete data, since this may have contributed to the reported omission rates. Based on monthly encounter submission and rejection reports, DCH also may want to consider expanding current performance goals or standards regarding encounter data submission and quality. Evaluation of CMO compliance with these performance goals can be accomplished either through an independent encounter data validation study or CMO self-reporting of medical record review. Future encounter data validation studies, whether conducted by the State or the CMOs, could involve evaluating the

Encounter Data Validation Study Final Report State of Georgia

Page 4-3 GA2009-10_EDV_FinalRpt_F1_1210

DISCUSSION
extent to which the omitted encounters are denied or are unpaid by the CMOs through a review of the CMOs' claim processing and adjudication system.
The CMOs should perform a root-cause analysis to identify barriers affecting the performance or documentation of required EPSDT components during office visits and develop a corrective action plan to address identified deficiencies. The EPSDT component completion rates showed wide variations in providers' documentation of each EPSDT component. This finding resulted in a low overall component completion rate of 10.6 percent. A root-cause analysis would identify potential barriers from which the CMOs should develop interventions to improve the documentation rate of the EPSDT components. Improvement activities should also consider educational outreach to providers and office staff members on the requirement to plot body mass index, weight, height, and head circumference.

Encounter Data Validation Study Final Report State of Georgia

Page 4-4 GA2009-10_EDV_FinalRpt_F1_1210

Appendix A. Data Abstraction Tool

Encounter Data Validation Study Final Report State of Georgia

Page A-1 GA2009-10_EDV_FinalRpt_F1_1210

DATA ABSTRACTION TOOL

Encounter Data Validation Study Final Report State of Georgia

Page A-2 GA2009-10_EDV_FinalRpt_F1_1210

DATA ABSTRACTION TOOL

Encounter Data Validation Study Final Report State of Georgia

Page A-3 GA2009-10_EDV_FinalRpt_F1_1210

DATA ABSTRACTION TOOL

Encounter Data Validation Study Final Report State of Georgia

Page A-4 GA2009-10_EDV_FinalRpt_F1_1210

Appendix B. Methodology Specifications Tables

The following tables provide detailed information and analysis specifications outlined in Section 2 (Overview and Methodology) of this report.

Table B-1--Valid Ranges or Values for the Data Field Completeness Analyses

Analyses Applied to

Field Member ID

Format Character

Valid Ranges or Values
State-supplied eligibility/enrollment file

Professional Encounters


Institutional Encounters


Provider ID

Character

State-supplied provider file





Principal/Primary Diagnosis

Character ICD-9 Manual





Additional Diagnoses Character ICD-9 Manual





Procedure Codes

Character

CPT and HCPCS Manual





Revenue Codes

Character 0001999X



Service From Date

Date

01/01/2008 12/31/2008





Service To Date

Date

01/01/2008 12/31/2008





Paid Date

Date 01/01/2008





Hospital Admission Date

Character

01/01/2008 12/31/2008



Hospital Discharge Date

Character 01/01/2008



Encounter Data Validation Study Final Report State of Georgia

Page B-1 GA2009-10_EDV_FinalRpt_F1_1210

METHODOLOGY SPECIFICATIONS TABLES

Table B-2--Age- and Gender-Specific Diagnoses/Procedures for the EDV Study

Description Diseases of male genital organs

ICD-9 600608

CPT-4

Criteria Male

Anomalies of male organs

752.5752.9

Male

Inflammatory disease of female pelvic organs Other disorders of female genital tract Complications of pregnancy, childbirth Anomalies of female organs

614616 617 629 630677 752.0752.4

Female Female Female Female

Normal pregnancy

V22.0V22.2

Female

High-risk pregnancy Postpartum Male genital system

V23.0V23.9 V24.0V24.2

5400055899

Female Female Male

Female genital system

5640558999 Female

Maternity care and delivery Child exam

V20V21

5900059899

Female Age < 18

Routine general medical exam Infant Early childhood 14 years

V70.0

99381/99391 99382/99392

Age 18 Age < 1 Age 14

Late childhood 511 years

99383/99393 Age 511

Adolescent 1217 years Adult 1839 years Adult 4064 years

99384/99394 99385/99395 99386/99396

Age 1217 Age 1839 Age 4064

Encounter Data Validation Study Final Report State of Georgia

Page B-2 GA2009-10_EDV_FinalRpt_F1_1210

METHODOLOGY SPECIFICATIONS TABLES

Table B-3--Place of Service Code for Professional Encounters

Value 11

Office

Description

Category Office visits

12

Home

Home visits

20

Urgent Care Facility

21

Inpatient Hospital

22

Outpatient Hospital

23

ER--Hospital

Facility-based visits

24

Ambulatory Surgical Center

41

Ambulance

Ambulance

50

Federally Qualified Health Center

Health center/clinic

53

Community Mental Health Center

71

Public Health Clinic

72

Rural Health Clinic

81

Independent Laboratory

Laboratory

Table B-4--Type of Bill Codes for Institutional Encounters

Value 11X

Description Inpatient Hospital

13X

Outpatient Hospital

2XX

Skilled Nursing Facility

Clinic (includes rural health clinic, hospital-based

clinic, independent renal dialysis center,

7XX

freestanding clinic, clinic at outpatient

rehabilitation facility, and community mental

health center)

8XX

Special Facility or Ambulatory Surgical Center

Encounter Data Validation Study Final Report State of Georgia

Page B-3 GA2009-10_EDV_FinalRpt_F1_1210

Appendix C. Detailed Results Tables and Notes
The following tables present detailed results from the electronic encounter data analysis component of the study. Occasionally, HSAG provided notes to describe the background for a particular analysis.

Analysis of Electronic Encounters

Table C-1--Encounters Included in the Administrative Analyses

Claim Type Statewide Total1 AMERIGROUP Peach State

Professional2

9,267,0264

2,214,245

2,433,228

WellCare 4,619,5534

Institutional3

1,420,619

270,410

457,760

692,449

Pharmacy

9,067,164

1,429,798

2,437,400

5,199,966

1 Some files received from DCH's data vendor contained records with no CMO identifier. Therefore, the statewide total reported on the first result panel may not be equal to the sum of the CMO encounter volumes. More specifically, 133,379 institutional encounters and 12,562 pharmacy encounters did not have a CMO identifier.
2 Professional encounters with the following place-of-service codes were included in the analyses: 11-Office, 12-Home, 20-Urgent Care Facility, 21-Inpatient Hospital, 22-Outpatient Hospital, 23-ER-Hospital, 24-Ambulatory Surgical Center, 41-Ambulance, 50-Federally Qualified Health Center, 53-Community Mental Health Center, 71-Public Health Clinic, 72-Rural Health Clinic, and 81-Independent Laboratory. At the statewide level, the professional encounters included in this study represented 92 percent of all professional encounters during the study period (i.e., with date of service between January 1, 2008, and December 31, 2008). Please note that place of service "99" (Other Unlisted Facility) was not included in these analyses.
3 Institutional encounters with the following type-of-bill values were included in the analyses: 11X-Inpatient Hospital, 13X-Outpatient Hospital, 2XX-Skilled Nursing Facility, 7XX-Clinic, 8XX-Special Facility. The institutional encounters included in this study represented 87 percent of all institutional encounters.
4 WellCare had 657 encounters with CLM_TCN populated with more than one place-of-service code; therefore, the sum total of all encounters, if categorized by place of service, would have been greater than the reported values. For WellCare, the sum total would be 4,620,210 and the statewide total would be 9,267,683.

Note: WellCare's membership was approximately two times the size of Peach State's and AMERIGROUP's. As such, it is expected that its overall number of encounters would be higher than the other CMOs.

Encounter Data Validation Study Final Report State of Georgia

Page C-1 GA2009-10_EDV_FinalRpt_F1_1210

DETAILED RESULTS TABLES AND NOTES

Table C-2--Utilization of Services

Statewide Total AMERIGROUP

Peach State

WellCare

Overview
Average number of members Total member months1
Total number of all encounters All encounters PMPY2

949,116 11,389,386 19,754,809
20.8

202,171 2,426,047 3,914,453
19.4

283,333 3,399,998 5,328,388
18.8

463,639 5,563,666 10,511,968
22.7

Professional Utilization3
Total number of professional encounters Professional encounters PMPY
Institutional Utilization4
Total number of institutional encounters Institutional encounters PMPY

9,267,026 9.8
1,420,619 1.5

2,214,245 11.0
270,410 1.3

2,433,228 8.6
457,760 1.6

4,619,553 10.0
692,449 1.5

Pharmacy Utilization
Total number of pharmacy encounters Average prescriptions PMPY

9,067,164 9.6

1,429,798 7.1

2,437,400 8.6

5,199,966 11.2

1 HSAG identified that some enrollment segments for certain members overlapped with different CMOs. As such, the total number of member months from each CMO will not sum to those in the Statewide Total column.
2 The measure, all encounters per member per year (PMPY), was calculated by dividing the total number of encounters by the average number of members.
3 Major place-of-service groups included office, home, facility-based settings, ambulance, health center/clinic, and laboratory. The number of encounters PMPY was reported for each group separately in Table C-3.
4 Major type-of-bill groups included inpatient hospital, outpatient hospital, skilled nursing facility, clinic, and special facility. The number of encounters PMPY is reported for each group separately in Table C-3.

Encounter Data Validation Study Final Report State of Georgia

Page C-2 GA2009-10_EDV_FinalRpt_F1_1210

DETAILED RESULTS TABLES AND NOTES

Table C-3--Utilization of Services by Place of Services (for Professional Encounters) or Type of Bill (for Institutional Encounters)

Statewide Total AMERIGROUP Peach State

WellCare

Professional Utilization
Total number of encounters (Encounters PMPY)1
Office visits

9,267,026 (9.8) 5,917,355 (6.2)

2,214,245 (11.0) 2,433,228 (8.6) 4,619,553 (10.0) 1,501,941 (7.4) 1,512,260 (5.3) 2,903,154 (6.3)

Home visits

137,517 (0.1)

28,481 (0.1)

42,114 (0.1)

66,922 (0.1)

Facility-based visits2

2,052,702 (2.2) 420,333 (2.1) 589,650 (2.1) 1,042,719 (2.2)

Ambulance

36,273 (0.04)

5,755 (0.03) 15,174 (0.05) 15,344 (0.03)

Health center/clinic3

569,280 (0.6)

148,441 (0.7) 102,006 (0.4) 318,833 (0.7)

Laboratory

554,556 (0.6)

109,294 (0.5) 172,024 (0.6) 273,238 (0.6)

Institutional Utilization
Total number of encounters (Encounters PMPY)1
Inpatient Hospital

1,420,619 (1.5) 160,159 (0.2)

270,410 (1.3) 27,545 (0.1)

457,760 (1.6) 49,186 (0.2)

692,449 (1.5) 83,428 (0.2)

Outpatient Hospital

1,216,192 (1.3) 239,009 (1.2) 385,435 (1.4) 591,748 (1.3)

Skilled Nursing Facility

2,809 (0.003)

9 (0.00004)

5 (0.00002)

2,795 (0.006)

Clinic4

28,735 (0.03)

895 (0.004)

20,403(0.07)

7,437 (0.02)

Special Facility or Ambulatory Surgical Center

12,724 (0.01)

2,952 (0.01)

2,731 (0.01)

7,041 (0.02)

1 The total number of encounters for each category is reported first. The value reported within the parentheses refers to PMPY encounters for the services under the specific category.
2 This category includes professional visits provided at urgent care facilities, inpatient hospitals, outpatient hospitals, emergency room at the hospital, and ambulatory surgical centers.
3 This category includes professional visits provided at Federally Qualified Health Centers, community mental health centers, public health clinics, and rural health clinics.
4 This category includes rural health clinics, hospital-based clinics, independent renal dialysis centers, free standing clinics, clinics at outpatient rehabilitation facilities, and community mental health centers.

Encounter Data Validation Study Final Report State of Georgia

Page C-3 GA2009-10_EDV_FinalRpt_F1_1210

DETAILED RESULTS TABLES AND NOTES

Table C-4 shows the results for professional encounter file completeness. Results in the "% Present" column show to what extent a particular data field was submitted with values (field completeness). Results in the "% Valid" column report whether the submitted values were reasonable. The reporting unit for all "% Present" results was based on the number of encounters, unless noted otherwise in the table.

Table C-4--Summary of Professional Encounter File Completeness

Statewide Total

AMERIGROUP

Peach State

WellCare

% Present % Valid % Present % Valid % Present % Valid % Present % Valid

Member ID1 Provider ID2 Service From Date3 Service To Date3 Primary Diagnosis4

100% 99.8% 100% 100% 88.5%

99.2% 86.6% 98.7% 98.7% 99.9%

Required Fields

100%

99.7%

99.4%

83.7%

100%

99.5%

100%

99.5%

85.2%

99.8%

100% 99.9% 100% 100% 89.9%

99.8% 90.1% 99.7% 99.7% 99.9%

100% 99.9% 100% 100% 89.3%

98.7% 86.1% 97.7% 97.7% 99.9%

Procedure Code 100% >99.9% 100% >99.9% 100% >99.9% 100%

100%

Paid Date 100%

99.9% 100%

100%

100%

99.9%

100%

99.7%

Optional Fields

Additional

6.8%

99.8% 27.1%

99.8%

0%

Diagnosis 14

--

0.6%

99.9%

Additional

2.7%

99.9% 11.0%

99.9%

0%

Diagnosis 24

--

0.1%

99.9%

Additional

1.1%

99.9%

4.5%

99.9%

0%

Diagnosis 34

--

<0.1%5 99.6%

1 Results under the "% Valid" columns were based on the total number of encounters in which the submitted member ID in the claims

file was also present in the demographic file. 2 Results under the "% Valid" columns were based on the total number of encounters in which the submitted provider ID in the claims

file was also present in the provider file. Although more than 99 percent of the encounters were submitted with a provider ID, the

statewide percent-valid rate for this field was 86.6 percent. Based on a review of the Georgia Families encounter data submission

policies, the CMOs are required to make sure that provider IDs match the State's provider files. Further communication with DCH in

March 2010 suggested that the slightly lower percent-valid rate was related to the fact that updates in the State's provider file may not

occur as frequently as they do in encounter files. Please note that the last character of the provider ID was removed before matching it

with the identifiers in the provider file. If the last character was not removed, the statewide "% Valid" rate would be reduced to 46.6

percent, with CMO variation ranging from 32.6 percent to 56.1 percent.

3 A total of 1,816 encounters were populated with Member ID "000000000." Therefore, results under the "% Valid" columns were based

on the total number of encounters with valid member IDs. 4 Results presented were based on the total number of professional encounters, including dental encounters. When dental encounters

were excluded, the "% Present" rates for statewide and all CMOs were 99.9 percent. 5 Actual percentage was 0.024 percent.

Encounter Data Validation Study Final Report State of Georgia

Page C-4 GA2009-10_EDV_FinalRpt_F1_1210

DETAILED RESULTS TABLES AND NOTES

Table C-5--Summary of Institutional Encounter File Completeness

Statewide Total

AMERIGROUP

Peach State

WellCare

% Present % Valid % Present % Valid % Present % Valid % Present % Valid

Member ID 100%

99.2%

Required Fields 100% 99.8%

100%

99.9%

100%

98.5%

Provider ID Admit Date Discharge Date

100% 100% 100%

82.5% 89.7%1 100%2

100% 100% 100%

93.2% 84.0% 100%

100% 100% 100%

97.3% 82.2% 100%

100% 100% 100%

68.6% 96.8% 100%

Paid Date 100%

99.9%

100%

99.9%

100%

100%

100%

99.8%

Service From Date3
Service To Date3

100% 100%

98.7% 98.6%

100% 100%

99.8% 99.7%

100% 100%

99.9% 99.8%

100% 100%

97.5% 97.4%

Primary Diagnosis
Procedure Code

99.9% 53.4%

>99.9% 37.4%

100% 70.9%

>99.9% 54.8%

100% 64.9%

>99.9% 52.6%

99.9% 40.0%

>99.9% 20.5%

Revenue Center Code

100%

100%

100%

100%

100%

100%

100%

100%

Optional Fields

Additional Diagnosis 1

54.9%

>99.9%

60.1%

>99.9%

51.9%

>99.9%

54.8%

>99.9%

Additional Diagnosis 2

18.8%

>99.9%

29.3%

>99.9%

0.1%

100% 27.0% >99.9%

Additional Diagnosis 3

9.4%

>99.9% 14.5% >99.9%

0.1%

100% 13.6% >99.9%

Additional 4.9%

>99.9%

7.5%

>99.9% 0.04%

100%

7.2%

>99.9%

Diagnosis 4

1 All but 96 of the approximately 147,000 invalid encounters had a date value of 1/1/0001 in the Admit Date field. Additionally,

values reported in the Admit Date field came in different date formats (i.e., dd-mm-yy or dd/mm/yyyy). For the encounters

submitted with a dd-mm-yy format, HSAG could not ascertain whether the "01" under the yy portion of the date referred to 2001 or

0001, the latter of which is obviously an invalid value.

2 Although all the encounters had a valid date format with a reasonable date, 18 percent (n=256,053) had a date value of 01-JAN-

2001. For encounters having this value in the Discharge-Date field, only 29.7 percent had a date in the Admit Date field that

appeared to occur before or on this date. Since HSAG could not confirm that the validity of the value was related to different date

format, the percentages reported for each CMO should be interpreted with caution.

3 HSAG determined reasonableness for the Service-From-Date and Service-To-Date fields by assessing whether the submitted

dates were within the study period.

Encounter Data Validation Study Final Report State of Georgia

Page C-5 GA2009-10_EDV_FinalRpt_F1_1210

DETAILED RESULTS TABLES AND NOTES

Table C-6--Age- and Gender-Appropriate Professional Encounters

Valid Encounters

Diagnosis/Service Examined Age-Appropriate Diagnoses
Child exam Routine general medical exam

Number of Professional Encounters
Examined
275,085
263,132
11,953

Number 267,887 261,302
6,585

Percentage 97.4% 99.30% 55.1%1

Age-Appropriate Services Infant Early childhood, 14 years Late childhood, 511 years Adolescent, 1217 years Adult, 1839 years Adult, 4064 years

459,797 185,354 141,235 79,212 42,104 10,495
1,397

450,113 181,815 138,581 77,140 41,125 10,117
1,335

97.9% 98.10% 98.10% 97.40% 97.70% 96.40% 95.60%

Gender-Appropriate Diagnoses Diseases of male genital organs Anomalies of male organs Inflammatory disease of female pelvic organs Other disorders of female genital tract Complications of pregnancy, childbirth Anomalies of female organs Normal pregnancy High-risk pregnancy Postpartum

642,789 24,697 6,950 63,746 138,247 407,956 1,193 275,277 19,082 21,550

641,587 24,219 6,784 63,646 138,077 407,690 1,171 275,241 19,072 21,545

99.8% 98.10% 97.60% 99.80% 99.90% 99.90% 98.20% 100.00% 99.90% 100.00%

Gender-Appropriate Services Male genital system Female genital system Maternity care and delivery

192,853 27,885 43,911 121,057

191,766 26,854 43,880 121,032

99.4% 96.30% 99.90% 100.00%

Total

1,886,433

1,867,211

99.00%

1 Fifty-five percent of encounters submitted with V70.0 were associated with encounters for patients 18 years of age or older. When the age criterion was lowered to 12 years of age or older, the percentage was reported as 85 percent.

Encounter Data Validation Study Final Report State of Georgia

Page C-6 GA2009-10_EDV_FinalRpt_F1_1210

DETAILED RESULTS TABLES AND NOTES

Table C-7--Age- and Gender-Appropriate Institutional Encounters

Valid Encounters

Diagnosis/Service Examined Age-Appropriate Diagnoses
Child exam Routine general medical exam Age-Appropriate Services2 Infant Early childhood 1-4 years Late childhood 5-11 years Adolescent 12-17 years Adult 18-39 years Adult 40-64 years

Number of Institutional Encounters Examined
19,445 18,675
770
41 9 4 3 2 14 9

Number 19,033 18,619
414
39 9 4 2 1 14 9

Percentage 97.9% 99.70% 53.8%1
95.1% 100.00% 100.00% 66.70% 50.00% 100.00% 100.00%

Gender-Appropriate Diagnoses

277,711

277,513

99.9%

Diseases of male genital organs

5,052

5,010

99.20%

Anomalies of male organs Inflammatory disease of female pelvic organs

1,939 11,703

1,904 11,689

98.20% 99.90%

Other disorders of female genital tract

30,583

30,546

99.90%

Complications of pregnancy, childbirth Anomalies of female organs Normal pregnancy High-risk pregnancy Postpartum

184,935 222
34,761 6,013 2,503

184,882 221
34,750 6,012 2,499

100.00% 99.50% 100.00% 100.00% 99.80%

Gender-Appropriate Services Male genital system Female genital system Maternity care and delivery

3,280 251 726 2,303

3,275 248 725 2,302

99.8% 98.80% 99.90% 100.00%

Total

300,477

299,860

99.80%

A certain number of claims/encounters in these categories contained more than one date in the Service From Date field.
Therefore, separate episodes were counted for these claims. 1 It was reported that 53.8 percent of encounters submitted with V70.0 were associated with encounters for patients 18 years of age
or older. When the age criterion was lowered to 12 years of age or older, the percentage was reported as 74 percent. 2 Since the number of encounters reported for services under this category was fewer than 30, any interpretation of the identified
patterns would lack scientific rigor. There are not enough observations to confidently draw reliable conclusions.

Encounter Data Validation Study Final Report State of Georgia

Page C-7 GA2009-10_EDV_FinalRpt_F1_1210

DETAILED RESULTS TABLES AND NOTES

Table C-8--Timeliness of Encounter Data Processing (Statewide)

Less Than 30 Days

Professional

Institutional

Pharmacy

Number

Percentage Number Percentage Number

of Total

of Total

Percentage of Total

1,697,332

18.3%

239,669

16.9%

348,775

3.9%

3160 Days

2,125,964

22.9%

390,707

27.5% 4,302,051 47.5%

6190 Days 91120 Days

1,355,646 978,441

14.6% 10.6%

222,701 169,044

15.7% 11.9%

1,742,332 521,097

19.2% 5.8%

121180 Days

1,175,427

12.7%

165,670

11.7%

715,565

7.9%

Greater Than 180 Days 1,934,216

20.9%

232,828

16.4% 1,437,344 15.9%

Total

9,267,026 100.0% 1,420,619 100.0% 9,067,164 100.0%

Encounter Data Validation Study Final Report State of Georgia

Page C-8 GA2009-10_EDV_FinalRpt_F1_1210

DETAILED RESULTS TABLES AND NOTES

Table C-9--Comparison of CMO Performance on Encounter Data Processing Timeliness

Professional Encounters 30 Days or Less 3160 Days 6190 Days 91120 Days 121180 Days Greater Than 180 Days

AMERIGROUP % of Total

Peach State % of Total

42.9% 21.0% 8.8% 5.2% 8.2% 13.9%

15.1% 29.1% 13.5% 11.3% 16.0% 15.1%

Total Institutional Encounters 30 Days or Less 3160 Days 6190 Days 91120 Days 121180 Days Greater Than 180 Days

100.0%
52.3% 29.8% 5.1% 2.7% 3.4% 6.7%

100.0%
13.7% 26.7% 13.4% 11.4% 17.1% 17.7%

Pharmacy Encounters Less Than 30 Days 3160 Days 6190 Days 91120 Days 121180 Days Greater Than 180 Days

Total

100.0%
5.2% 25.1% 10.1% 5.0% 30.3% 24.3%

100.0%
2.1% 38.1% 18.2% 7.4% 3.8% 30.3%

Total

100.0%

100.0%

WellCare % of Total
8.3% 20.6% 18.0% 12.8% 13.1% 27.3% 100.0%
5.1% 27.2% 21.3% 15.8% 11.3% 19.3% 100.0%
4.3% 58.0% 22.2% 5.2% 3.6% 6.8% 100.0%

Encounter Data Validation Study Final Report State of Georgia

Page C-9 GA2009-10_EDV_FinalRpt_F1_1210

DETAILED RESULTS TABLES AND NOTES

Table C-10--Statewide Monthly Encounter Data Volume by Encounter Type

Month

Professional

Institutional

Pharmacy

Jan 2008

812,316

128,256

770,060

Feb 2008

811,504

140,406

952,979

Mar 2008

788,712

132,317

894,457

Apr 2008

759,860

126,798

863,528

May 2008

709,371

1,972

688,044

Jun 2008

663,393

116,213

584,827

Jul 2008

738,702

124,919

588,727

Aug 2008

763,881

133,453

678,789

Sep 2008

788,444

125,865

710,939

Oct 2008

841,042

132,625

790,522

Nov 2008

772,755

124,570

752,814

Dec 2008

817,046

133,225

791,478

Encounter Data Validation Study Final Report State of Georgia

Page C-10 GA2009-10_EDV_FinalRpt_F1_1210

DETAILED RESULTS TABLES AND NOTES

The following section presents detailed results tables from the medical record review component of the study.

Medical Record Review

CMO
AMERIGROUP Peach State WellCare Statewide

Table C-11--Record Submission Rates

Initial Sample Size
(n)
411

Valid Exclusions
0

Adjusted Sample Size
411

Number of Records Submitted
409

411

0

411

0

411

411

411

401

1,233

0

1,233

1,221

Percentage of Records Submitted 99.5%
100.0%
97.6%
99.0%

Table C-12--Date of Service Medical Record Agreement and Omission Rates

Medical Record Agreement Medical Record Omission

CMO AMERIGROUP
Peach State WellCare

Date of Service Identified in Electronic
Encounter Data1

Number With Supporting Documentation in Medical
Records

Percentage

Number Without any Supporting Documentation in Medical
Records

Percentage

570

530

93.0%

40

7.0%

600

578

96.3%

22

3.7%

596

550

92.3%

46

7.7%

Statewide

1,766

1,658

93.9%

108

6.1%

1 The number reported here includes the original sample records that HSAG coders selected for validation and 533 additional dates of service randomly selected from the submitted medical record that were also validated and found to be present in the electronic encounter data.

Encounter Data Validation Study Final Report State of Georgia

Page C-11 GA2009-10_EDV_FinalRpt_F1_1210

DETAILED RESULTS TABLES AND NOTES

Table C-13--Date of Service Encounter Data Omission Rates

Encounter Data Omission

CMO AMERIGROUP
Peach State WellCare

Date of Service Identified in Medical
Records1 691 707 688

Number With No Evidence of Submission in the
Electronic Encounter Data
161
129
138

Percentage 23.3% 18.2% 20.1%

Statewide

2,086

428

20.5%

1 To evaluate encounter data omission, after the coders validated the selected EPSDT date of service, they randomly selected one additional EPSDT visit from the submitted medical record. If the HSAG coders did not find an additional EPSDT visit in the medical record, they selected any physician office visit.

Table C-14--Diagnosis Code Medical Record Omission and Encounter Data Omission Rates

Medical Record Omission

Encounter Data Omission

CMO

Number of Diagnoses Identified in Electronic Encounter
Data

Number Without Any Supporting Documentation
in Medical Records

Percent

AMERIGROUP 1,183

159

13.4%

Number of Diagnoses Identified in
Medical Records
1,928

Number With No Evidence of
Submission in the Electronic Encounter Data
904

Percent 46.9%

Peach State WellCare

789 1,449

68

8.6%

2,018

229

15.8%

1,903

1,297 683

64.3% 35.9%

Statewide

3,421

456

13.3%

5,849

2,884

49.3%

Encounter Data Validation Study Final Report State of Georgia

Page C-12 GA2009-10_EDV_FinalRpt_F1_1210

DETAILED RESULTS TABLES AND NOTES

Table C-15--Procedure Code Medical Record Omission and Encounter Data Omission Rates

Medical Record Omission

Encounter Data Omission

CMO

Number of Procedures Identified in Electronic Encounter
Data

Number Without Any Supporting Documentation
in Medical Records

Percent

AMERIGROUP 1,871

415

22.2%

Peach State

2,269

513

22.6%

WellCare

1,985

387

19.5%

Number of Procedures Identified in
Medical Records
2,499
2,916
2,611

Number With No Evidence of Submission in the Electronic Encounter Data
1,043
1,160
1,013

Percent 41.7% 39.8% 38.8%

Statewide

6,125

1,315

21.5%

8,026

3,216

40.1%

Table C-16--Diagnosis Coding Accuracy Rates and Types of Error

Accuracy Results

Inaccurate Code Specificity Error

CMO

Number of Diagnoses From Validated Date of Service in Electronic Encounter Data

Validated by
Medical Records

Percent

Number of Invalid
Diagnoses

AMERIGROUP

1,024

932

91.0%

92

Number 80

Percent 87.0%

Number 12

Percent 13.0%

Peach State WellCare

721 1,220

674

93.5%

47

1,132 92.8%

88

41

87.2%

6

12.8%

80

90.9%

8

9.1%

Statewide

2,965

2,738 92.3%

227

201 88.5%

26

11.5%

Encounter Data Validation Study Final Report State of Georgia

Page C-13 GA2009-10_EDV_FinalRpt_F1_1210

DETAILED RESULTS TABLES AND NOTES

Table C-17--Procedure Coding Accuracy Rates and Types of Error

Accuracy Results

Inaccurate Code

Higher Level of Service in
Medical Record1

Lower Level of Service in Medical Record2

CMO

Number of

Procedures

From Validated

Total

Date of Service Validated

Number

in Electronic

by

of

Encounter Medical

Invalid

Data

Records

%

Codes

N

%

N

%

N

%

AMERIGROUP

1,456

1,397 95.9% 59

31 52.5% 0 0.0% 28 47.5%

Peach State

1,756

1,699 96.8% 57

19 33.3% 0 0.0% 38 66.7%

WellCare

1,598

1,525 95.4% 73

36 49.3% 1 1.4% 36 49.3%

Statewide

4,810

4,621 96.1% 189 86 45.5% 1 0.5% 102 54.0%

1 Results showed that the number and percentage of procedures documented in the medical records reflected a higher level of service than the procedure code submitted in the encounter.
2 Results showed that the number and percentage of procedures documented in the medical records reflected a lower level of service than the procedure code submitted in the encounter.

Table C-18--Statewide EPSDT Component Completion Rates

EPSDT Component Initial/Interval History Physical Examination Developmental/Behavioral Surveillance Health Education Height Plotted on a Growth Chart Weight Plotted on a Growth Chart Vision Assessment Hearing Assessment Head Circumference Plotted on a Growth Chart1 BMI Plotted on a Growth Chart2 Dental Inspection/Referral Immunization Status Addressed

Validated Date of Service 1,125 1,125 1,125 1,125 1,125 1,125 1,125 1,125
395
730 1,125 1,125

Number With Component Documented
1,063 1,024 968 913 447 448 850 748
127
125 931 878

Percent 94.5% 91.0% 86.0% 81.2% 39.7% 39.8% 75.6% 66.5%
32.2%
17.1% 82.8% 78.0%

Completed All Required Components

1,125

119

10.6%

1 Head circumference was evaluated only for members who were 24 months of age or younger. 2 Body mass index was evaluated only for members who were 24 months of age or older.

Encounter Data Validation Study Final Report State of Georgia

Page C-14 GA2009-10_EDV_FinalRpt_F1_1210

DETAILED RESULTS TABLES AND NOTES

Table C-19--Statewide EPSDT Component Completion Rates, Before and After the Bright Futures Guidelines Implementation

After Implementation (> July 1,

Before Implementation (< July 1, 2008)

2008)

EPSDT Component

Validated Number With Date of Component Service Documented

Initial/Interval History

467

447

Physical Examination

467

422

Developmental/Behavioral Surveillance

467

400

Health Education

467

374

Height Plotted on a Growth Chart 467

179

Weight Plotted on a Growth

467

181

Chart

Vision Assessment

467

353

Hearing Assessment

467

314

Head Circumference Plotted on a 164

50

Growth Chart1

BMI Plotted on a Growth Chart2

303

51

Dental Inspection/Referral

467

389

Immunization Status Addressed

467

364

Percent 95.7% 90.4% 85.7%
80.1% 38.3% 38.8%
75.6% 67.2% 30.5%
16.8% 83.3% 77.9%

Validated Number With Date of Component Service Documented Percent

658

616

93.6%

658

602

91.5%

658

568

86.3%

658

539

81.9%

658

268

40.7%

658

267

40.6%

658

497

75.5%

658

434

66.0%

231

77

33.3%

427

74

17.3%

658

542

82.4%

658

514

78.1%

Completed All Required Components

467

40

8.6%

658

1 Head circumference was evaluated only for members who were 24 months of age or younger. 2 Body mass index was evaluated only for members who were 24 months of age or older.

79

12.0%

Encounter Data Validation Study Final Report State of Georgia

Page C-15 GA2009-10_EDV_FinalRpt_F1_1210

DETAILED RESULTS TABLES AND NOTES

Table C-20--CMO EPSDT Component Completion Rates

AMERIGROUP

Peach State

WellCare

EPSDT Component Initial/Interval History Physical Examination Developmental/Behavioral Surveillance Health Education Height Plotted on a Growth Chart Weight Plotted on a Growth Chart Vision Assessment Hearing Assessment Head Circumference Plotted on a Growth Chart1 BMI Plotted on a Growth Chart2 Dental Inspection/Referral Immunization Status Addressed

Validated Date of Service
350
336
318

Validated Date of
Percent Service Percent
94.3% 367 94.3%
90.6% 353 90.7%
85.7% 331 85.1%

Validated Date of Service
346
335
319

Percent 94.8% 91.8% 87.4%

300

80.9% 321 82.5%

292

80.0%

147

39.6% 165 42.4%

135

37.0%

149

40.2% 167 42.9%

132

36.2%

275

74.1% 296 76.1%

279

76.4%

243

65.5% 264 67.9%

241

66.0%

41

35.7%

52

33.3%

34

27.4%

44

17.2%

37

15.9%

44

18.3%

299

80.6% 331 85.1%

301

82.5%

285

76.8% 310 79.7%

283

77.5%

Completed All Required Components3

43

11.6%

40

10.3%

36

9.9%

1 Head circumference was evaluated only for members who were 24 months of age or younger. 2 Body mass index was evaluated only for members who were 24 months of age or older. 3 The lowest rates across all CMOs were in documenting height, weight, BMI, and head circumference. These lower
rates, compared to the rates for the other individual EPSDT components, may relate to the requirement of plotting the measures on a height and weight growth chart in order to qualify as a positive response for the documentation of height and weight. This requirement also applied to the documentation of head circumference and BMI. When the overall calculation excluded these components, the statewide EPSDT component completion rate would increase from 10.6 percent to 39.1 percent, with CMO-specific rates ranging from 36.4 percent to 41.4 percent.

Encounter Data Validation Study Final Report State of Georgia

Page C-16 GA2009-10_EDV_FinalRpt_F1_1210

Appendix D. AMERIGROUP Summary of Findings

Table D-1--Number and Percentage of Professional Encounters by Place of Service, AMERIGROUP and Statewide

Statewide

AMERIGROUP

Office Home Urgent Care Facility Inpatient Hospital Outpatient Hospital ER-Hospital Ambulatory Surgical Center Ambulance Federally Qualified Health Center Community Mental Health Center Public Health Clinic Rural Health Clinic Independent Laboratory Total

Number 5,917,355 137,517
56,930 598,182 548,907 829,730 18,953 36,273
9,616 198,131 273,879 87,654 554,556 9,267,683

% Total 63.8% 1.5% 0.6% 6.5% 5.9% 9.0% 0.2% 0.4% 0.1% 2.1% 3.0% 0.9% 6.0% 100.0%

Number 1,501,941
28,481 3,647 114,171 120,842 177,169 4,504 5,755 3,124 51,157 71,852 22,308 109,294 2,214,245

% Total 67.8% 1.3% 0.2% 5.2% 5.5% 8.0% 0.2% 0.3% 0.1% 2.3% 3.2% 1.0% 4.9% 100.0%

Table D-2--Number and Percentage of Institutional Encounters by Type of Bill, AMERIGROUP and Statewide

Statewide

AMERIGROUP

Number % Total

Clinic 28,735 2.0%

Inpatient Hospital 160,159 11.3%

Outpatient Hospital 1,216,192 85.6%

Skilled Nursing Facility 2,809

0.2%

Special Facility 12,724

0.9%

Total 1,420,619 100.0%

Number 895
27,545 239,009
9 2,952 270,410

% Total 0.3% 10.2% 88.4% 0.0% 1.1%
100.0%

Encounter Data Validation Study Final Report State of Georgia

Page D-1 GA2009-10_EDV_FinalRpt_F1_1210

AMERIGROUP SUMMARY OF FINDINGS

Table D-3--Age- and Gender-Appropriate Professional Encounters, AMERIGROUP Valid Encounters

Diagnosis/Service Examined

Number of Professional Encounters
Examined

Number

Percent

Age-Appropriate Diagnoses Child exam Routine general medical exam

120,454 4,263

119,710 2,294

99.4% 53.8%1

Age-Appropriate Services Infant Early childhood, 14 years Late childhood, 511 years Adolescent, 1217 years Adult, 1839 years Adult, 4064 years

63,742 55,275 32,927 17,543 2,913
370

62,239 54,113 31,971 17,093 2,763
352

97.6% 97.9% 97.1% 97.4% 94.9% 95.1%

Gender-Appropriate Diagnoses Diseases of male genital organs Anomalies of male organs Inflammatory disease of female pelvic organs Other disorders of female genital tract Complications of pregnancy, childbirth Anomalies of female organs Normal pregnancy High-risk pregnancy Postpartum

5,933 1,972 16,190 33,751 71,781 356 57,885 5,364 4,070

5,761 1,911 16,157 33,688 71,700 351 57,871 5,356 4,069

97.1% 96.9% 99.8% 99.8% 99.9% 98.6% 99.9% 99.9% 99.9%

Gender-Appropriate Services Male genital system Female genital system Maternity care and delivery

4,833 8,637 19,512

4,532 8,635 19,505

93.8% 99.9% 99.9%

Total

527,771

520,071

98.5%

1 The 53.8 percent of encounters submitted with V70.0 were associated with patients 18 years of age or older. When the age criterion was lowered to 12 years of age or older, the percentage was reported as 83.7 percent.

Encounter Data Validation Study Final Report State of Georgia

Page D-2 GA2009-10_EDV_FinalRpt_F1_1210

AMERIGROUP SUMMARY OF FINDINGS

Table D-4--Age- and Gender-Appropriate Institutional Encounters, AMERIGROUP
Valid Encounters

Diagnosis/Service Examined

Number of Institutional Encounters Examined

Number

Percent

Age-Appropriate Diagnoses Child exam Routine general medical exam
Age-Appropriate Services2 Infant

4,452 194
0

4,431 111
-

99.5% 57.2%1
-

Early childhood, 14 years

0

-

-

Late childhood, 511 years Adolescent, 1217 years Adult, 1839 years Adult, 4064 years

1

1

100%

1

0

0%

9

9

100%

5

5

100%

Gender-Appropriate Diagnoses Diseases of male genital organs

1,069

1,058

99.0%

Anomalies of male organs

462

453

98.1%

Inflammatory disease of female pelvic organs Other disorders of female genital tract Complications of pregnancy, childbirth Anomalies of female organs

2,285 6,057 30,338
40

2,282 6,048 30,325
40

99.9% 99.9% 99.9% 100%

Normal pregnancy

6,327

6,325

99.9%

High-risk pregnancy

1,266

1,266

100%

Postpartum

475

475

100%

Gender-Appropriate Services Male genital system Female genital system Maternity care and delivery

86

85

98.8%

308

307

99.7%

451

450

99.8%

Total

53,826

53,671

99.7%

1 The 57.2 percent of encounters submitted with V70.0 were associated with patients 18 years of age or older. When the age criterion was lowered to 12 years of age or older, the percentage was reported as 80.9 percent.
2 Since the number of encounters reported for services under this category was less than 30, any interpretation of the identified patterns would lack scientific rigor. There are not enough observations to confidently draw reliable conclusions.

Encounter Data Validation Study Final Report State of Georgia

Page D-3 GA2009-10_EDV_FinalRpt_F1_1210

AMERIGROUP SUMMARY OF FINDINGS Figure D-1--Number of AMERIGROUP Professional Encounters by Month of Service
Figure D-2--Number of AMERIGROUP Institutional Encounters by Month of Service

Encounter Data Validation Study Final Report State of Georgia

Page D-4 GA2009-10_EDV_FinalRpt_F1_1210

AMERIGROUP SUMMARY OF FINDINGS Figure D-3--Number of AMERIGROUP Pharmacy Encounters by Month of Service

Encounter Data Validation Study Final Report State of Georgia

Page D-5 GA2009-10_EDV_FinalRpt_F1_1210

Appendix E. Peach State Summary of Findings

Table E-1--Number and Percentage of Professional Encounters by Place of Service, Peach State and Statewide

Statewide

Peach State

Office Home Urgent Care Facility Inpatient Hospital Outpatient Hospital ER-Hospital Ambulatory Surgical Center Ambulance Federally Qualified Health Center Community Mental Health Center Public Health Clinic Rural Health Clinic Independent Laboratory Total

Number 5,917,355 137,517
56,930 598,182 548,907 829,730 18,953 36,273
9,616 198,131 273,879 87,654 554,556 9,267,683

% Total 63.8% 1.5% 0.6% 6.5% 5.9% 9.0% 0.2% 0.4% 0.1% 2.1% 3.0% 0.9% 6.0% 100.0%

Number 1,512,260
42,114 3,585 189,308 166,662 225,883 4,212 15,174
85 46,835 30,571 24,515 172,024 2,433,228

% Total 62.2% 1.7% 0.1% 7.8% 6.8% 9.3% 0.2% 0.6% 0.0% 1.9% 1.3% 1.0% 7.1% 100.0%

Table E-2--Number and Percentage of Institutional Encounters by Type of Bill, Peach State and Statewide

Statewide

Peach State

Clinic Inpatient Hospital Outpatient Hospital Skilled Nursing Facility
Special Facility Total

Number 28,735 160,159 1,216,192 2,809 12,724 1,420,619

% Total 2.0% 11.3% 85.6% 0.2% 0.9%
100.0%

Number 20,403 49,186 385,435
5 2,731 457,760

% Total 4.5% 10.7% 84.2% 0.0% 0.6%
100.0%

Encounter Data Validation Study Final Report State of Georgia

Page E-1 GA2009-10_EDV_FinalRpt_F1_1210

PEACH STATE SUMMARY OF FINDINGS

Table E-3--Age- and Gender-Appropriate Professional Encounters, Peach State
Valid Encounters

Diagnosis/Service Examined

Number of Professional Encounters
Examined

Number

Percent

Age-Appropriate Diagnoses Child exam Routine general medical exam

24,974 2,287

24,780 1,420

99.2% 62.1%1

Age-Appropriate Services Infant

12,422

12,266

98.7%

Early childhood, 14 years Late childhood, 511 years Adolescent, 1217 years Adult, 1839 years

8,189 4,946 3,491 2,214

8,083 4,883 3,445 2,186

98.7% 98.7% 98.7% 98.7%

Adult, 4064 years

322

318

98.8%

Gender-Appropriate Diagnoses Diseases of male genital organs

6,876

6,820

99.2%

Anomalies of male organs Inflammatory disease of female pelvic organs Other disorders of female genital tract Complications of pregnancy, childbirth

1,955 20,077 39,908 135,703

1,920 20,074 39,904 135,685

98.2% 99.9% 99.9% 99.9%

Anomalies of female organs

292

292

100.0%

Normal pregnancy

80,518

80,515

99.9%

High-risk pregnancy Postpartum

4,992 6,909

4,992 6,909

100.0% 100.0%

Gender-Appropriate Services Male genital system Female genital system

8,556 11,523

8,437 11,520

98.6% 99.9%

Maternity care and delivery

39,629

39,628

99.9%

Total

415,783

414,077

99.6%

1 The 62.1 percent of encounters submitted with V70.0 were associated with patients 18 years of age or older. When the age criterion was lowered to 12 years of age or older, the percentage was reported as 88.4 percent.

Encounter Data Validation Study Final Report State of Georgia

Page E-2 GA2009-10_EDV_FinalRpt_F1_1210

PEACH STATE SUMMARY OF FINDINGS

Table E-4--Age- and Gender-Appropriate Institutional Encounters, Peach State
Valid Encounters

Diagnosis/Service Examined

Number of Institutional Encounters Examined

Number

Percent

Age-Appropriate Diagnoses Child exam Routine general medical exam
Age-Appropriate Services2 Infant

5,662 183
8

5,654 106
8

99.9% 57.9%1
100.0%

Early childhood, 14 years Late childhood, 511 years Adolescent, 1217 years Adult, 1839 years

2

2

100.0%

0

-

-

1

1

100.0%

1

1

100.0%

Adult, 4064 years

3

3

100.0%

Gender-Appropriate Diagnoses Diseases of male genital organs

1,436

1,426

99.3%

Anomalies of male organs Inflammatory disease of female pelvic organs Other disorders of female genital tract Complications of pregnancy, childbirth

516 3,089 8,582 60,605

513 3,089 8,579 60,598

99.4% 100.0% 99.9% 99.9%

Anomalies of female organs

56

56

100.0%

Normal pregnancy

10,812

10,812

100.0%

High-risk pregnancy Postpartum

1,255 785

1,255 785

100.0% 100.0%

Gender-Appropriate Services Male genital system Female genital system

126

126

100.0%

352

352

100.0%

Maternity care and delivery

1,788

1,788

100.0%

Total

95,262

95,154

99.9%

1 The 57.9 percent of encounters submitted with V70.0 were associated with patients 18 years of age or older. When the age criterion was lowered to 12 years of age or older, the percentage was reported as 69.9 percent.
2 Since the number of encounters reported for services under this category was less than 30, any interpretation of the identified patterns would lack scientific rigor. There are not enough observations to confidently draw reliable conclusions.

Encounter Data Validation Study Final Report State of Georgia

Page E-3 GA2009-10_EDV_FinalRpt_F1_1210

PEACH STATE SUMMARY OF FINDINGS Figure E-1--Number of Peach State Professional Encounters by Month of Service
Figure E-2--Number of Peach State Institutional Encounters by Month of Service

Encounter Data Validation Study Final Report State of Georgia

Page E-4 GA2009-10_EDV_FinalRpt_F1_1210

PEACH STATE SUMMARY OF FINDINGS Figure E-3--Number of Peach State Pharmacy Encounters by Month of Service

Encounter Data Validation Study Final Report State of Georgia

Page E-5 GA2009-10_EDV_FinalRpt_F1_1210

Appendix F. WellCare Summary of Findings

Table F-1--Number and Percentage of Professional Encounters by Place of Service, WellCare and Statewide

Statewide

WellCare

Number

% Total

Number % Total

Office

5,917,355

63.8%

2,903,154

62.8%

Home

137,517

1.5%

66,922

1.4%

Urgent Care Facility

56,930

0.6%

49,698

1.1%

Inpatient Hospital

598,182

6.5%

294,703

6.4%

Outpatient Hospital

548,907

5.9%

261,403

5.7%

ER-Hospital

829,730

9.0%

426,678

9.2%

Ambulatory Surgical Center

18,953

0.2%

10,237

0.2%

Ambulance

36,273

0.4%

15,344

0.3%

Federally Qualified Health Center

9,616

0.1%

6,407

0.1%

Community Mental Health Center

198,131

2.1%

100,139

2.2%

Public Health Clinic

273,879

3.0%

171,456

3.7%

Rural Health Clinic

87,654

0.9%

40,831

0.9%

Independent Laboratory

554,556

6.0%

273,238

5.9%

Total 9,267,683

100.0% 4,620,210 100.0%

Note: WellCare had 657 encounters containing more than one place of service in the detail files. The most common places of service shared within an encounter were office, home, and community mental health center.

Table F-2--Number and Percentage of Institutional Encounters by Type of Bill, WellCare and Statewide

Statewide

WellCare

Inpatient Hospital Outpatient Hospital Skilled Nursing Facility
Clinic Special Facility
Total

Number 28,735 160,159 1,216,192 2,809 12,724 1,420,619

% Total 2.0% 11.3% 85.6% 0.2% 0.9%
100.0%

Number 7,437 83,428
591,748 2,795 7,041
692,449

% Total 1.1% 12.0% 85.5% 0.4% 1.0% 100.0%

Encounter Data Validation Study Final Report State of Georgia

Page F-1 GA2009-10_EDV_FinalRpt_F1_1210

WELLCARE SUMMARY OF FINDINGS

Table F-3--Age- and Gender-Appropriate Professional Encounters, WellCare
Valid Encounters

Diagnosis/Service Examined

Number of Professional Encounters
Examined

Number

Percent

Age-Appropriate Diagnoses Child exam Routine general medical exam

117,704 5,403

116,812 2,871

99.2% 53.1%1

Age-Appropriate Services Infant Early childhood, 14 years

109,190 77,771

107,310 76,385

98.3% 98.2%

Late childhood, 511 years

41,339

40,286

97.5%

Adolescent, 1217 years

21,070

20,587

97.7%

Adult, 1839 years Adult, 4064 years

5,368 705

5,168 665

96.3% 94.3%

Gender-Appropriate Diagnoses Diseases of male genital organs Anomalies of male organs

11,888 3,023

11,638 2,953

97.9% 97.7%

Inflammatory disease of female pelvic organs

27,479

27,415

99.8%

Other disorders of female genital tract

64,588

64,485

99.8%

Complications of pregnancy, childbirth Anomalies of female organs Normal pregnancy High-risk pregnancy

200,472 545
136,874 8,726

200,305 528
136,855 8,724

99.9% 96.9% 99.9% 99.9%

Postpartum

10,571

10,567

99.9%

Gender-Appropriate Services Male genital system Female genital system Maternity care and delivery

14,496 23,751 61,916

13,885 23,725 61,899

95.8% 99.9% 99.9%

Total

942,879

933,063

99.0%

1 The 53.1 percent of encounters submitted with V70.0 were associated with patients 18 years of age or older. When the age criterion was lowered to 12 years of age or older, the percentage was reported as 84.4 percent.

Encounter Data Validation Study Final Report State of Georgia

Page F-2 GA2009-10_EDV_FinalRpt_F1_1210

WELLCARE SUMMARY OF FINDINGS

Table F-4--Age- and Gender-Appropriate Institutional Encounters, WellCare
Valid Encounters

Diagnosis/Service Examined

Number of Institutional Encounters Examined

Number

Percent

Child exam Routine general medical exam Age-Appropriate Services2 Infant

Age-Appropriate Diagnoses 8,561 393
1

8,534 197
1

99.7% 50.1%1
100.0%

Early childhood, 14 years

2

2

100.0%

Late childhood, 511 years

2

1

50.0%

Adolescent, 1217 years Adult, 1839 years Adult, 4064 years

0

-

-

4

4

100.0%

1

1

100.0%

Gender-Appropriate Diagnoses Diseases of male genital organs

2,547

2,526

99.2%

Anomalies of male organs

961

938

97.6%

Inflammatory disease of female pelvic organs

6,329

6,318

99.8%

Other disorders of female genital tract Complications of pregnancy, childbirth Anomalies of female organs Normal pregnancy

15,944 93,992
126 17,622

15,919 93,959
125 17,613

99.8% 99.9% 99.2% 99.9%

High-risk pregnancy

3,492

3,491

99.9%

Postpartum

1,243

1,239

99.7%

Gender-Appropriate Services Male genital system Female genital system Maternity care and delivery

39

37

94.9%

66

66

100.0%

64

64

100.0%

Total

151,389

151,119

99.8%

1 The 50.1 percent of encounters submitted with V70.0 were associated with patients 18 years of age or older. When the age criterion was lowered to 12 years of age or older, the percentage was reported as 71.5 percent.
2 Since the number of encounters reported for services under this category was less than 30, any interpretation of the identified patterns would lack scientific rigor. There are not enough observations to confidently draw reliable conclusions.

Encounter Data Validation Study Final Report State of Georgia

Page F-3 GA2009-10_EDV_FinalRpt_F1_1210

WELLCARE SUMMARY OF FINDINGS Figure F-1--Number of WellCare Professional Encounters by Month of Service
Figure F-2--Number of WellCare Institutional Encounters by Month of Service

Encounter Data Validation Study Final Report State of Georgia

Page F-4 GA2009-10_EDV_FinalRpt_F1_1210

WELLCARE SUMMARY OF FINDINGS Figure F-3--Number of WellCare Pharmacy Encounters by Month of Service

Encounter Data Validation Study Final Report State of Georgia

Page F-5 GA2009-10_EDV_FinalRpt_F1_1210