Caveats Related to Historical Data
As of Q22013
Inpatient Data
WHAIC staff identified a significant change in the average length of stay during the processing of the Health Care Data Report for Mendota Mental Health (060) and Winnebago Mental Health (154). The significant changes identified a combined 20% decrease in average length of days and 13% decrease in days.The facilities were contacted for a brief explanation of the changes and provided the following
Mendota Mental Health, Madison (060);In 2010 Mendota Mental Health closed 3 civil units; however, during this same period a Forensic unit was opened in 2010. The Forensic unit did not have a turnover rate in patient stays like the civil units therefore this resulted in a decrease in days and average length of stays.
Winnebago Mental Health, Winnebago (154),notified WHAIC that the Forensic and Civil data were combined and over the course of the last few years the average length of stay has been steadily declining. The facility specifically stated that for the Civil data the average LOS in FY 2012 was 10.8 days, and thus far in FY 2013 it was 9.6 days.
Kindred Hospital, Milwaukee (181), has changed its name to:
Post Acute Specialty Hospital of Milwaukee, LLCEffective Q32013
Southwest Health Center, Platteville (108) was notified by WHAIC following a review of the readmissions report for Q112 to review its inpatient record submission for accuracy. The facility notified WHAIC that it inadvertently missed submitting 69 inpatient records in Q112 for total sum of 852,046.08. Added Q42012
WHA Information Center concluded an audit of potential duplicate inpatient records from 2010 and 2011 as a result of the readmissions project. There were four facilities that were found to have submitted duplicate inpatient records due to vendor issues, late charges, rebills, or incorrect bill types assigned to the record. Please refer to the table below for the facility information, the quarter and year, number of overstated records and the total overstated dollar amount. Added Q42012
Facility Name / Quarter/Year / Over stated records / Overstated Dollar amount014 - Black River / Q112 / 5 / 123,370.00
Q411 / 7 / 56,522.50
Q311 / 5 / 16,620.25
Q211 / 10 / 53,728.00
Q111 / 4 / 41,278.00
038 - Burnett Medical Center / Q212 / 4 / 25,665.25
Q112 / 14 / 140,748.75
Q411 / 23 / 155,478.00
Q311 / 11 / 120,070.00
Q211 / 18 / 304,662.50
Q111 / 11 / 108,981.25
Q410 / 15 / 238,438.25
108 - Southwest Health Center / Q212 / 25 / 200,352.00
Q112 / 12 / 75,457.17
Q411 / 14 / 134,492.00
Q311 / 30 / 256,019.20
Q211 / 15 / 176,223.73
Q111 / 30 / 343,866.13
Q410 / 12 / 78,013.70
152 - Tri-County (Gundersen Health Tri-County) / Q111 / 6 / 51,362.09
Q410 / 9 / 91,274.70
Wheaton Franciscan Healthcare-St Francis, Inc., Milwaukee (085) notified WHAIC that for the three year period (2009-2011),23 cases of birth trauma were erroneously identified. The facility educated the coders in accurate coding for this measure to avoid future misrepresentation. The WHAIC Quality Indicator report, for the indicator Birth Trauma – Injury to Neonate, was also affected during this same period and has a caveat in Appendix F to reflect the proper number of cases. The table below identifies by quarter/year the number of cases coded incorrectly. Added Q2 2012
Quarter/Year / Number of neonate cases coded incorrectlyQ209 / 2
Q309 / 1
Q409 / 3
Q210 / 2
Q310 / 1
Q410 / 2
Q111 / 3
Q211 / 4
Q311 / 2
Q411 / 3
Mercy Hospital and Trauma Center, Janesville (048) – WHA Information Center notified Mercy Hospital and Trauma Center that it had used an incorrect NPI on 24 records where Carlos Ortega, MD was an attending physician in Q1 2011. The hospital used Dr. Ortega’s organizational NPI (1295753093), instead of his physician NPI (1972525269). Added Q2 2012
Oconomowoc Memorial Hospital, Oconomowoc (098) – WHA Information Center notified Oconomowoc Memorial that it had used an incorrect NPI on one record where Philip Marden, MD was an attending physician in Q1 2011. The hospital used Dr. Marden’s organizational NPI (1073652525), instead of his physician NPI (1073659546). Added Q2 2012
WHA Information Center recently concluded an audit of inpatient records for the Q3 2011 data submission cycle. There were four facilities that submitted multiple inpatient records with an incorrect attending physician identified by 10 zeros, instead of the correct NPI number for the actual attending provider (MD or DO). Below is a table that identifies the facility, the number of records affected, the reason for the oversight and how they intend to correct further omissions. Added Q4 2011
Facility Name/Number / Number of INP records / Reason for Omission / Action plan to remedy populating MD and DO.Aspirus Wausau Hospital (145) / 502 / The facility misunderstood the frequency in which to update the NPIs with WHAICs database. In addition, the staff cleared edits using 10 zero’s instead of validating the MD/DO with WHAIC. / More frequent submission of NPI numbers to WHAIC and staff education as to appropriateness of MD and DO NPI numbers in inpatient data.
United Hospital (305) / 196 / Doctors of Osteopathy were not included in the submission of files. / Inclusion of DOs will be added to extract and submitted to WHAIC.
Froedtert Hospital (079) / 55 / There is one physician NPI that did not get populated on Q3 inpatient records, yet populated on outpatient. The reason for omission is unknown for this provider. / Froedtert staff is working on a remedy to verify the physicians NPI number will be populated on inpatient records for future reporting.
Waukesha Memorial Hospital (141) / 77 / There are four physicians that were submitted in the facilities inpatient data with 10 zeros. The reason for the omission is unknown at this time. / The facility staff is working on a remedy to make sure the physician’s NPI numbers get populated for future reporting.
Tomah Memorial Hospital, Tomah (135), notified WHAIC that as a result of a recent internal audit of medical records and coding compliance, there were 36 Inpatient records (Q4 2009-Q3 2010) that were discovered that resulted in subsequent changes. WHAIC has available, upon request, a listing by HDS number and/or record ID per quarter of the records specified in the table below. Please contact WHAIC for a copy of the excel spreadsheet for both the fixed-width and relational record updates.Added Q4 2010
Quarter/Year / Total Records / Issue / ResolveQ4 09 / 2 / Principal diagnosis coding error / Switched order of principal diagnosis and admitting diagnosis
4 / Incorrect diagnosis codes / Added correct Diagnosis
1 / Wrong account number / Corrected account number
4 / Missing secondary diagnosis codes / Added secondary diagnosis codes
Q110 / 3 / Missing secondary diagnosis codes / Added Secondary diagnosis codes
1 / Wrong account number / Corrected account number
1 / Incorrect diagnosis codes / Added correct Diagnosis
1 / Principal diagnosis coding error / Switched order of principal diagnosis and admitting diagnosis
1 / DRG Change / DRG change from 189 to 1 DX Codes: 427.89, 786.05, 300.00
1 / POA error / No change in DRG POA is N
Q2 10 / 2 / Incorrect principal diagnosis code / Corrected principal and/or added additional
Q3 10 / 3 / Principal Diagnosis coding errors / Corrected principal diagnosis
8 / Secondary diagnosis errors / Corrected and/or added secondary diagnosis codes
1 / POA Error / POA changed from Y to N - 70703, 70702, 70705, and 70721
Ministry Saint Clare's Hospital, Weston (308), notified WHAIC that it had a miscoded record with an inappropriate diagnosis code. The chart was reviewed extensively and the facility found no documentation to support a Vascular Catheter-Associated Infection. The coder inadvertently erred by coding an IV infiltration code 999.31. This code should not have been in the patient record. Added Q3 2010
Gundersen Lutheran Medical Center, LaCrosse (056), notified WHAIC that its INP data submissions for the period Q4 2008 through Q3 2009 inadvertently included a total of 185 hospice records that did not meet the type-of-bill criteria that were specified in the BHI data submission manual and were later adopted by WHAIC. The table below identifies the number of hospice records in each quarter that should not have been submitted. WHAIC has available, upon request, a listing by HDS number and/or record ID per quarter of the records specified in the table below. Please contact WHAIC for a copy of the excel spreadsheet for both the fixed-width and relational record updates.Added Q2 2010
Facility name/ID / Quarter/Year / Total recordsGundersen Lutheran Medical Center (056) / Q4 08 / 32
Q1 09 / 66
Q2 09 / 33
Q3 09 / 54
Columbia St. Mary’s, Inc.:Milwaukee Campus (089) and Ozaukee Campus (110), notified WHAIC that its INP data submissions for the period Q1 through Q4 2009 inadvertently included 79 hospice records that did not meet the type-of-bill criteria that were specified in the BHI data submission manual and were later adopted by WHAIC. The table below identifies the number of hospice records in each quarter for each facility that should not have been submitted. Please refer to(Columbia St Mary 089 and 110 Hospice Data Q109_Q409 historical caveat Q1 10.xls) for both the fixed-width and relational record updates. Added Q1 2010
Facility name/ID / Quarter/Year / Total recordsSt. Mary’s Ozaukee (110) / Q1 09 / 15
St. Mary’s Ozaukee (110) / Q2 09 / 22
St. Mary’s Ozaukee (110) / Q3 09 / 17
St. Mary’s Ozaukee (110) / Q4 09 / 17
St. Mary’s Milwaukee (089) / Q1 09 / 2
St. Mary’s Milwaukee (089) / Q2 09 / 2
St. Mary’s Milwaukee (089) / Q3 09 / 4
Ministry Health Care’s Door County Memorial Hospital. Sturgeon Bay, (133). Door County staff notified WHA Information Center that a total of 501 records from its Q1 2008 thru Q2 2009 inpatient data submissions excluded principal procedures and procedure physicians. This omission resulted in some records being assigned to an incorrect DRG, MSDRG, APRDRG, and/or MDC values. Please refer to (133INP1Q008_Q209.xls) file for both the fixed-width and relational record fixes. The caveat provides the “old” and “new” assignments. To update your files, please use the “new” assignment codes. The “old” code represents the values in your current data sets. (note: HDSNUM is for fixed-width files and Record_ID is for the relational files.The table below identifies the total and percent of records affected (501 records) by the principal procedure omission. Added Q1 2010
Quarter/Year / Total Records Affected / # DRG / # MSDRG / # APRDRGQ108 thru Q209 / 501 / 171– 34% / 165- 33% / 179- 34%
Monroe Clinic, Monroe (091). WHAIC’s validation process during Q3 2009 identified a 30 percent decrease in INP data submissions compared to Q2 2009. Monroe staff investigated and determined a programming issue with their extract inadvertently omitted records from their Q3 09 data submission. Monroe staff fixed the extract and successfully submitted all Q3 2009 INP records. Added Q12010
Meriter Hospital, Madison (061), notified WHAIC that one INP record in Q2 2009 included an incorrect operating physician (Other/Procedure Physician) license number, 18896. Meriter staff inadvertently submitted a license number from a like named physician on the record. Added Q1 10
Quarter/Year / Total Records / “Other Physician 1 and 2” Incorrect / “Other Physician 1 and 2” CorrectQ2 09 / 1 / 18896 / 19788
Southwest Health Center, Platteville (108), notified WHAIC that 12 records in their Q2 2009 inpatient data submission included an incorrect operating physician (“Other/Procedure Physician”) license number, 24874. Southwest staff inadvertently submitted an Iowa license number which mapped to a valid WI license number. Added Q3 2009
Quarter/Year / Total Records / “Other Physician”- incorrect / “Other Physician - correctQ2 09 / 12 / 24874 (IA) / 52466
Norwood Health Center, Marshfield (068), notified WHAIC that an incorrect discharge date was reported on a Q1 2008 inpatient record which subsequently produced an erroneous length of stay in the inpatient discharge data set. Norwood staff noted the correct length of stay should have been reported as 12 days instead of 377 days. Added Q3 2009
Quarter/Year / Record_ID (relational) / HDS_Number (fixed width) / “LOS” - incorrect / “LOS” – correctQ1 08 / 24874 (IA) / 52466 / 377 / 12
BayAreaMedicalCenter, Marinette (067). WHA Information staff notified BayAreaMedicalCenter that some secondary procedures appeared to be duplicated from the principal procedure field. In some cases, this duplication created an inaccurate, bilateral grouping assignment (i.e., DRG/MSRDRG/APRDRG). Below is a breakdown by year/quarter, number of records with a duplicated procedure code,number of records whose grouping was inaccurately assigned because of the duplicate procedure code, and the total inpatient records. Please refer to caveat file (067_Caveats.csv) which provides both the fixed-width and relational record updates for the “DRG” field in the primary record (HDSNUM = fixed-width, RecordID = relational). Bay Area Medical Center indicated the data submission for Q1 2009 data is accurate. Added Q1 2009
Quarter/Year / # of Records with a duplicate procedure code / # of Records whose assignment was affected by duplicate procedure code / Total Inpatient RecordsQ307 / 690 / 18 / 2071
Q407 / 680 / 24 / 2034
Q108 / 379 / 25 / 2167
Q208 / 694 / 23 / 2097
Q308 / 695 / 19 / 4248
Columbia Center, Inc., Mequon (196). WHA Information staff notified Columbia Center that its total charges significantly increased for the reporting period of Q4 2007 thru Q2 2008.ColumbiaCenter investigated and determined that a programming error of itsextract inserted erroneous revenue record line items which inflated total charges.Please refer to caveat file (196_Caveat.xls) which provides both the fixed-width and relational record updates for the “Total Charge” field in the primary record (HDSNum = fixed-width, RecordID = relational). Columbia later fixed the programming error and indicated the data submission for Q32008 are accurate.Added Q1 2009
Baldwin Area Medical Center, Baldwin (007), notified WHA Information Center during Q1 2008 data submission cycle that 21 Inpatient records from their Q4 2007 data submission had an incorrect attending physician of ‘OTH000’ assigned to their records. Baldwin staff indicated Dr. Roloff should have been assigned to these records with a license number of 48926. Added Q1 2008
Outpatient Surgery Data
Mercy Medical Center, Oshkosh (103) notified WHAIC that three records were inadvertently omitted from Q412 outpatient surgery data submission. Mercy Medical Center staff indicated these three records were omitted due to the “end” date of service falling in Q113 data instead of extracting by procedure date. Added Q1 2013
St. Joseph’s Hospital, Marshfield (069). St. Joseph’s staff indicated four records were inadvertently omitted from the Q412 outpatient surgery data submission. St. Joseph staff indicated these four records were omitted due to the end date of service falling in Q113 instead of extracting by procedure date. Added Q412
Pain Management and Treatment Center Surgery Center Inc., Milwaukee (254) - WHAIC staff notified the facility that ethnicity was missing from their reported data and that the Q212 data submission had nearly twice as many records as previous quarters. The facility notified WHAIC that there was an error in their program and that not all the procedures were getting reported. The error was corrected as of Q212. The table below has the missing procedures identified for the past 4 quarters. Added Q2 2012
QQ/YY / Total OPS Records submitted / Number of records missing / Total records for the quarterQ112 / 155 / 365 / 520
Q411 / 180 / 207 / 387
Q311 / 199 / 244 / 443
Q211 / 199 / 247 / 446
Riverview Surgery Center, Janesville (219), notified WHAIC that the facility closed on January 9, 2012. Patients are directed to the new Dean St. Mary Hospital. Added Q1 2012
Agnesian HealthCare/St. Agnes Hospital, Fond du Lac (034) was notified by WHAIC that in 2011, 218 records were submitted with a principal procedure code that was insignificant in comparison to what was performed on the patient. The facility has corrected Q112 submission and has corrected the extract for future reporting. Added Q1 2012
Boscobel Area Health Care, Boscobel (016), WHAIC notified the facility that they may be duplicating the principal procedure in the additional procedure field since Q1 2010. The facility verified the services provided and reviewed the record level detail and found that it was duplicating the principal procedure. As of Q12012the vendor notified the facility that a fix has been put in place to correct duplication of principal procedures in future reporting. The table below has a listing by quarter and year of the number of outpatient surgery procedures that they believe have been inadvertently duplicated. Added Q1 2012
Patient Type / Quarter/Year / Number of Principal Procedures Submitted / Number of principal procedures that are duplicated on the recordOPS / Q110 / 118 / 115
Q210 / 91 / 85
Q310 / 104 / 101
Q410 / 96 / 90
Q111 / 114 / 102
Q211 / 83 / 78
Q311 / 120 / 113
Bone and Joint Outpatient Surgery Center, LLC, Wausau (279), WHAIC notified the facility that they may be duplicating the principal procedure in the additional procedure field since Q1 2009. The facility reported the extract has been updated effective with Q4 2011 data submissions. The table below has a listing by quarter and year of the number of outpatient surgery procedures that may have been inadvertently duplicated. Added Q1 2012
Patient Type / Quarter/Year / Number of Principal Procedures Submitted / Number of principal procedures that are duplicated on the recordOPS / Q109 / 442 / 442
Q209 / 439 / 439
Q309 / 504 / 504
Q409 / 549 / 549
Q110 / 498 / 498
Q210 / 583 / 583
Q310 / 706 / 706
Q410 / 836 / 836
The following facilities were contacted during a recent audit of 2011 outpatient surgery (OPS) records that contained a duplicate procedure code. Each facility was given a listing of OPS records that contained a duplicated procedure and the patient control number in order to validate its data submission. As provided in the table below, several facilities reported that they misrepresented the procedures as a result of the extract inadvertently duplicating the principal procedure in the additional procedure field. Some facilitiesreported that their vendor did not properly format the extract to include some or all of the modifiers in the principal procedure or additional procedure fields which also led to the conclusion that the procedures were duplicated. The table below summarizes the findings from the audit and the impact the errors had on the facilities data submitted in during 2011. Added Q1 2012
Facility # /Name / Total OPS Records in 2011 / Duplicate records / Records missing modifiers / Reason for issue / Fix to issue001 – Amery / 1711 / 1370 / Extract populated the principal procedure code in the additional procedure field. / Manually corrected Q112.Extract corrected effective Q212 submission.
003 – Appleton Medical Center / 20215 / 168 / Modifiers were not populated in the Principal or Additional Procedure fields / Facility working with Vendor to update extract.
014 – Black River Falls / 740 / 220 / Extract populated the principal procedure code in the additional procedure field. / Manually corrected Q112. Extract corrected effective Q212 submission.
016 – Boscobel Area Health Care / 432 / 293 / Extract populated the principal procedure code in the additional procedure field. / Extract corrected effective Q112 submission.
025 – Memorial Hospital of Lafayette / 425 / 379 / Extract populated the principal procedure code in the additional procedure field. / Extract corrected effective Q112 submission.
026 – Upland Hills / 2397 / 2198 / Extract populated the principal procedure code in the additional procedure field. / Extract corrected effective Q112 submission.
029 – Mayo – Eau Claire / 14016 / 1772 / Extract populated the principal procedure code in the additional procedure field. / Extract corrected effective Q212 submission.
039 – Bellin Hospital / 14028 / 660 / 84 records had the same injection identified
576 were duplicates because the professional services CPT code was included, but not the charge. / Facility corrected its extract.
045 – St. Joseph’s Community Hospital / 472 / 369 / Extract populated the principal procedure code in the additional procedure field. / Manually corrected Q112. Extract corrected effective Q212 submission.
056 – Gundersen Lutheran HS / 23008 / 228 / Modifiers were not populated in the Principal or Additional Procedure fields / Facility working with Vendor to update extract.
061 – Meriter Hospital / 15190 / 204 / Modifiers were not populated in the Principal or Additional Procedure fields / Facility working with Vendor to update extract.
064 – U W Hospital and Clinics / 88193 / 2503 / Modifiers were not populated in the Principal or Additional Procedure fields / Facility working with Vendor to update extract.
069 – Ministry Saint Jospeh’s Hospital (Marshfield) / 4395 / 140 / Extract populated the principal procedure code in the additional procedure field. / Extract corrected effective Q212 submission.
092 – Theda Clark Medical Center / 12811 / 107 / Modifiers were not populated in the Principal or Additional Procedure fields / Facility working with Vendor to update extract.
098 – Oconomowoc / 3896 / 158 / Modifiers were not populated in the Principal or Additional Procedure fields / Facility working with Vendor to update extract.
135 – Tomah Memorial Hospital / 1249 / 1131 / Extract populated the principal procedure code in the additional procedure field. / Manually corrected Q112. Extract corrected effective Q112 submission.
138 – Vernon Memorial Hospital / 1667 / 1285 / Extract populated the principal procedure code in the additional procedure field. / Manually corrected Q112. Extract corrected effective Q212.
139 – UW Health Watertown / 4773 / 1103
(Q1-Q311) / Extract did not populate modifiers in Principal or Additional Procedure field. / Vendor updated extract effective Q311
141 – Waukesha Memorial Hospital / 21902 / 781 / Modifiers were not populated in the Principal or Additional Procedure fields / Facility working with Vendor to update extract.
155 – Riverview Hospital Association / 4286 / 3278 / Extract populated the principal procedure code in the additional procedure field. / Extract corrected effective Q212 submission.
233 – West Bend Surgery Center / 4796 / 1716 / Extract populated the principal procedure code in the additional procedure field / Facility working with Vendor to update extract.
251 – Wisconsin Health Center ASC / 9073 / 1709 / Extract populated the principal procedure code in the additional procedure field. / Extract corrected effective Q212 submission.
257 – Nova Med / 901 / 1160 / Modifiers were not populated in the Principal or Additional Procedure fields / Facility working with Vendor to update extract.
258 – Froedtert Surgery Center / 3712 / 1497 / Extract populated the principal procedure code in the additional procedure field. / Facility working with Vendor to update extract.
259 – Wisconsin Surgery Center / 2118 / 149 / Modifiers were not populated in the Principal or Additional Procedure fields / Facility working with Vendor to update extract.
261 – SurgiCenter of Greater Madison / 5663 / 1021 / Modifiers were not populated in the Principal or Additional Procedure fields / Facility working with Vendor to update extract.
263 – Sheboygan Medical Center / 2481 / 450 / Modifiers were not populated in the Principal or Additional Procedure fields / Facility working with Vendor to update extract.
273 – Access Medical Center / 8840 / 1628 / Modifiers were not populated in the Principal or Additional Procedure fields / Facility working with Vendor to update extract.
274 – United Medical Center / 4600 / 793 / Modifiers were not populated in the Principal or Additional Procedure fields / Facility working with Vendor to update extract.
285 – Pain Center of Green Bay / 7592 / 1542 / Modifiers were not populated in the Principal or Additional Procedure fields / Facility working with Vendor to update extract.
286 – Pain Center of Franklin / 6100 / 231 / Modifiers were not populated in the Principal or Additional Procedure fields / Facility working with Vendor to update extract.
292 – Pain Center of Waukesha / 1627 / 102 / Modifiers were not populated in the Principal or Additional Procedure fields / Facility working with Vendor to update extract.
280 – The Surgery Center / 7592 / Modifiers were not properly populated in the Principal or Additional Procedure fields. / Manually corrected Q112. Facility working with Vendor to update extract.
Upland Hills Health, Dodgeville (026) notified WHAIC that due to a system vendor issue, it was discovered that since 2007 through Q4 2011 approximately 50 outpatient surgery records per quarter were submitted to WHA Information Center with a principal procedure code of 36415 (venipuncture) instead of the actual procedure (code) performed on the patient. The vendor has been contacted to correct future reporting of the correct principal procedure; however, in the meantime, the facility will manually correct the Q12012 data to correctly identify the principal procedure performed. Added Q4 2011