Navy Medicine DQ by huanghengdong

VIEWS: 2 PAGES: 79

									        1a. What percentage of appointments were closed in meeting your "End of Day"
              processing requirements, "Every appointment - Every day?" (B.5a)


                           Reporting Month   Dec 09   Jan 10   Feb 10    Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10   Oct 10   Nov 10
                               Data Month    Oct 09   Nov 09   Dec 09    Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10
                 NAVY                        99%      99%       100%     100%     99%      100%     99%      100%     100%     100%     100%     99%
           NAVY MEDICINE EAST                100%     100%      100%     100%     100%     100%     100%     100%     100%     100%     100%     99%
                             NH PENSACOLA    100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%     100%
                           NH JACKSONVILLE   100%     100%      100%      100%    98%      100%     100%     100%     100%     100%     100%     100%
                          NHC GREAT LAKES    100%     100%      98%       100%    100%     100%     100%     100%     100%     100%     100%     100%
                          NH CAMP LEJEUNE    100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%     100%
                          NH CHERRY POINT    100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%     100%
           NAVAL HEALTH CARE NEW ENGLAND     100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%     100%
                            NH CHARLESTON    100%     100%      99%       100%    100%     100%     100%     100%     100%     100%      99%      99%
                         NMC PORTSMOUTH      100%      99%      100%      100%    100%     100%      99%      99%      99%     100%      99%      98%
                      NH GUANTANAMO BAY       98%     100%      100%      100%    100%     100%     100%     100%     100%     100%      99%      92%
                                 NH NAPLES   100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%     100%
                                   NH ROTA   100%     100%      100%      100%    100%     100%      99%     100%     100%      99%      99%      99%
                              NH SIGONELLA   100%     100%      100%      100%    100%     100%     100%     100%      99%     100%     100%     100%
        NATIONAL CAPITAL REGION              99%      99%       100%      99%     97%       99%     97%      100%     100%     100%     100%     100%
                          NNMC BETHESDA       98%      99%      99%        99%     99%      99%      95%      99%      99%      99%      99%      99%
                       NHC PATUXENT RIVER    100%      97%      100%      100%     99%     100%      96%     100%     100%     100%     100%     100%
                           NHC ANNAPOLIS      99%     100%      100%      100%     93%     100%      99%      99%     100%     100%     100%     100%
                            NHC QUANTICO      97%      99%      100%       97%     96%      96%      97%     100%     100%     100%     100%      99%
          NAVY MEDICINE WEST                 100%     99%       100%     100%     100%     100%     100%     100%     100%     100%     100%     99%
                      NH CAMP PENDLETON       99%      99%      98%       100%    100%      99%     100%     100%     100%     100%     100%     100%
                             NH LEMOORE      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%     100%
                           NMC SAN DIEGO      99%     100%      100%      100%    100%     100%     100%     100%     100%     100%      96%      89%
                     NH TWENTYNINE PALMS      98%      91%      100%      100%    100%     100%     100%     100%     100%     100%     100%      99%
                           NH BREMERTON       99%      98%      100%       99%    100%     100%     100%     100%      99%      99%      99%     100%
                          NH OAK HARBOR      100%      99%      99%       100%    98%      100%     100%      96%     100%     100%     100%     100%
                              NHC HAWAII     100%     100%      99%        99%    99%      100%     100%     100%     100%     100%     100%     100%
                                NH GUAM      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%     100%
                             NH OKINAWA      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%     100%
                            NH YOKOSUKA      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%     100%

                                   Legend                      95% - 100%
                                                               80% - 94%
Updated: 12/8/2010                                             79% and Below                                              Navy DQMC 12/17/2011
                                                               N/A                                                                Page 2 of 29
     2a. What percentage of Outpatient Encounters, other than APVs, have been coded
                     within 3 business days of the encounter? (B.6a)

                           Reporting Month   Dec 09   Jan 10   Feb 10    Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10   Oct 10   Nov 10
                               Data Month    Oct 09   Nov 09   Dec 09    Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10
                 NAVY                        92%      91%       90%       90%     91%       92%     92%       93%     93%      94%      93%      93%
           NAVY MEDICINE EAST                93%      92%       92%       90%     92%       94%     93%       94%     94%      94%      94%      94%
                             NH PENSACOLA     96%      96%       96%      88%      89%      95%      94%      96%      97%      97%      96%      95%
                           NH JACKSONVILLE    89%      88%       89%      86%      88%      88%      92%      92%      91%      92%      93%      94%
                          NHC GREAT LAKES     97%      97%       87%      98%      98%      98%      96%      98%      98%      98%      97%      97%
                          NH CAMP LEJEUNE     93%      79%       72%      82%      90%      86%      70%      85%      87%      87%      86%      90%
                          NH CHERRY POINT     84%      86%       96%      96%      96%      95%      95%      95%      96%      97%      97%      96%
           NAVAL HEALTH CARE NEW ENGLAND      90%      93%       92%      93%      91%      95%      96%      95%      92%      92%      92%      94%
                            NH CHARLESTON     92%      95%       93%      94%      92%      98%      96%      98%      98%      97%      97%      98%
                              NH BEAUFORT     89%      91%       82%      88%      93%      96%      99%      98%      98%      98%      98%      97%
                         NH CORPUS CHRISTI    99%     100%       99%      82%      77%      89%      90%      85%      86%      90%      89%      91%
                         NMC PORTSMOUTH       90%      87%       89%      87%      87%      88%      88%      88%      88%      89%      89%      89%
                      NH GUANTANAMO BAY       99%      97%       99%      97%      99%      97%      98%      95%      96%      95%      96%      87%
                                 NH NAPLES    94%      88%       94%      95%      94%      94%      91%      95%      96%      94%      92%      94%
                                   NH ROTA    92%      96%       95%      91%      94%      93%      92%      92%      92%      95%      94%      92%
                              NH SIGONELLA    98%      98%      100%      77%      95%      98%      98%      99%      98%      96%      98%      97%
        NATIONAL CAPITAL REGION              90%      89%       88%       91%     92%       91%     92%       92%     92%      93%      92%      92%
                          NNMC BETHESDA       75%      78%      83%       84%      82%      82%      82%      83%      83%      85%      84%      84%
                       NHC PATUXENT RIVER     92%      89%      75%       91%      93%      93%      92%      91%      91%      91%      92%      90%
                           NHC ANNAPOLIS      98%      95%      99%       92%      96%      93%      98%      96%      98%      99%      97%      97%
                            NHC QUANTICO      95%      95%      95%       96%      97%      97%      96%      97%      96%      96%      96%      96%
          NAVY MEDICINE WEST                 90%      90%       89%       90%     90%       91%     92%       92%     92%      93%      93%      93%
                      NH CAMP PENDLETON       91%      95%      88%       91%      89%      91%      90%      89%      90%      90%      90%      91%
                             NH LEMOORE       98%      97%      97%       97%      96%      97%      96%      97%      98%      97%      95%      95%
                           NMC SAN DIEGO      84%      77%      81%       83%      85%      86%      85%      85%      86%      86%      89%      90%
                     NH TWENTYNINE PALMS      94%      96%      91%       92%      95%      95%      96%      96%      95%      96%      95%      92%
                           NH BREMERTON       93%      90%      91%       91%      90%      93%      95%      94%      94%      94%      94%      94%
                          NH OAK HARBOR       95%      97%      96%       94%      96%      97%      96%      94%      96%      96%      97%      93%
                              NHC HAWAII      96%      95%      97%       95%      97%      97%      96%      97%      98%      98%      99%      99%
                                NH GUAM       78%      82%      75%       79%      75%      79%      83%      91%      85%      93%      94%      93%
                             NH OKINAWA       79%      80%      81%       86%      87%      86%      89%      87%      90%      90%      91%      91%
                            NH YOKOSUKA       93%      92%      91%       91%      89%      92%      91%      92%      92%      92%      90%      91%

                                   Legend                      95% - 100%                                                 Navy DQMC 12/17/2011
                                                               80% - 94%                                                          Page 3 of 29
Updated: 12/8/2010                                             79% and Below
                                                               N/A
          2b. What percentage of APVs have been coded within 15 calendar days of the
                                     encounter? (B.6b)

                           Reporting Month   Dec 09   Jan 10   Feb 10    Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10   Oct 10   Nov 10
                               Data Month    Oct 09   Nov 09   Dec 09    Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10
                 NAVY                        92%      88%       84%       88%     91%       93%     92%       89%     88%      93%      91%      93%
           NAVY MEDICINE EAST                93%      92%       85%       87%     90%       92%     91%       89%     81%      92%      89%      94%
                             NH PENSACOLA     96%      93%      89%        88%    87%       90%      87%      88%      94%      95%      90%      96%
                           NH JACKSONVILLE    76%      72%      49%        72%    92%       98%      96%      96%      94%      99%      86%      93%
                          NHC GREAT LAKES     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A
                          NH CAMP LEJEUNE     86%      66%      59%        41%    53%       57%      75%      79%      50%      75%      69%      82%
                          NH CHERRY POINT    100%     100%      89%       100%    96%       99%     100%     100%      94%      91%     100%      98%
           NAVAL HEALTH CARE NEW ENGLAND      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A
                            NH CHARLESTON     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A
                              NH BEAUFORT     99%     100%      100%       98%    98%      100%     100%     100%     100%      98%      98%     100%
                         NH CORPUS CHRISTI    N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A
                         NMC PORTSMOUTH       94%     100%      99%        99%    99%       98%     100%     100%      99%     100%     100%      99%
                      NH GUANTANAMO BAY      100%     100%      89%        95%    100%      90%      78%     100%      75%     100%      92%      80%
                                 NH NAPLES   100%      95%      83%        98%    98%       98%      96%      98%      93%      98%      89%     100%
                                   NH ROTA    82%      93%      90%        77%    85%       91%      74%      28%      10%      62%      70%      95%
                              NH SIGONELLA   100%     100%      100%      100%    95%      100%     100%     100%     100%      97%     100%     100%
        NATIONAL CAPITAL REGION              92%      92%       89%       83%     86%       91%     89%       85%     92%      95%      88%      90%
                          NNMC BETHESDA       92%      92%      89%       83%      86%      91%      89%      85%      92%      95%      88%      90%
                       NHC PATUXENT RIVER     N/A      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A
                           NHC ANNAPOLIS      N/A      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A
                            NHC QUANTICO      N/A      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A
          NAVY MEDICINE WEST                 91%      84%       82%       90%     93%       93%     95%       89%     95%      95%      92%      92%
                      NH CAMP PENDLETON       96%      98%      68%        98%    99%       98%      97%     100%      97%      96%      93%      98%
                             NH LEMOORE      100%     100%      100%       91%    87%      100%     100%     100%     100%     100%      98%     100%
                           NMC SAN DIEGO      99%      97%      98%        96%    95%       97%      96%      97%      98%      98%      98%      98%
                     NH TWENTYNINE PALMS      76%      72%      42%        90%    93%       90%      96%      89%      95%      88%      59%      73%
                           NH BREMERTON       97%      99%      92%        99%    97%       97%      99%      97%      98%      98%      99%      97%
                          NH OAK HARBOR       85%      42%      73%        81%    100%      99%     100%     100%     100%     100%     100%      96%
                              NHC HAWAII      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A
                                NH GUAM       90%      86%      84%        88%    87%       89%      86%      85%      84%      88%      98%      96%
                             NH OKINAWA       82%      66%      86%        68%    82%       68%      80%      72%      81%      88%      83%      72%
                            NH YOKOSUKA       97%      92%      99%       100%    99%      100%      99%      62%     100%     100%     100%      98%

                                   Legend                      95% - 100%
                                                               80% - 94%                                                  Navy DQMC 12/17/2011
Updated: 12/8/2010                                             79% and Below                                                      Page 4 of 29
                                                               N/A
 2c. What percentage of Inpatient records have been coded within 30 calendar days after
                                    discharge? (B.6c)
                           Reporting Month   Dec 09   Jan 10   Feb 10    Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10   Oct 10   Nov 10
                               Data Month    Oct 09   Nov 09   Dec 09    Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10
                 NAVY                        60%      71%       69%       84%     89%       86%     94%       85%     89%      91%      95%      92%
           NAVY MEDICINE EAST                93%      98%       79%       92%     93%       84%     96%       80%     91%      86%      94%      93%
                             NH PENSACOLA    100%     100%      88%        88%    93%       79%      90%      72%      74%      81%     74%      71%
                           NH JACKSONVILLE    77%     100%      44%        68%    97%      100%      98%      97%      98%      97%     99%      99%
                          NHC GREAT LAKES     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A
                          NH CAMP LEJEUNE     95%     100%      99%        98%    97%       64%      97%      98%      69%      40%     90%      87%
                          NH CHERRY POINT     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A
           NAVAL HEALTH CARE NEW ENGLAND      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A
                            NH CHARLESTON     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A
                              NH BEAUFORT     99%     100%      100%      100%    100%      96%     100%      96%     100%     100%     95%      96%
                         NH CORPUS CHRISTI    N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A
                         NMC PORTSMOUTH       97%      97%      79%        76%    80%       68%     100%      98%      97%     100%     99%      99%
                      NH GUANTANAMO BAY      100%     100%      100%      100%    93%      100%     100%     100%     100%      94%     100%     100%
                                 NH NAPLES   100%     100%      38%       100%    98%      100%      98%     100%     100%      97%     93%      92%
                                   NH ROTA    72%     100%      63%        97%    82%       52%      81%      29%      79%      81%     94%      92%
                              NH SIGONELLA   100%      88%      100%      100%    100%      96%     100%      30%     100%      87%     100%     100%
        NATIONAL CAPITAL REGION               0%       0%       11%       20%     81%       55%     54%       58%     71%      88%      89%      91%
                          NNMC BETHESDA       0%       0%       11%       20%      81%      55%      54%      58%      71%      88%      89%      91%
                       NHC PATUXENT RIVER     N/A      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A
                           NHC ANNAPOLIS      N/A      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A
                            NHC QUANTICO      N/A      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A
          NAVY MEDICINE WEST                 33%      52%       66%       82%     85%       91%     96%       93%     90%      96%      97%      92%
                      NH CAMP PENDLETON        0%       0%      26%        98%    97%       99%      97%      98%      98%      99%     96%      99%
                             NH LEMOORE       40%       8%      84%       100%    99%      100%     100%     100%     100%     100%     100%     100%
                           NMC SAN DIEGO       0%       0%       0%        48%    95%       99%      98%     100%     100%      99%     99%      100%
                     NH TWENTYNINE PALMS      11%      97%      37%        98%    99%       94%      97%      98%     100%     100%     99%      100%
                           NH BREMERTON       28%      98%      89%        81%    49%       68%      96%      99%      99%      91%     97%      95%
                          NH OAK HARBOR       62%     100%      97%        96%    100%     100%     100%     100%     100%     100%     100%     99%
                              NHC HAWAII      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A
                                NH GUAM       77%      97%      95%        89%    93%       93%      97%      96%      93%      91%     90%      94%
                             NH OKINAWA       58%       0%      100%      100%    100%      99%      95%      96%      96%      97%     96%      92%
                            NH YOKOSUKA       23%      65%      64%        30%    35%       71%      87%      47%      23%      87%     93%      51%

                                   Legend                      95% - 100%
                                                               80% - 94%
                                                                                                                          Navy DQMC 12/17/2011
Updated: 12/8/2010                                             79% and Below
                                                                                                                                  Page 5 of 29
                                                               N/A
3a. Was monthly MEPRS/EAS financial reconciliation process completed, validated and
              approved prior to monthly MEPRS transmission? (C.1a)


                           Reporting Month   Dec 09   Jan 10   Feb 10    Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10     Sep 10   Oct 10   Nov 10
                               Data Month    Oct 09   Nov 09   Dec 09    Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10     Jul 10   Aug 10   Sep 10
                 NAVY                        100%     100%     100%      100%     100%     100%     100%     100%     100%       100%     100%     100%
           NAVY MEDICINE EAST                100%     100%     100%      100%     100%     100%     100%     100%     100%       100%     100%     100%
                             NH PENSACOLA    100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
                           NH JACKSONVILLE   100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
                          NHC GREAT LAKES    100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
                          NH CAMP LEJEUNE    100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
                          NH CHERRY POINT    100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
           NAVAL HEALTH CARE NEW ENGLAND     100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
                            NH CHARLESTON    100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
                              NH BEAUFORT    100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
                         NH CORPUS CHRISTI   100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
                         NMC PORTSMOUTH      100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
                      NH GUANTANAMO BAY      100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
                                 NH NAPLES   100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
                                  NH ROTA    100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
                             NH SIGONELLA    100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
        NATIONAL CAPITAL REGION              100%     100%     100%      100%     100%     100%     100%     100%     100%       100%     100%     100%
                          NNMC BETHESDA      100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
                       NHC PATUXENT RIVER    100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
                           NHC ANNAPOLIS     100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
                            NHC QUANTICO     100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
          NAVY MEDICINE WEST                 100%     100%     100%      100%     100%     100%     100%     100%     100%       100%     100%     100%
                      NH CAMP PENDLETON      100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
                             NH LEMOORE      100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
                           NMC SAN DIEGO     100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
                     NH TWENTYNINE PALMS     100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
                           NH BREMERTON      100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
                          NH OAK HARBOR      100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
                              NHC HAWAII     100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
                                NH GUAM      100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
                             NH OKINAWA      100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
                            NH YOKOSUKA      100%     100%      100%     100%     100%     100%     100%     100%     100%       100%     100%     100%
                                                                                                                               Navy DQMC 12/17/2011
                                   Legend                      95% - 100%                                                              Page 6 of 29
                                                               80% - 94%
Updated: 12/8/2010                                             79% and Below
                                                               N/A
  3b. Were the data load status, outlier/variance, WWR-EAS IV, and allocation tabs in the
     current MEWACS document reviewed and explanations provided for flagged data
                                     anomalies? (C.1c)

                           Reporting Month   Dec 09   Jan 10   Feb 10    Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10   Oct 10   Nov 10
                               Data Month    Oct 09   Nov 09   Dec 09    Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10
                 NAVY                        100%     100%      100%     100%     100%     100%     100%     100%     100%     100%     100%     100%
           NAVY MEDICINE EAST                100%     100%      100%     100%     100%     100%     100%     100%     100%     100%     100%     100%
                             NH PENSACOLA    100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%
                           NH JACKSONVILLE   100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%
                          NHC GREAT LAKES    100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%
                          NH CAMP LEJEUNE    100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%
                          NH CHERRY POINT    100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%
           NAVAL HEALTH CARE NEW ENGLAND     100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%
                            NH CHARLESTON    100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%
                              NH BEAUFORT    100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%
                         NH CORPUS CHRISTI   100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%
                         NMC PORTSMOUTH      100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%
                      NH GUANTANAMO BAY      100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%
                                 NH NAPLES   100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%
                                   NH ROTA   100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%
                              NH SIGONELLA   100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%
        NATIONAL CAPITAL REGION              100%     100%      100%     100%     100%     100%     100%     100%     100%     100%     100%     100%
                          NNMC BETHESDA      100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%
                       NHC PATUXENT RIVER    100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%
                           NHC ANNAPOLIS     100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%
                            NHC QUANTICO     100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%
          NAVY MEDICINE WEST                 100%     100%      100%     100%     100%     100%     100%     100%     100%     100%     100%     100%
                      NH CAMP PENDLETON      100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%
                             NH LEMOORE      100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%
                           NMC SAN DIEGO     100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%
                     NH TWENTYNINE PALMS     100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%
                           NH BREMERTON      100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%
                          NH OAK HARBOR      100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%
                              NHC HAWAII     100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%
                                NH GUAM      100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%
                             NH OKINAWA      100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%
                            NH YOKOSUKA      100%     100%      100%     100%     100%     100%     100%     100%     100%      100%    100%     100%

                                   Legend                      95% - 100%                                                      Navy DQMC 12/17/2011
                                                               80% - 94%                                                               Page 8 of 29
Updated: 12/8/2010                                             79% and Below
                                                               N/A
  3c. For DMHRSi, what is the percentage of submitted timecards by the suspense date?
                                         (C.1e)


                           Reporting Month   Dec 09   Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10   Oct 10     Nov 10
                               Data Month    Oct 09   Nov 09   Dec 09   Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10     Sep 10
                 NAVY                        97%      98%      97%       98%     99%       99%     99%       98%     99%      97%       99%       97%
           NAVY MEDICINE EAST                99%      99%      99%       99%     99%       99%     99%       99%     100%     98%       99%       97%
                             NH PENSACOLA     99%      99%      99%      99%     99%      98%       96%      96%      97%      97%       99%       99%
                           NH JACKSONVILLE    99%     100%     100%     100%     100%     100%     100%     100%     100%     100%      100%      100%
                          NHC GREAT LAKES    100%     100%     100%     100%     100%     100%     100%     100%     100%     100%      100%      100%
                          NH CAMP LEJEUNE     98%      97%      97%      99%     99%      99%       98%      99%     100%      99%       99%       98%
                          NH CHERRY POINT     99%      99%     100%      99%     95%      99%      100%     100%     100%      99%       97%       93%
           NAVAL HEALTH CARE NEW ENGLAND     100%     100%     100%     100%     100%     100%     100%     100%     100%     100%      100%      100%
                            NH CHARLESTON    100%     100%     100%     100%     100%     100%      97%     100%     100%     100%      100%      100%
                              NH BEAUFORT     98%     100%     100%     100%     100%     100%     100%     100%     100%     100%      100%      100%
                         NH CORPUS CHRISTI    99%     100%     100%     100%     100%     100%     100%     100%     100%     100%      100%      100%
                         NMC PORTSMOUTH       93%      94%      96%      99%     99%      96%       97%      96%      97%      94%       91%       89%
                      NH GUANTANAMO BAY       99%     100%     100%     100%     100%     100%     100%     100%     100%      99%       99%      100%
                                 NH NAPLES    99%      99%      99%     100%     100%     100%     100%      99%     100%      95%      100%       99%
                                   NH ROTA    98%      99%      96%     100%     100%     98%       94%      99%     100%      95%       94%       87%
                              NH SIGONELLA    99%      97%      99%      89%     100%     100%     100%      99%     100%     100%      100%       95%
        NATIONAL CAPITAL REGION              95%      95%      95%       98%     99%       99%     99%       98%     99%      97%       98%       98%
                          NNMC BETHESDA       97%      96%      93%      94%     97%      96%       97%      96%      95%      93%       94%       95%
                       NHC PATUXENT RIVER    100%     100%     100%     100%     100%     100%     100%     100%     100%     100%      100%      100%
                           NHC ANNAPOLIS      82%      84%      89%      98%     100%     100%     100%      97%      99%      95%      100%      100%
                            NHC QUANTICO      99%      98%      98%      98%     100%     100%      99%      99%     100%     100%       98%       98%
          NAVY MEDICINE WEST                 97%      97%      96%       97%     98%       98%     98%       97%     98%      96%       99%       96%
                      NH CAMP PENDLETON       98%      98%      98%      99%     99%      99%      100%     100%     100%     100%     100%        99%
                             NH LEMOORE       99%      98%      96%      99%     100%     100%      99%      99%      96%      96%     100%        91%
                           NMC SAN DIEGO      94%      95%      94%      94%     96%      96%       97%      97%      97%      95%      96%        95%
                     NH TWENTYNINE PALMS      93%      92%      80%      86%     94%      93%       90%      84%      97%      89%      99%        94%
                           NH BREMERTON       94%      91%      92%      95%     95%      98%       99%      94%      97%      95%      95%        91%
                          NH OAK HARBOR       95%      99%      99%      98%     100%     98%       97%      99%     100%      96%      98%        96%
                              NHC HAWAII      98%      99%     100%     100%     100%     100%     100%     100%     100%      99%     100%       100%
                                NH GUAM       99%     100%      99%      99%     100%     99%      100%      99%      99%      99%     100%        99%
                             NH OKINAWA       99%     100%     100%     100%     100%     100%     100%     100%     100%     100%     100%       100%
                            NH YOKOSUKA       99%     100%     100%     100%     100%     100%     100%     100%      97%      92%     100%        99%
                                                                                                                         Navy DQMC 12/17/2011
                                                                                                                                   Page 8 of 29


Updated: 12/8/2010
  3d. For DMHRSi, what is the percentage of approved timecards by the suspense date?
                                         (C.1f)


                           Reporting Month   Dec 09   Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10   Oct 10     Nov 10
                               Data Month    Oct 09   Nov 09   Dec 09   Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10     Sep 10
                 NAVY                        97%      98%      98%      99%      99%       99%     99%       99%     98%      98%       99%       98%
           NAVY MEDICINE EAST                99%      99%      100%     100%     100%     100%     99%       99%     99%      99%       99%       99%
                             NH PENSACOLA    100%     100%     100%      98%     99%      97%       94%      93%      96%      98%       99%       99%
                           NH JACKSONVILLE   100%     100%     100%     100%     100%     100%     100%     100%     100%     100%      100%      100%
                          NHC GREAT LAKES    100%     100%     100%     100%     100%     100%     100%     100%     100%     100%      100%      100%
                          NH CAMP LEJEUNE     98%      96%      97%     100%     100%     100%     100%     100%      99%      99%      100%       99%
                          NH CHERRY POINT     98%      98%     100%      98%     100%     99%      100%     100%      99%      99%       99%      100%
           NAVAL HEALTH CARE NEW ENGLAND     100%     100%     100%     100%     100%     100%     100%     100%     100%     100%      100%      100%
                            NH CHARLESTON    100%     100%     100%     100%     100%     100%     100%     100%     100%     100%      100%      100%
                              NH BEAUFORT    100%     100%     100%     100%     100%     100%     100%     100%     100%     100%       99%      100%
                         NH CORPUS CHRISTI   100%     100%     100%     100%     100%     100%     100%     100%     100%     100%      100%      100%
                         NMC PORTSMOUTH       91%      95%      98%      99%     98%      98%       98%      97%      95%      94%       95%       91%
                      NH GUANTANAMO BAY       99%      97%     100%     100%     100%     100%      99%     100%      99%      98%      100%       99%
                                 NH NAPLES    99%     100%     100%     100%     100%     100%     100%     100%     100%      99%      100%       99%
                                   NH ROTA   100%     100%     100%     100%     100%     100%     100%     100%     100%      97%       99%       96%
                              NH SIGONELLA   100%      98%     100%     100%     100%     100%     100%     100%     100%     100%      100%      100%
        NATIONAL CAPITAL REGION              93%      96%      95%       97%     99%       99%     99%       98%     97%      98%       99%       99%
                          NNMC BETHESDA       96%      95%      96%      96%     96%      96%       97%      96%      93%      94%       97%       96%
                       NHC PATUXENT RIVER    100%     100%     100%     100%     100%     100%     100%     100%     100%     100%      100%      100%
                           NHC ANNAPOLIS      77%      92%      86%      97%     99%      100%     100%      99%      97%     100%      100%      100%
                            NHC QUANTICO      97%      95%      97%      96%     99%      99%       98%      98%      99%      99%       97%       98%
          NAVY MEDICINE WEST                 97%      97%      96%       98%     99%       99%     99%       99%     98%      98%       98%       97%
                      NH CAMP PENDLETON       98%      99%      99%      99%     99%      99%      100%     100%     100%     100%     100%       100%
                             NH LEMOORE      100%      99%     100%      99%     100%     100%      99%     100%      95%     100%     100%        92%
                           NMC SAN DIEGO      90%      90%      88%      93%     94%      94%       94%      95%      95%      92%      93%        90%
                     NH TWENTYNINE PALMS      92%      89%      77%      92%     97%      97%       95%      99%      96%      95%      99%        96%
                           NH BREMERTON       95%      92%      98%      96%     97%      100%     100%      98%      96%      99%      96%        94%
                          NH OAK HARBOR       99%      99%      99%      99%     100%     98%       98%      99%      99%      97%      96%        96%
                              NHC HAWAII      97%      99%      98%      99%     99%      99%      100%     100%     100%      98%     100%       100%
                                NH GUAM      100%     100%     100%     100%     100%     100%     100%     100%      99%     100%     100%       100%
                             NH OKINAWA      100%     100%     100%     100%     100%     100%     100%     100%     100%     100%     100%       100%
                            NH YOKOSUKA      100%     100%     100%     100%     100%     100%     100%     100%      95%      95%     100%        99%
                                                                                                                         Navy DQMC 12/17/2011
                                                                                                                                   Page 8 of 29


Updated: 12/8/2010
    4a. Compliance with TMA or Service-Level guidance for timely submission of data (C.3).
                                   MEPRS/EAS - 45 days

                              Reporting Month   Dec 09   Jan 10   Feb 10    Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10    Sep 10   Oct 10    Nov 10
                                  Data Month    Oct 09   Nov 09   Dec 09    Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10    Jul 10   Aug 10    Sep 10
                  NAVY                          75%       0%       50%        71%    79%       89%     89%       86%      93%      100%     64%        82%
            NAVY MEDICINE EAST                  79%       0%       50%        79%    79%       93%     93%       79%     100%      100%     71%        93%
                                NH PENSACOLA     0%       0%        0%        0%      0%       0%       0%       0%      100%       100%    100%      100%
                              NH JACKSONVILLE    0%       0%        0%       100%    100%     100%     100%      0%      100%       100%     0%       100%
                             NHC GREAT LAKES    100%      0%       100%       0%     100%     100%     100%     100%     100%       100%     0%        0%
                             NH CAMP LEJEUNE    100%      0%        0%       100%    100%     100%     100%     100%     100%       100%    100%      100%
                             NH CHERRY POINT    100%      0%        0%       100%    100%     100%     100%     100%     100%       100%    100%      100%
              NAVAL HEALTH CARE NEW ENGLAND     100%      0%        0%       100%    100%     100%     100%     100%     100%       100%    100%      100%
                               NH CHARLESTON    100%      0%       100%      100%     0%      100%     100%     100%     100%       100%    100%      100%
                                 NH BEAUFORT     0%       0%       100%      100%    100%     100%     100%     100%     100%       100%    100%      100%
                            NH CORPUS CHRISTI   100%      0%        0%       100%    100%     100%     100%     100%     100%       100%    100%      100%
                            NMC PORTSMOUTH      100%      0%        0%       100%    100%     100%     100%     100%     100%       100%     0%       100%
                         NH GUANTANAMO BAY      100%      0%       100%      100%    100%     100%     100%     100%     100%       100%    100%      100%
                                    NH NAPLES   100%      0%       100%      100%    100%     100%     100%     100%     100%       100%    100%      100%
                                      NH ROTA   100%      0%       100%       0%      0%      100%     100%      0%      100%       100%     0%       100%
                                 NH SIGONELLA   100%      0%       100%      100%    100%     100%     100%     100%     100%       100%    100%      100%
         NATIONAL CAPITAL REGION                25%       0%       25%        50%    75%       75%     75%      100%     75%       100%     75%       100%
                             NNMC BETHESDA      100%      0%        0%       100%    100%     100%     100%     100%     100%       100%    100%      100%
                          NHC PATUXENT RIVER     0%       0%       100%      100%    100%     100%     100%     100%     100%       100%    100%      100%
                              NHC ANNAPOLIS      0%       0%        0%        0%      0%       0%       0%      100%      0%        100%     0%       100%
                               NHC QUANTICO      0%       0%        0%        0%     100%     100%     100%     100%     100%       100%    100%      100%
            NAVY MEDICINE WEST                  90%       0%       60%        70%    80%       90%     90%       90%     90%       100%     50%        60%
                         NH CAMP PENDLETON      100%      0%       100%      100%    100%     100%     100%     100%     100%       100%    100%      100%
                                NH LEMOORE      100%      0%        0%       100%     0%       0%       0%      100%     100%       100%     0%        0%
                              NMC SAN DIEGO      0%       0%        0%        0%      0%      100%     100%     100%     100%       100%    100%       0%
                        NH TWENTYNINE PALMS     100%      0%       100%      100%    100%     100%     100%     100%     100%       100%     0%       100%
                              NH BREMERTON      100%      0%       100%      100%    100%     100%     100%     100%     100%       100%     0%        0%
                              NH OAK HARBOR     100%      0%        0%        0%     100%     100%     100%     100%     100%       100%    100%      100%
                                 NHC HAWAII     100%      0%       100%      100%    100%     100%     100%      0%       0%        100%     0%       100%
                                   NH GUAM      100%      0%       100%      100%    100%     100%     100%     100%     100%       100%    100%      100%
                                NH OKINAWA      100%      0%        0%        0%     100%     100%     100%     100%     100%       100%    100%      100%
                               NH YOKOSUKA      100%      0%       100%      100%    100%     100%     100%     100%     100%       100%     0%        0%

                                      Legend                      95% - 100%
                                                                  80% - 94%
Updated: 12/8/2010                                                79% and Below                                                Navy DQMC 12/17/2011
                                                                  N/A                                                                  Page 9 of 29
      4b. Compliance with TMA or Service-Level guidance for timely submission of data
                                          (C.3).
                        SIDR/CHCS - 5th working day of the month
                           Reporting Month   Dec 09   Jan 10   Feb 10    Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10   Oct 10    Nov 10
                               Data Month    Oct 09   Nov 09   Dec 09    Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10    Sep 10
                 NAVY                        95%      89%       100%      95%     84%      100%     100%     100%     95%      95%      100%      100%
           NAVY MEDICINE EAST                100%     100%      100%      89%     78%      100%     100%     100%     100%     100%     100%      100%
                             NH PENSACOLA    100%     100%      100%       0%      0%      100%     100%     100%     100%     100%     100%      100%
                           NH JACKSONVILLE   100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                          NHC GREAT LAKES     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                          NH CAMP LEJEUNE    100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                          NH CHERRY POINT     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
           NAVAL HEALTH CARE NEW ENGLAND      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                            NH CHARLESTON     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                              NH BEAUFORT    100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                         NH CORPUS CHRISTI    N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                         NMC PORTSMOUTH      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                      NH GUANTANAMO BAY      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                                 NH NAPLES   100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                                   NH ROTA   100%     100%      100%      100%     0%      100%     100%     100%     100%     100%     100%      100%
                              NH SIGONELLA   100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
        NATIONAL CAPITAL REGION              100%      0%       100%     100%     100%     100%     100%     100%     100%     100%     100%      100%
                          NNMC BETHESDA      100%      0%       100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                       NHC PATUXENT RIVER     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                           NHC ANNAPOLIS      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                            NHC QUANTICO      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
          NAVY MEDICINE WEST                 89%      89%       100%     100%     89%      100%     100%     100%     89%      89%      100%      100%
                      NH CAMP PENDLETON      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                             NH LEMOORE      100%      0%       100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                           NMC SAN DIEGO     100%     100%      100%      100%    100%     100%     100%     100%      0%       0%      100%      100%
                     NH TWENTYNINE PALMS     100%     100%      100%      100%     0%      100%     100%     100%     100%     100%     100%      100%
                           NH BREMERTON      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                          NH OAK HARBOR      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                              NHC HAWAII      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                                NH GUAM       0%      100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                             NH OKINAWA      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                            NH YOKOSUKA      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%

                                   Legend                      95% - 100%                                                 Navy DQMC 12/17/2011
                                                               80% - 94%                                                          Page 10 of 29
Updated: 12/8/2010                                             79% and Below
                                                               N/A
4c. Compliance with TMA or Service-Level guidance for timely submission of data (C.3).
                     WWR/CHCS - 10th calendar day of the month

                           Reporting Month   Dec 09   Jan 10   Feb 10    Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10   Oct 10    Nov 10
                               Data Month    Oct 09   Nov 09   Dec 09    Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10    Sep 10
                 NAVY                        96%      96%       93%      100%     100%     100%     96%      100%     100%     96%      100%      100%
           NAVY MEDICINE EAST                93%      93%       86%      100%     100%     100%     93%      100%     100%     93%      100%      100%
                             NH PENSACOLA    100%      0%        0%       100%    100%     100%     100%     100%     100%     100%     100%      100%
                           NH JACKSONVILLE   100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                          NHC GREAT LAKES    100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                          NH CAMP LEJEUNE    100%     100%      100%      100%    100%     100%      0%      100%     100%     100%     100%      100%
                          NH CHERRY POINT    100%     100%       0%       100%    100%     100%     100%     100%     100%     100%     100%      100%
           NAVAL HEALTH CARE NEW ENGLAND      0%      100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                            NH CHARLESTON    100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                              NH BEAUFORT    100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                         NH CORPUS CHRISTI   100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                         NMC PORTSMOUTH      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                      NH GUANTANAMO BAY      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                                 NH NAPLES   100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                                   NH ROTA   100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                              NH SIGONELLA   100%     100%      100%      100%    100%     100%     100%     100%     100%      0%      100%      100%
        NATIONAL CAPITAL REGION              100%     100%      100%     100%     100%     100%     100%     100%     100%     100%     100%      100%
                          NNMC BETHESDA      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                       NHC PATUXENT RIVER    100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                           NHC ANNAPOLIS     100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                            NHC QUANTICO     100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
          NAVY MEDICINE WEST                 100%     100%      100%     100%     100%     100%     100%     100%     100%     100%     100%      100%
                      NH CAMP PENDLETON      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                             NH LEMOORE      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                           NMC SAN DIEGO     100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                     NH TWENTYNINE PALMS     100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                           NH BREMERTON      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                          NH OAK HARBOR      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                              NHC HAWAII     100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                                NH GUAM      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                             NH OKINAWA      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                            NH YOKOSUKA      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%

                                   Legend                      95% - 100%                                                 Navy DQMC 12/17/2011
                                                               80% - 94%                                                          Page 11 of 29
Updated: 12/8/2010                                             79% and Below
                                                               N/A
   4d. Compliance with TMA or Service-Level guidance for timely submission of data (C.3).
                                    SADR/ADM - Daily

                           Reporting Month   Dec 09   Jan 10   Feb 10    Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10    Sep 10   Oct 10     Nov 10
                               Data Month    Oct 09   Nov 09   Dec 09    Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10    Jul 10   Aug 10     Sep 10
                 NAVY                        94%       93%      91%        98%    96%       98%     99%       99%     99%       100%      100%       99%
           NAVY MEDICINE EAST                94%       92%      86%        99%    95%       99%     99%       98%     99%        99%      100%       99%
                             NH PENSACOLA    78%       72%       74%      100%    100%     100%     100%     97%      100%        97%     100%      100%
                           NH JACKSONVILLE   100%     100%       69%       99%    100%     100%     100%     98%       98%       100%     100%      100%
                          NHC GREAT LAKES    85%      100%      100%      100%    100%     97%      100%     100%     100%       100%     100%      99%
                          NH CAMP LEJEUNE    100%     100%       76%      100%     93%     100%      93%     87%      100%       100%     100%      100%
                          NH CHERRY POINT    100%     100%      100%      100%    100%     100%      93%     100%     100%       100%     100%      100%
           NAVAL HEALTH CARE NEW ENGLAND     100%     100%      100%      100%    100%     100%     100%     100%     100%       100%     100%      100%
                            NH CHARLESTON    100%     100%       87%      100%     96%     97%      100%     97%      100%       100%     100%      100%
                              NH BEAUFORT    100%      68%       67%      100%     98%     97%      100%     98%      100%       100%     100%      100%
                         NH CORPUS CHRISTI   76%      100%      100%       95%     61%     96%      100%     97%       93%       100%     100%      100%
                         NMC PORTSMOUTH      100%      89%      100%      100%     98%     100%     100%     98%      100%       100%     100%      100%
                      NH GUANTANAMO BAY      100%     100%       97%      100%    100%     97%      100%     94%       93%        90%     100%      100%
                                 NH NAPLES   100%     100%      100%       98%    100%     100%     100%     99%      100%       100%     100%      83%
                                   NH ROTA   90%       93%       81%      100%    100%     100%     100%     100%     100%       100%     100%      100%
                              NH SIGONELLA   87%       72%       49%      100%     77%     99%      100%     100%     100%       100%     100%      100%
        NATIONAL CAPITAL REGION              92%       95%      94%        96%    100%      99%     100%     100%     100%      100%      99%       100%
                          NNMC BETHESDA      81%      100%      100%       95%    100%     100%     100%     100%     100%       100%      97%      100%
                       NHC PATUXENT RIVER    90%       90%       76%       95%    100%     100%     100%     100%     100%       100%     100%      100%
                           NHC ANNAPOLIS     100%     100%      100%       94%    100%     100%     100%     100%     100%       100%     100%      100%
                            NHC QUANTICO     97%       89%      100%      100%    100%     97%      100%     100%     100%       100%     100%      100%
          NAVY MEDICINE WEST                 94%       93%      98%        97%    96%       98%     97%      100%     99%       100%      99%        99%
                      NH CAMP PENDLETON      100%     100%      100%      100%     85%     99%       98%     100%      97%       100%     100%      99%
                             NH LEMOORE      97%      100%      100%      100%    100%     100%     100%     100%     100%       100%     100%      100%
                           NMC SAN DIEGO     85%       83%      100%       98%     98%     97%      100%     100%     100%       100%     100%      97%
                     NH TWENTYNINE PALMS     83%       73%      100%      100%     87%     98%       98%     100%      98%       100%     100%      100%
                           NH BREMERTON      88%       85%      100%       82%    100%     100%     100%     100%     100%       100%      97%      100%
                          NH OAK HARBOR      100%     100%       94%      100%    100%     100%     100%     100%     100%       100%      97%      100%
                              NHC HAWAII     90%       89%      100%      100%     96%     100%      85%     100%      93%       100%     100%      100%
                                NH GUAM      100%     100%       87%      100%    100%     100%     100%     100%     100%       100%     100%      97%
                             NH OKINAWA      100%     100%      100%      100%    100%     100%     100%     100%     100%       100%     100%      100%
                            NH YOKOSUKA      100%     100%      100%       90%     96%     81%       93%     100%     100%       100%     100%      100%

                                   Legend                      95% - 100%
                                                               80% - 94%                                                    Navy DQMC 12/17/2011
Updated: 12/8/2010                                             79% and Below                                                        Page 12 of 29
                                                               N/A
                       5a. Outcome of monthly inpatient coding audit:
     What percentage of inpatient records whose assigned DRG codes were correct? (C.5c)

                           Reporting Month   Dec 09   Jan 10    Feb 10         Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10      Sep 10    Oct 10     Nov 10
                               Data Month    Oct 09   Nov 09    Dec 09         Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10      Jul 10    Aug 10     Sep 10
                 NAVY                        97%       95%       96%            96%     95%       97%     97%       95%     92%          89%       86%        97%
           NAVY MEDICINE EAST                94%       91%       94%            96%     90%       94%     95%       94%     95%          88%       84%        96%
                             NH PENSACOLA     67%     72%         72%          80%       75%     75%       75%      72%      77%         100%      79%        90%
                           NH JACKSONVILLE   100%     98%        100%          100%     100%     100%      97%      97%      97%         100%     100%       100%
                          NHC GREAT LAKES     N/A      N/A        N/A           N/A      N/A      N/A      N/A      N/A      N/A          N/A      N/A        N/A
                          NH CAMP LEJEUNE     98%     99%         95%          100%      45%     93%       97%      90%      90%          97%      90%        93%
                          NH CHERRY POINT     N/A      N/A        N/A           N/A      N/A      N/A      N/A      N/A      N/A          N/A      N/A        N/A
           NAVAL HEALTH CARE NEW ENGLAND      N/A      N/A        N/A           N/A      N/A      N/A      N/A      N/A      N/A          N/A      N/A        N/A
                            NH CHARLESTON     N/A      N/A        N/A           N/A      N/A      N/A      N/A      N/A      N/A          N/A      N/A        N/A
                              NH BEAUFORT     98%     100%        98%          98%      100%     100%     100%     100%     100%         100%      97%       100%
                         NH CORPUS CHRISTI    N/A      N/A        N/A           N/A      N/A      N/A      N/A      N/A      N/A          N/A      N/A        N/A
                         NMC PORTSMOUTH       95%     67%         97%          90%       87%     93%       90%      87%      97%          97%      90%        83%
                      NH GUANTANAMO BAY      100%     100%       100%          100%     100%     100%     100%     100%     100%           0%       0%       100%
                                 NH NAPLES   100%     100%        90%          100%     100%     100%     100%     100%     100%         100%     100%       100%
                                   NH ROTA   100%     100%       100%          100%     100%     100%     100%     100%     100%         100%     100%       100%
                              NH SIGONELLA    90%     87%         90%          96%      100%     89%      100%     100%      95%         100%      97%        96%
        NATIONAL CAPITAL REGION              96%       97%       96%            97%     96%       95%     97%       95%     87%          100%      95%       100%
                          NNMC BETHESDA       96%      97%       96%            97%      96%      95%      97%      95%      87%         100%      95%       100%
                       NHC PATUXENT RIVER     N/A      N/A       N/A            N/A      N/A      N/A      N/A      N/A      N/A          N/A      N/A        N/A
                           NHC ANNAPOLIS      N/A      N/A       N/A            N/A      N/A      N/A      N/A      N/A      N/A          N/A      N/A        N/A
                            NHC QUANTICO      N/A      N/A       N/A            N/A      N/A      N/A      N/A      N/A      N/A          N/A      N/A        N/A
           NAVY MEDICINE WEST                100%      99%       99%            96%     99%       99%     98%       97%     89%          89%       87%        99%
                      NH CAMP PENDLETON      100%     97%         97%          100%     100%     96%       97%      97%     100%         100%     100%       100%
                             NH LEMOORE      100%     100%       100%          100%     100%     100%     100%     100%     100%         100%       0%        93%
                           NMC SAN DIEGO      96%     96%         93%          93%       97%     97%       93%      97%     100%          97%      97%       100%
                     NH TWENTYNINE PALMS     100%     100%       100%          100%     100%     100%     100%     100%     100%         100%     100%       100%
                           NH BREMERTON      100%     100%       100%          100%     100%     100%     100%     100%     100%         100%     100%       100%
                           NH OAK HARBOR     100%     100%       100%          100%     100%     100%     100%     100%     100%         100%      97%       100%
                              NHC HAWAII      N/A      N/A        N/A           N/A      N/A      N/A      N/A      N/A      N/A          N/A      N/A        N/A
                                NH GUAM      100%     100%       100%          100%     100%     100%     100%     100%     100%         100%     100%       100%
                             NH OKINAWA      100%     100%        97%          93%      100%     100%     100%      97%     100%         100%     100%       100%
                            NH YOKOSUKA      100%     99%        100%          75%       97%     97%       93%      82%      0%            0%      93%        97%

                                   Legend                      95% - 100%
                                                               80% - 94%
Updated: 12/8/2010                                             79% and Below
                                                               N/A                                                                   Navy DQMC 12/17/2011
                                                                                                                                             Page 13 of 29
 5b. Inpatient Professional Services Rounds encounters E&M codes audited and deemed
                                      correct (C.5f)
                           Reporting Month   Dec 09   Jan 10   Feb 10    Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10   Oct 10    Nov 10
                               Data Month    Oct 09   Nov 09   Dec 09    Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10    Sep 10
                 NAVY                        97%      98%       97%       96%     93%       95%     97%       95%     92%      93%      91%       92%
           NAVY MEDICINE EAST                96%      96%       95%       97%     95%       94%     95%       94%     96%      96%      94%       96%
                             NH PENSACOLA     98%      93%      88%        92%    88%       93%      92%      91%      88%     100%      96%       93%
                           NH JACKSONVILLE    82%      93%      83%        94%    86%       87%      82%      67%      90%      81%      86%       88%
                          NHC GREAT LAKES     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                          NH CAMP LEJEUNE     93%     100%      96%       100%    100%      80%     100%      93%     100%     100%     100%       97%
                          NH CHERRY POINT     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
           NAVAL HEALTH CARE NEW ENGLAND      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                            NH CHARLESTON     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                              NH BEAUFORT     93%     100%      98%        94%    97%       97%      87%      97%      97%     100%     100%       97%
                         NH CORPUS CHRISTI    N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                         NMC PORTSMOUTH      100%      94%      95%        96%    95%       88%     100%     100%      90%      97%     100%       97%
                      NH GUANTANAMO BAY      100%      96%      96%        96%    93%      100%     100%     100%     100%      85%      86%       95%
                                 NH NAPLES   100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                                   NH ROTA   100%     100%      100%      100%    100%     100%     100%     100%     100%     100%      83%      100%
                              NH SIGONELLA   100%      90%      100%      100%    93%       97%      97%     100%     100%     100%      97%       94%
        NATIONAL CAPITAL REGION              87%      96%       95%       95%     92%       95%     94%       91%     93%      96%      90%       100%
                          NNMC BETHESDA       87%      96%      95%       95%      92%      95%      94%      91%      93%      96%      90%      100%
                       NHC PATUXENT RIVER     N/A      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                           NHC ANNAPOLIS      N/A      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                            NHC QUANTICO      N/A      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
          NAVY MEDICINE WEST                 99%      100%      100%      96%     91%       96%     99%       96%     87%      89%      88%       88%
                      NH CAMP PENDLETON      100%     100%      100%       97%    100%     100%     100%      89%     100%     100%     100%       96%
                             NH LEMOORE      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                           NMC SAN DIEGO      89%     100%      100%      100%    100%      89%      97%      97%      97%     100%     100%       97%
                     NH TWENTYNINE PALMS      98%     100%      97%       100%    68%       97%     100%     100%     100%     100%     100%      100%
                           NH BREMERTON      100%     100%      100%      100%    100%     100%     100%     100%      92%     100%      99%      100%
                          NH OAK HARBOR      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                              NHC HAWAII      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                                NH GUAM      100%     100%      100%       93%    97%      100%     100%     100%     100%     100%      97%      100%
                             NH OKINAWA      100%      97%      100%      100%    100%     100%     100%      97%      97%     100%     100%      100%
                            NH YOKOSUKA      100%      99%      100%       70%    55%       74%      93%      77%       0%      0%        0%        0%

                                   Legend                      95% - 100%
                                                               80% - 94%                                                  Navy DQMC 12/17/2011
Updated: 12/8/2010                                             79% and Below                                                      Page 13 of 29
                                                               N/A
5c. Inpatient Professional Services Rounds encounters ICD9 codes audited and deemed
                                     correct (C.5g)
                           Reporting Month   Dec 09   Jan 10   Feb 10    Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10   Oct 10    Nov 10
                               Data Month    Oct 09   Nov 09   Dec 09    Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10    Sep 10
                 NAVY                        95%      94%       93%       92%     93%       93%     94%       92%     90%      90%      87%       86%
           NAVY MEDICINE EAST                93%      91%       92%       92%     92%       91%     92%       90%     95%      91%      87%       84%
                             NH PENSACOLA     85%      74%      75%        67%    81%       68%      66%      63%      88%      85%      77%       73%
                           NH JACKSONVILLE    70%      73%      95%        86%    91%       94%      92%      81%      96%      65%      61%       57%
                          NHC GREAT LAKES     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                          NH CAMP LEJEUNE     97%      88%      86%        96%    62%       75%      96%      96%      88%      87%      92%       88%
                          NH CHERRY POINT     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
           NAVAL HEALTH CARE NEW ENGLAND      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                            NH CHARLESTON     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                              NH BEAUFORT     94%      95%      96%        99%    100%     100%      97%      89%      96%      95%      90%       98%
                         NH CORPUS CHRISTI    N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                         NMC PORTSMOUTH      100%      96%      98%       100%    96%       93%      98%      92%      88%      98%      95%       92%
                      NH GUANTANAMO BAY       94%     100%      97%        98%    100%      95%      90%      92%     100%      94%      95%       88%
                                 NH NAPLES   100%     100%      100%       93%    100%     100%     100%     100%     100%     100%     100%      100%
                                   NH ROTA   100%     100%      87%       100%    100%     100%     100%     100%     100%     100%      78%       87%
                              NH SIGONELLA    97%      93%      92%        87%    96%       95%      92%      94%      98%      96%      95%       77%
        NATIONAL CAPITAL REGION              92%      88%       96%       96%     94%      100%     96%       95%     96%      97%      95%       97%
                          NNMC BETHESDA       92%      88%      96%       96%      94%     100%      96%      95%      96%      97%      95%       97%
                       NHC PATUXENT RIVER     N/A      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                           NHC ANNAPOLIS      N/A      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                            NHC QUANTICO      N/A      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
          NAVY MEDICINE WEST                 98%      97%       94%       93%     95%       94%     96%       95%     85%      88%      85%       87%
                      NH CAMP PENDLETON      100%      97%      100%      100%    100%     100%     100%      92%     100%     100%     100%      100%
                             NH LEMOORE      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                           NMC SAN DIEGO      98%     100%      84%       100%    98%       98%      98%     100%      98%      96%     100%       92%
                     NH TWENTYNINE PALMS     100%      99%      97%        85%    88%       79%      88%      94%      99%      99%      96%       99%
                           NH BREMERTON      100%     100%      100%      100%    100%     100%     100%     100%      93%      99%      89%      100%
                          NH OAK HARBOR      100%     100%      100%      100%    100%      98%     100%      96%      99%      99%      98%       98%
                              NHC HAWAII      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                                NH GUAM       87%      80%      83%        73%    90%       97%      93%     100%      83%     100%      93%       98%
                             NH OKINAWA       97%     100%      83%        90%    100%      90%     100%      97%      97%     100%      93%       95%
                            NH YOKOSUKA      100%     100%      100%       85%    77%       80%      84%      73%       0%       0%       0%        0%

                                   Legend                      95% - 100%
                                                               80% - 94%                                                  Navy DQMC 12/17/2011
Updated: 12/8/2010                                             79% and Below                                                      Page 13 of 29
                                                               N/A
    5d. Inpatient Professional Services Rounds encounters CPT codes audited and deemed
                                         correct (C.5h)
                           Reporting Month   Dec 09   Jan 10   Feb 10    Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10       Sep 10   Oct 10     Nov 10
                               Data Month    Oct 09   Nov 09   Dec 09    Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10       Jul 10   Aug 10     Sep 10
                 NAVY                        96%       95%      97%       96%     95%       95%     96%       93%     92%           92%      89%        88%
           NAVY MEDICINE EAST                92%       93%      96%       94%     93%       93%     93%       90%     97%           96%      93%        92%
                             NH PENSACOLA    98%      100%       93%      93%      76%     90%       78%     79%      95%          100%       81%      94%
                           NH JACKSONVILLE   53%       84%       95%      70%      61%     100%      79%     67%      82%          85%        75%      64%
                          NHC GREAT LAKES     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A
                          NH CAMP LEJEUNE    89%       93%      100%      100%    100%     73%       96%     98%      100%         93%       100%      86%
                          NH CHERRY POINT     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A
           NAVAL HEALTH CARE NEW ENGLAND      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A
                            NH CHARLESTON     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A
                              NH BEAUFORT    97%      100%       95%      94%     100%     100%      95%     83%      100%         100%      100%      94%
                         NH CORPUS CHRISTI    N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A
                         NMC PORTSMOUTH      100%      67%      100%      100%    100%     80%       89%     100%     100%         94%        97%      100%
                      NH GUANTANAMO BAY      100%      93%       95%      96%     100%     100%     100%     85%      100%         100%      100%      90%
                                 NH NAPLES   100%     100%      100%      100%    100%     100%     100%     100%     100%         100%      100%      100%
                                   NH ROTA   100%     100%      100%      100%    100%     100%     100%     100%     100%         100%       83%      100%
                              NH SIGONELLA   92%      100%       87%      96%     100%     94%       96%     100%     96%          96%       100%      96%
        NATIONAL CAPITAL REGION              100%     100%      100%      100%    100%      99%     100%     100%     100%          99%      95%        69%
                          NNMC BETHESDA      100%     100%      100%      100%    100%      99%     100%     100%     100%          99%      95%        69%
                       NHC PATUXENT RIVER     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A      N/A        N/A
                           NHC ANNAPOLIS      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A      N/A        N/A
                            NHC QUANTICO      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A      N/A        N/A
          NAVY MEDICINE WEST                 99%       97%      98%       98%     97%       97%     99%       96%     86%           86%      85%        86%
                      NH CAMP PENDLETON      100%     100%      100%      100%    100%     100%     100%     63%      100%         100%      100%      100%
                             NH LEMOORE      100%     100%      100%      100%    100%     100%     100%     100%     100%         100%      100%      100%
                           NMC SAN DIEGO     94%       92%       85%      89%     100%     100%     100%     100%     100%         88%       100%      100%
                     NH TWENTYNINE PALMS     98%      100%      100%      100%     85%     97%       97%     100%     100%         100%       90%      100%
                           NH BREMERTON      100%     100%      100%      100%    100%     100%     100%     100%     100%         100%      100%      100%
                          NH OAK HARBOR      100%     100%      100%      100%    100%     100%     100%     100%     100%         100%      100%      100%
                              NHC HAWAII      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A
                                NH GUAM      97%       83%      100%      97%      97%     100%      97%     100%     83%          88%        97%      97%
                             NH OKINAWA      100%     100%       93%      100%    100%     97%      100%     100%     93%          100%       80%      81%
                            NH YOKOSUKA      100%     100%      100%      96%      87%     80%       96%     100%      0%           0%        0%        0%

                                   Legend                      95% - 100%
                                                               80% - 94%
Updated: 12/8/2010                                             79% and Below
                                                                                                                               Navy DQMC 12/17/2011
                                                               N/A
                                                                                                                                       Page 13 of 29
 5e. What percentage of completed and current (signed within the past 12 months) DD Form
               2569s (TPC insurance info) are available for audit (Inpatient)?
                           Reporting Month   Dec 09   Jan 10   Feb 10    Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10       Sep 10   Oct 10     Nov 10
                               Data Month    Oct 09   Nov 09   Dec 09    Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10       Jul 10   Aug 10     Sep 10
                 NAVY                        98%       84%      85%       79%     86%       91%     91%       88%     92%           91%      97%        95%
           NAVY MEDICINE EAST                96%       72%      73%       68%     79%       83%     88%       83%     92%           84%      96%        89%
                             NH PENSACOLA    96%      100%       96%      63%     100%     100%      93%     100%     100%         100%       90%      97%
                           NH JACKSONVILLE   100%      95%       96%      100%    100%     100%      93%     100%     100%         100%      100%      93%
                          NHC GREAT LAKES     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A
                          NH CAMP LEJEUNE    87%       66%       54%      50%      75%     100%      93%     95%      100%         92%       100%      96%
                          NH CHERRY POINT     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A
           NAVAL HEALTH CARE NEW ENGLAND      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A
                            NH CHARLESTON     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A
                              NH BEAUFORT    100%     100%      100%      100%    100%     100%     100%     100%     100%         100%      100%      100%
                         NH CORPUS CHRISTI    N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A
                         NMC PORTSMOUTH      97%       0%        94%      95%      96%     100%      88%     100%     100%         100%      100%      100%
                      NH GUANTANAMO BAY       N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A
                                 NH NAPLES    N/A      N/A       0%        0%      0%       0%       58%      0%      50%           9%        86%      50%
                                   NH ROTA    N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A
                              NH SIGONELLA    N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A
        NATIONAL CAPITAL REGION              100%     100%      100%      96%     98%       96%     100%      98%     99%           99%      99%       100%
                          NNMC BETHESDA      100%     100%      100%       96%     98%      96%     100%      98%      99%          99%      99%       100%
                       NHC PATUXENT RIVER     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A      N/A        N/A
                           NHC ANNAPOLIS      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A      N/A        N/A
                            NHC QUANTICO      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A      N/A        N/A
          NAVY MEDICINE WEST                 99%       89%      92%       86%     90%       97%     93%       92%     92%           96%      97%        98%
                      NH CAMP PENDLETON      100%     100%       61%      80%      89%     98%       85%     89%      89%          93%        89%      93%
                             NH LEMOORE      100%      93%       93%      85%     100%     100%     100%     99%      92%          90%        93%      97%
                           NMC SAN DIEGO     100%      36%       93%      42%      43%     88%       75%     56%      67%          95%       100%      98%
                     NH TWENTYNINE PALMS     100%     100%      100%      100%     98%     100%     100%     100%     100%         100%      100%      100%
                           NH BREMERTON      100%     100%      100%      96%     100%     100%      96%     100%     96%          100%      100%      100%
                          NH OAK HARBOR      90%       97%      100%      100%    100%     95%      100%     100%     100%         92%       100%      100%
                              NHC HAWAII      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A
                                NH GUAM      100%     100%      100%      97%     100%     100%      97%     97%      100%         100%      100%      100%
                             NH OKINAWA       N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A
                            NH YOKOSUKA       N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A

                                   Legend                      95% - 100%
                                                               80% - 94%
Updated: 12/8/2010                                             79% and Below
                                                               N/A                                                             Navy DQMC 12/17/2011
                                                                                                                                       Page 13 of 29
     5f. What percentage of available, current and complete DD form 2569s are verified to be
          current in the patient insurance information (PII) module in CHCS (Inpatient)?
                           Reporting Month   Dec 09   Jan 10   Feb 10    Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10       Sep 10   Oct 10     Nov 10
                               Data Month    Oct 09   Nov 09   Dec 09    Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10       Jul 10   Aug 10     Sep 10
                 NAVY                        98%       90%      99%       99%     100%     99%      100%     100%     100%         100%     100%       100%
           NAVY MEDICINE EAST                95%       73%      97%       97%     100%     100%     100%     100%     100%         100%     100%       100%
                             NH PENSACOLA    100%      93%      100%      100%    100%     100%     100%     100%     100%         100%      100%      100%
                           NH JACKSONVILLE   100%     100%      100%      100%    100%     100%     100%     100%     100%         100%      100%      100%
                          NHC GREAT LAKES     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A
                          NH CAMP LEJEUNE    77%       73%       84%      83%     100%     100%     100%     100%     100%         100%      100%      100%
                          NH CHERRY POINT     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A
           NAVAL HEALTH CARE NEW ENGLAND      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A
                            NH CHARLESTON     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A
                              NH BEAUFORT    100%     100%      100%      100%    100%     100%     100%     100%     100%         100%      100%      100%
                         NH CORPUS CHRISTI    N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A
                         NMC PORTSMOUTH      100%      0%       100%      100%    100%     100%     100%     100%     100%         100%      100%      100%
                      NH GUANTANAMO BAY       N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A
                                 NH NAPLES    N/A      N/A       N/A       N/A     N/A      N/A     100%      N/A     100%         100%      100%      100%
                                   NH ROTA    N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A
                              NH SIGONELLA    N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A
        NATIONAL CAPITAL REGION              100%     100%      100%      100%    100%     100%     100%      98%     100%         100%      99%       100%
                          NNMC BETHESDA      100%     100%      100%      100%    100%     100%     100%      98%     100%         100%      99%       100%
                       NHC PATUXENT RIVER     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A      N/A        N/A
                           NHC ANNAPOLIS      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A      N/A        N/A
                            NHC QUANTICO      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A      N/A        N/A
          NAVY MEDICINE WEST                 99%      100%      100%      100%    100%      99%     100%     100%     100%         100%     100%       100%
                      NH CAMP PENDLETON      100%     100%      100%      100%    100%     100%     100%     100%     100%         100%      100%      100%
                             NH LEMOORE      100%     100%      100%      100%    100%     100%     100%     100%     100%         100%      100%      100%
                           NMC SAN DIEGO     100%     100%      100%      100%    100%     100%     100%     100%     100%         100%      100%      100%
                     NH TWENTYNINE PALMS     100%     100%      100%      100%    100%     100%     100%     100%     100%         100%      100%      100%
                           NH BREMERTON      96%      100%      100%      100%    100%     100%     100%     100%     100%         100%      100%      100%
                          NH OAK HARBOR      100%     100%      100%      100%    100%     91%      100%     100%     100%         100%      100%      100%
                              NHC HAWAII      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A
                                NH GUAM      100%     100%      100%      100%    100%     100%     100%     100%     100%         100%      100%      100%
                             NH OKINAWA       N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A
                            NH YOKOSUKA       N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A          N/A       N/A       N/A

                                   Legend                      95% - 100%
                                                               80% - 94%
Updated: 12/8/2010                                             79% and Below
                                                               N/A                                                             Navy DQMC 12/17/2011
                                                                                                                                       Page 13 of 29
          6a. Is the documentation of the encounter selected to be audited available?
        Documentation includes documentation in the medical record, loose (hard copy)
         documentation or an electronic record of the encounter in AHLTA (Outpatient).
                                        (Denominator equals sample size.)
                    Reporting Month Dec 09 Jan 10 Feb 10
                                                          (C.6) Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10
                                                         Mar 10
                                Data Month   Oct 09   Nov 09   Dec 09    Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10    Jul 10   Aug 10   Sep 10
                 NAVY                        100%     100%      100%     100%     100%     100%     100%      99%     99%       100%     100%     100%
           NAVY MEDICINE EAST                100%     99%       100%     100%     100%     100%     100%      98%     100%      100%     100%     99%
                             NH PENSACOLA    100%     100%      100%     100%     100%     100%     100%     71%      100%      100%     100%     100%
                           NH JACKSONVILLE   100%     93%       100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                          NHC GREAT LAKES    100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                          NH CAMP LEJEUNE    100%     100%      99%      97%      93%      100%     100%     100%     100%      100%     100%     100%
                          NH CHERRY POINT    100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
           NAVAL HEALTH CARE NEW ENGLAND     98%      97%       98%      100%     100%     100%     99%      99%      98%       99%      99%      99%
                            NH CHARLESTON    100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     93%
                              NH BEAUFORT    100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                         NH CORPUS CHRISTI   100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                         NMC PORTSMOUTH      99%      100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                      NH GUANTANAMO BAY      100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                                 NH NAPLES   100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                                   NH ROTA   100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                              NH SIGONELLA   100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     97%      100%
        NATIONAL CAPITAL REGION              100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                          NNMC BETHESDA      100%     100%      99%      100%     100%     98%      100%     98%      100%      100%     98%      100%
                       NHC PATUXENT RIVER    100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                           NHC ANNAPOLIS     100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                            NHC QUANTICO     100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
          NAVY MEDICINE WEST                 100%     100%      100%     100%     100%     100%     100%     100%     99%       100%     100%     100%
                      NH CAMP PENDLETON      100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                             NH LEMOORE      100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                           NMC SAN DIEGO     100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                     NH TWENTYNINE PALMS     100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                           NH BREMERTON      100%     100%      100%     100%     100%     100%     100%     100%     97%       97%      100%     100%
                          NH OAK HARBOR      100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                              NHC HAWAII     100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                                NH GUAM      100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                             NH OKINAWA      100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                            NH YOKOSUKA      100%     100%      100%     100%     100%     100%     100%     100%     90%       100%     100%     100%
                                                                                                                               Navy DQMC 12/17/2011
                                   Legend                      95% - 100%                                                              Page 14 of 29
                                                               80% - 94%
Updated: 12/8/2010                                             79% and Below
                                                               N/A
         6b. What is the percentage of E & M codes deemed correct (Outpatient)? (C.6)


                           Reporting Month   Dec 09   Jan 10   Feb 10    Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10   Oct 10    Nov 10
                               Data Month    Oct 09   Nov 09   Dec 09    Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10    Sep 10
                 NAVY                        85%      86%       84%       82%     81%       83%     79%       82%     80%      80%      80%       77%
           NAVY MEDICINE EAST                85%      85%       85%       83%     82%       85%     83%       86%     85%      81%      79%       75%
                             NH PENSACOLA     76%      69%      64%       66%      65%      64%      58%      67%      79%      75%      82%       80%
                           NH JACKSONVILLE    81%      71%      81%       76%      69%      84%     100%      87%      69%      70%      71%       67%
                          NHC GREAT LAKES     90%      95%      93%       92%      95%     100%      92%      96%      96%      96%      70%       69%
                          NH CAMP LEJEUNE     80%      60%      74%       69%      46%      67%      76%      79%      77%      72%      23%       75%
                          NH CHERRY POINT     95%      98%      95%       86%      86%      93%      92%      84%      97%      93%      91%       71%
           NAVAL HEALTH CARE NEW ENGLAND      95%      86%      94%       91%      88%      89%      89%     100%      90%      93%      90%       83%
                            NH CHARLESTON    100%     100%      100%      95%      95%      84%      90%      77%      87%      83%      87%       83%
                              NH BEAUFORT     84%      85%      84%       96%      97%      90%      87%      90%      87%      80%      87%       80%
                         NH CORPUS CHRISTI    91%      93%      96%       93%      95%      98%      90%      90%      93%      90%      97%       80%
                         NMC PORTSMOUTH       64%      79%      54%       63%      66%      65%      70%      72%      82%      67%      73%       72%
                      NH GUANTANAMO BAY       96%      94%      94%       93%      93%      90%      91%      96%      94%      83%      78%       63%
                                 NH NAPLES    78%      79%      88%       82%      84%      89%      82%      73%      90%      71%      93%      100%
                                   NH ROTA    80%      98%      86%       78%      79%      90%      75%      98%      76%      79%      93%       77%
                              NH SIGONELLA    82%      84%      81%       75%      90%      89%      63%      90%      74%      87%      67%       44%
        NATIONAL CAPITAL REGION              81%      90%       81%       78%     80%       80%     78%       80%     68%      82%      87%       77%
                          NNMC BETHESDA       94%      84%      74%       84%      67%      87%      92%      88%      63%      85%      92%       51%
                       NHC PATUXENT RIVER    100%      96%      86%       80%      74%      82%      85%      74%      83%      86%      97%       94%
                           NHC ANNAPOLIS      64%      87%      80%       75%      86%      92%      75%      81%      58%      74%      85%       73%
                            NHC QUANTICO      66%      94%      82%       74%      91%      59%      59%      78%      69%      81%      73%       90%
          NAVY MEDICINE WEST                 85%      86%       84%       82%     80%       82%     76%       79%     76%      77%      80%       80%
                      NH CAMP PENDLETON       81%      77%      90%        50%    73%       77%      60%      64%      57%      67%      68%       72%
                             NH LEMOORE       81%      80%      71%        92%    74%       92%      80%      71%      75%      96%      90%       80%
                           NMC SAN DIEGO      97%      97%      94%       100%    97%       97%      97%      97%      94%      97%      93%       93%
                     NH TWENTYNINE PALMS      67%      80%      67%        90%    54%       86%      84%      72%      71%      92%      79%       82%
                           NH BREMERTON       67%      83%      90%        73%    87%       80%      70%      80%      61%      61%      75%       77%
                          NH OAK HARBOR       97%      97%      91%        97%    94%       93%      97%      81%      88%      87%      87%       90%
                              NHC HAWAII      97%      90%      92%        90%    85%       89%      90%      95%      90%      94%     100%       93%
                                NH GUAM       68%      80%      80%        89%    63%       71%      77%      78%      80%      66%      75%       70%
                             NH OKINAWA       97%      74%      65%        73%    72%       72%      45%      64%      81%      51%      46%       80%
                            NH YOKOSUKA      100%      99%      100%       70%    100%      58%      57%      87%      67%      60%      90%       60%

                                   Legend                      95% - 100%
                                                               80% - 94%
                                                                                                                          Navy DQMC 12/17/2011
Updated: 12/8/2010                                             79% and Below
                                                                                                                                  Page 15 of 29
                                                               N/A
          6c. What is the percentage of ICD-9 codes deemed correct (Outpatient)? (C.6)


                           Reporting Month   Dec 09   Jan 10   Feb 10    Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10   Oct 10    Nov 10
                               Data Month    Oct 09   Nov 09   Dec 09    Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10    Sep 10
                 NAVY                        90%      91%       91%       90%     90%       88%     88%       91%     90%      86%      87%       87%
           NAVY MEDICINE EAST                90%      90%       92%       90%     90%       88%     90%       91%     91%      84%      87%       85%
                             NH PENSACOLA     78%      70%      70%       72%      71%      61%      78%      85%      82%      83%      91%       86%
                           NH JACKSONVILLE    83%      84%      92%       88%      75%      93%      93%      90%      90%      76%      85%       89%
                          NHC GREAT LAKES     98%      94%      91%       91%      95%      97%      91%      96%      98%     100%      90%       70%
                          NH CAMP LEJEUNE     80%      65%      87%       81%      85%      80%      71%      87%      90%      30%      71%       86%
                          NH CHERRY POINT     94%      98%      99%       98%      96%      92%      97%      98%     100%     100%      95%       84%
           NAVAL HEALTH CARE NEW ENGLAND      95%      91%      97%       93%      96%      94%      93%      97%      97%      94%      95%       94%
                            NH CHARLESTON    100%     100%      100%      95%      99%      61%      97%      87%      82%      90%      87%       86%
                              NH BEAUFORT     95%      91%      95%       91%      94%      91%      96%      96%      81%      91%      82%       90%
                         NH CORPUS CHRISTI    92%      93%      98%       98%      95%      95%      97%      97%     100%      93%      93%       76%
                         NMC PORTSMOUTH       80%      98%      81%       75%      79%      88%      83%      81%      80%      79%      72%       87%
                      NH GUANTANAMO BAY       98%      97%      97%       95%      96%      97%      95%      95%      94%      85%      86%       87%
                                 NH NAPLES    85%      93%      91%       93%      96%      96%      89%      86%      96%      81%     100%       93%
                                   NH ROTA    90%      97%      93%       94%      89%      89%      88%      97%      95%      89%      82%       80%
                              NH SIGONELLA    97%      92%      92%       95%      96%      95%      92%      87%      95%      89%      82%       82%
        NATIONAL CAPITAL REGION              90%      93%       90%       90%     89%       88%     86%       88%     88%      88%      91%       95%
                          NNMC BETHESDA       97%      95%      95%       95%      90%      94%      90%      92%      95%     100%      96%       93%
                       NHC PATUXENT RIVER     94%      96%      89%       91%      81%      88%      83%      78%      91%      87%      90%       95%
                           NHC ANNAPOLIS      86%      95%      84%       98%      90%      85%      83%      90%      81%      83%      93%       90%
                            NHC QUANTICO      81%      87%      93%       76%      94%      86%      86%      91%      84%      81%      84%      100%
          NAVY MEDICINE WEST                 90%      91%       90%       90%     91%       88%     87%       91%     89%      89%      85%       86%
                      NH CAMP PENDLETON       93%      84%      82%       80%     79%       78%      75%      96%      67%      86%      83%       79%
                             NH LEMOORE       88%      85%      82%       96%     90%       97%      91%      93%      80%      94%      95%       84%
                           NMC SAN DIEGO      98%      95%      89%       96%     90%       95%      97%      95%      96%      98%      98%       94%
                     NH TWENTYNINE PALMS      80%     100%      80%       97%     90%       86%      84%      60%      90%      96%      80%       92%
                           NH BREMERTON       93%      87%      90%       93%     97%       83%      80%      87%      94%      84%      83%       96%
                          NH OAK HARBOR       91%      90%      98%       98%     98%       96%      93%      96%      94%      98%      98%       91%
                              NHC HAWAII      93%      98%      97%       97%     95%       97%      98%      96%      93%      98%     100%       98%
                                NH GUAM       91%      93%      94%       95%     88%       90%      93%      90%      93%      93%      97%       88%
                             NH OKINAWA       72%      83%      85%       84%     85%       85%      77%      95%      96%      70%      77%       82%
                            NH YOKOSUKA      100%      99%      100%      62%     100%      72%      80%      97%      85%      72%      40%       57%

                                   Legend                      95% - 100%
                                                               80% - 94%
Updated: 12/8/2010                                             79% and Below                                              Navy DQMC 12/17/2011
                                                                                                                                  Page 16 of 29
                                                               N/A
           6d. What is the percentage of CPT codes deemed correct (Outpatient)? (C.6)


                           Reporting Month   Dec 09   Jan 10   Feb 10    Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10   Oct 10    Nov 10
                               Data Month    Oct 09   Nov 09   Dec 09    Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10    Sep 10
                 NAVY                        90%      91%       90%       89%     90%       90%     89%       88%     89%      92%      87%       87%
           NAVY MEDICINE EAST                91%      89%       90%       89%     91%       91%     91%       87%     88%      91%      83%       84%
                             NH PENSACOLA     73%      85%      79%       81%     69%       80%      82%      80%      95%      83%      89%       97%
                           NH JACKSONVILLE    80%      71%      80%       86%     82%       97%      91%      90%      78%      92%      88%       95%
                          NHC GREAT LAKES     96%      95%      95%       98%     96%       96%      96%     100%     100%      96%      68%       87%
                          NH CAMP LEJEUNE     84%      64%      73%       45%     66%       75%      86%      73%      37%      57%      88%       76%
                          NH CHERRY POINT     99%     100%      99%       98%     95%       97%      94%     100%     100%     100%      98%       88%
           NAVAL HEALTH CARE NEW ENGLAND      96%      91%      96%       96%     98%       95%      97%      89%      98%      98%     100%       82%
                            NH CHARLESTON    100%     100%      100%      97%     98%       88%      97%      77%      93%      92%      98%       84%
                              NH BEAUFORT     91%      95%      91%       97%     100%      92%      94%      92%      97%      96%      98%       93%
                         NH CORPUS CHRISTI    95%      94%      96%       97%     99%       97%     100%     100%      97%     100%      96%      100%
                         NMC PORTSMOUTH       91%      73%      77%       80%     81%       86%      75%      79%      78%      89%      87%       79%
                      NH GUANTANAMO BAY       98%      95%      98%       98%     95%      100%      95%      96%      99%      92%      87%       90%
                                 NH NAPLES    96%      93%      97%       94%     95%       86%      85%      79%     100%      92%      92%       51%
                                   NH ROTA    96%      95%      93%       94%     96%       90%      93%      74%      77%      93%       0%       73%
                              NH SIGONELLA    80%      90%      83%       90%     98%       92%      82%      84%      77%      89%      78%       74%
        NATIONAL CAPITAL REGION              90%      91%       93%       84%     92%       84%     91%       94%     91%      96%      95%       95%
                          NNMC BETHESDA      100%     100%      100%      70%      84%      97%     100%      95%      73%      88%      88%       82%
                       NHC PATUXENT RIVER    100%     100%      94%       95%      98%      99%      97%      96%      95%      95%      95%      100%
                           NHC ANNAPOLIS      68%      82%      90%       77%      97%      67%      94%      98%      97%     100%      98%       98%
                            NHC QUANTICO      91%      82%      88%       92%      87%      73%      73%      87%      98%     100%     100%      100%
          NAVY MEDICINE WEST                 89%      95%       90%       92%     89%       93%     86%       89%     91%      91%      88%       90%
                      NH CAMP PENDLETON       79%      88%      66%        78%    68%       84%      74%      89%      63%      95%      70%       90%
                             NH LEMOORE       91%      97%      81%        95%    84%       95%      86%      71%      92%      97%      90%      100%
                           NMC SAN DIEGO      93%      97%      90%        98%    95%      100%     100%     100%     100%      96%     100%       94%
                     NH TWENTYNINE PALMS      75%      97%      97%        97%    90%      100%     100%      82%      95%      98%      91%       87%
                           NH BREMERTON       90%      93%      93%        90%    87%       93%      83%      87%      84%      90%      82%       95%
                          NH OAK HARBOR      100%     100%      100%      100%    97%       94%      94%     100%     100%     100%      97%       92%
                              NHC HAWAII      95%      92%      95%        95%    92%       94%      96%      73%      93%     100%      94%       96%
                                NH GUAM       92%      95%      94%       100%    92%       96%      93%      96%      96%      88%      91%       92%
                             NH OKINAWA       74%      87%      86%        88%    88%       88%      79%      88%      91%      81%      82%       72%
                            NH YOKOSUKA      100%     100%      100%       75%    100%      81%      56%     100%     100%      67%      83%       78%

                                   Legend                      95% - 100%
                                                               80% - 94%
                                                                                                                          Navy DQMC 12/17/2011
Updated: 12/8/2010                                             79% and Below
                                                                                                                                  Page 17 of 29
                                                               N/A
   6e. What percentage of completed and current (signed within the past 12 months) DD
          Form 2569s (TPC Insurance Info) are available for audit (Outpatient)?
                                         (C.6)
                           Reporting Month   Dec 09   Jan 10   Feb 10    Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10   Oct 10    Nov 10
                               Data Month    Oct 09   Nov 09   Dec 09    Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10    Sep 10
                 NAVY                        78%      78%       73%       75%     76%       74%     77%       73%     76%      76%      75%       74%
           NAVY MEDICINE EAST                75%      73%       59%       64%     64%       64%     64%       60%     65%      68%      69%       68%
                             NH PENSACOLA     71%      67%      61%       63%     100%      60%      61%      54%      67%      69%      63%       67%
                           NH JACKSONVILLE   100%      88%      85%       88%     84%       90%      93%      60%      60%      83%      67%       90%
                          NHC GREAT LAKES     44%      70%      50%       50%     50%       74%      72%      72%      57%      67%      75%       75%
                          NH CAMP LEJEUNE     75%      67%      53%       57%     100%      79%      83%      70%      81%     100%     100%       82%
                          NH CHERRY POINT     94%      95%      48%       77%     65%       70%      80%      92%     100%     100%      93%       81%
           NAVAL HEALTH CARE NEW ENGLAND      78%      81%      76%       76%     67%       72%      60%      66%      73%      80%      70%       94%
                            NH CHARLESTON     92%      92%      92%       96%     93%       93%      99%      94%      95%      97%      96%       90%
                              NH BEAUFORT     77%      80%      77%       75%     80%       80%      81%      84%      86%      83%      84%       82%
                         NH CORPUS CHRISTI    96%      91%      96%       96%     50%       70%      58%      50%      64%      67%      77%       59%
                         NMC PORTSMOUTH       20%       0%      8%        24%     13%       14%      17%      21%      27%       5%      20%       22%
                      NH GUANTANAMO BAY       N/A      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                                 NH NAPLES    N/A      N/A      0%         0%      0%        0%       0%       0%       0%       0%      15%        6%
                                   NH ROTA    N/A      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                              NH SIGONELLA    N/A      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
        NATIONAL CAPITAL REGION              86%      83%       84%       84%     85%       84%     86%       85%     84%      86%      87%       81%
                          NNMC BETHESDA       50%      48%      50%        50%    50%       40%      50%      44%      40%      50%      50%       30%
                       NHC PATUXENT RIVER     92%      90%      89%        89%    89%       95%      95%      96%      95%      96%      96%       95%
                           NHC ANNAPOLIS     100%     100%      100%      100%    100%     100%     100%     100%     100%      96%     100%      100%
                            NHC QUANTICO     100%      95%      97%        98%    99%       99%     100%      99%     100%     100%     100%      100%
          NAVY MEDICINE WEST                 78%      81%       87%       87%     89%       82%     91%       85%     88%      83%      78%       79%
                      NH CAMP PENDLETON       87%      80%      97%       94%     94%       97%     100%     100%     100%      97%      96%       90%
                             NH LEMOORE       74%      76%      95%       88%     89%       91%      83%      81%      79%      79%      79%       77%
                           NMC SAN DIEGO      38%      50%      67%       50%     62%        0%      92%      36%      67%      31%      18%       50%
                     NH TWENTYNINE PALMS      90%      90%      100%      97%     97%       97%     100%     100%     100%     100%     100%      100%
                           NH BREMERTON       86%      70%      71%       81%     89%       87%      79%      90%      87%      75%      95%       70%
                          NH OAK HARBOR       72%     100%      93%       90%     87%       83%      90%      90%      70%      83%      90%       93%
                              NHC HAWAII      96%     100%      95%       98%     100%     100%      90%      87%     100%     100%      50%       58%
                                NH GUAM       N/A      N/A      80%       97%     97%      100%      93%      97%     100%      97%      97%       97%
                             NH OKINAWA       N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                            NH YOKOSUKA       N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A

                                   Legend                      95% - 100%                                                 Navy DQMC 12/17/2011
                                                               80% - 94%                                                          Page 18 of 29
Updated: 12/8/2010                                             79% and Below
                                                               N/A
6f. What percentage of available, current and complete DD Form 2569s are verified to be
  correct in the Patient Insurance Information (PII) module in CHCS (Outpatient)? (C.6)

                           Reporting Month   Dec 09   Jan 10   Feb 10    Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10   Oct 10    Nov 10
                               Data Month    Oct 09   Nov 09   Dec 09    Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10    Sep 10
                 NAVY                        97%      93%       98%       99%     100%      95%     100%     100%     100%     100%     96%       100%
           NAVY MEDICINE EAST                95%      87%       96%       99%     100%     100%     100%     100%     100%     100%     91%       100%
                             NH PENSACOLA    100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                           NH JACKSONVILLE   100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                          NHC GREAT LAKES    100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                          NH CAMP LEJEUNE     50%      72%       70%       91%    100%     100%     100%     100%     100%     100%     100%      100%
                          NH CHERRY POINT    100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
           NAVAL HEALTH CARE NEW ENGLAND     100%     100%      100%       99%    100%     98%      100%     100%     100%     100%     100%       98%
                            NH CHARLESTON    100%     100%       93%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                              NH BEAUFORT    100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                         NH CORPUS CHRISTI   100%     100%      100%      100%    100%     100%     100%     100%     100%     100%      0%       100%
                         NMC PORTSMOUTH      100%       0%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                      NH GUANTANAMO BAY       N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                                 NH NAPLES    N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A     100%      100%
                                   NH ROTA    N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                              NH SIGONELLA    N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
        NATIONAL CAPITAL REGION              99%      98%       97%      100%     100%     100%     100%      99%     100%     100%     100%      100%
                          NNMC BETHESDA      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       99%
                       NHC PATUXENT RIVER    100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                           NHC ANNAPOLIS     100%     100%      100%      100%    100%     100%     100%      97%     100%     100%     100%      100%
                            NHC QUANTICO      97%      93%       87%       98%    99%      99%      100%      99%     100%     100%     100%      100%
          NAVY MEDICINE WEST                 99%      99%       100%     100%     100%      87%     100%     100%     100%     100%     100%      99%
                      NH CAMP PENDLETON       94%      90%      100%       97%    100%     94%      100%      97%     100%     100%     100%      100%
                             NH LEMOORE      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                           NMC SAN DIEGO     100%     100%      100%      100%    100%      0%      100%     100%     100%     100%     100%      100%
                     NH TWENTYNINE PALMS     100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                           NH BREMERTON      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                          NH OAK HARBOR      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                              NHC HAWAII     100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       95%
                                NH GUAM       N/A      N/A      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                             NH OKINAWA       N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                            NH YOKOSUKA       N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A

                                   Legend                      95% - 100%                                                 Navy DQMC 12/17/2011
                                                               80% - 94%                                                          Page 18 of 29
Updated: 12/8/2010                                             79% and Below
                                                               N/A
    7a. (APV) Is the documentation of the encounter selected to be audited available?
    Documentation includes documentation in the medical record, loose (hard copy)
 documentation or an electronic encounter in AHLTA. (Denominator equals sample size.)
                                           C.7)
                           Reporting Month   Dec 09   Jan 10   Feb 10    Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10   Oct 10   Nov 10
                               Data Month    Oct 09   Nov 09   Dec 09    Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10
                 NAVY                        100%     100%      99%      100%     100%     100%     100%      99%     99%      100%     100%     100%
           NAVY MEDICINE EAST                100%     99%       99%      100%     100%     100%     100%      99%     98%      100%     100%     100%
                             NH PENSACOLA    100%     100%      100%     100%     100%     100%     100%     86%      87%       100%     100%     100%
                           NH JACKSONVILLE   100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                          NHC GREAT LAKES     N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A      N/A      N/A
                          NH CAMP LEJEUNE    100%     100%      87%      100%     100%     100%     100%     100%     100%      100%     100%     100%
                          NH CHERRY POINT    100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
           NAVAL HEALTH CARE NEW ENGLAND      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A      N/A      N/A
                            NH CHARLESTON     N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A      N/A      N/A
                              NH BEAUFORT    100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                         NH CORPUS CHRISTI    N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A      N/A      N/A
                         NMC PORTSMOUTH      98%      93%       100%     95%      100%     100%     100%     100%     90%       100%     100%     100%
                      NH GUANTANAMO BAY      100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                                 NH NAPLES   100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                                   NH ROTA   100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                              NH SIGONELLA   100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
        NATIONAL CAPITAL REGION              100%     100%      100%      97%     100%      99%     100%     100%     100%     100%     100%     100%
                          NNMC BETHESDA      100%     100%      100%      97%     100%      99%     100%     100%     100%      100%     100%     100%
                       NHC PATUXENT RIVER     N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A      N/A      N/A
                           NHC ANNAPOLIS      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A      N/A      N/A
                            NHC QUANTICO      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A      N/A      N/A
          NAVY MEDICINE WEST                 100%     100%      100%     100%     100%     100%     100%     100%     100%     100%     100%     100%
                      NH CAMP PENDLETON      100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                             NH LEMOORE      100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                           NMC SAN DIEGO     100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                     NH TWENTYNINE PALMS     100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                           NH BREMERTON      100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                          NH OAK HARBOR      100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                              NHC HAWAII      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A      N/A      N/A
                                NH GUAM      100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                             NH OKINAWA      100%     100%      100%     100%     100%     100%     100%     100%     100%      100%     100%     100%
                            NH YOKOSUKA      100%     100%      100%     100%     100%     97%      100%     100%     100%      100%     100%     100%
                                                                                                                               Navy DQMC 12/17/2011
                                   Legend                      95% - 100%                                                              Page 19 of 29
                                                               80% - 94%
Updated: 12/8/2010                                             79% and Below
                                                               N/A
                7b. What is the percentage of ICD-9 codes deemed correct (APV)? (C.7)


                           Reporting Month   Dec 09   Jan 10   Feb 10    Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10   Oct 10    Nov 10
                               Data Month    Oct 09   Nov 09   Dec 09    Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10    Sep 10
                 NAVY                        95%      96%       96%       95%     95%       96%     96%       96%     97%      97%      95%       96%
           NAVY MEDICINE EAST                92%      95%       93%       94%     92%       96%     94%       96%     95%      96%      93%       96%
                             NH PENSACOLA     98%     100%      100%      100%    90%      100%      88%      94%     100%      93%      97%       97%
                           NH JACKSONVILLE    82%      83%      82%        78%    74%       97%      99%      97%      89%     100%      91%       96%
                          NHC GREAT LAKES     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                          NH CAMP LEJEUNE     86%      90%      77%        79%    86%       75%      82%      91%      80%      84%      85%       96%
                          NH CHERRY POINT    100%      96%      100%      100%    98%      100%     100%     100%     100%     100%      90%       87%
           NAVAL HEALTH CARE NEW ENGLAND      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                            NH CHARLESTON     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                              NH BEAUFORT     94%     100%      96%        97%    98%       98%      93%      89%     100%     100%      96%      100%
                         NH CORPUS CHRISTI    N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                         NMC PORTSMOUTH       97%      95%      97%        92%    95%       94%      96%      96%      92%      98%      98%       98%
                      NH GUANTANAMO BAY      100%     100%      100%      100%    100%      95%     100%     100%      92%      95%      88%      100%
                                 NH NAPLES   100%     100%      100%       99%    99%      100%     100%     100%     100%     100%     100%       98%
                                   NH ROTA    96%      95%      100%      100%    95%      100%      93%     100%     100%      87%      92%       90%
                              NH SIGONELLA    71%      87%      79%        90%    85%       96%      93%      94%     100%      99%      96%       96%
        NATIONAL CAPITAL REGION              96%      96%       100%      97%     96%      100%     98%      100%     99%      99%      98%       95%
                          NNMC BETHESDA       96%      96%      100%      97%      96%     100%      98%     100%      99%      99%      98%       95%
                       NHC PATUXENT RIVER     N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                           NHC ANNAPOLIS      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                            NHC QUANTICO      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
          NAVY MEDICINE WEST                 97%      98%       99%       96%     98%       96%     98%       96%     99%      97%      97%       96%
                      NH CAMP PENDLETON      100%     100%      100%      100%    100%     100%     100%     100%     100%      99%     100%      100%
                             NH LEMOORE       98%      97%      100%       96%    100%     100%      97%      87%     100%     100%      95%       98%
                           NMC SAN DIEGO      86%      94%      95%        96%    92%       95%      94%      96%      96%      97%      97%       96%
                     NH TWENTYNINE PALMS      96%     100%      100%       88%    97%       97%      97%      94%     100%      97%      95%       91%
                           NH BREMERTON      100%     100%      100%      100%    100%     100%     100%     100%      98%     100%     100%      100%
                          NH OAK HARBOR       97%      93%      96%        98%    98%       97%      98%      95%     100%      94%      92%       88%
                              NHC HAWAII      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                                NH GUAM      100%     100%      100%       97%    100%      97%     100%     100%     100%     100%     100%      100%
                             NH OKINAWA      100%     100%      100%       91%    97%      100%     100%     100%     100%      99%     100%       98%
                            NH YOKOSUKA      100%      97%      100%      100%    95%       76%      95%      90%     100%      91%      94%       96%

                                   Legend                      95% - 100%
                                                               80% - 94%
Updated: 12/8/2010                                             79% and Below                                              Navy DQMC 12/17/2011
                                                                                                                                  Page 21 of 29
                                                               N/A
                 7c. What is the percentage of CPT codes deemed correct (APV)? (C.7)


                           Reporting Month   Dec 09   Jan 10   Feb 10    Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10   Oct 10    Nov 10
                               Data Month    Oct 09   Nov 09   Dec 09    Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10    Sep 10
                 NAVY                        97%      96%       95%       92%     94%       96%     97%       97%     98%      98%      97%       98%
           NAVY MEDICINE EAST                95%      95%       92%       94%     95%       95%     98%       96%     97%      97%      96%       98%
                             NH PENSACOLA     80%      77%      60%        73%    90%       80%      94%      94%      93%      93%     100%       99%
                           NH JACKSONVILLE    86%      92%      89%        89%    79%       98%      99%      96%      90%      99%      92%       98%
                          NHC GREAT LAKES     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                          NH CAMP LEJEUNE     96%      96%      82%        94%    92%       80%      89%      89%      93%      98%      94%       97%
                          NH CHERRY POINT    100%      93%      100%      100%    98%      100%     100%     100%     100%     100%      98%       98%
           NAVAL HEALTH CARE NEW ENGLAND      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                            NH CHARLESTON     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                              NH BEAUFORT     99%      95%      99%        95%    98%       98%      97%      98%     100%      99%      94%       99%
                         NH CORPUS CHRISTI    N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                         NMC PORTSMOUTH       99%      96%      96%        96%    99%       98%     100%      99%      98%      98%      95%       98%
                      NH GUANTANAMO BAY       94%     100%      100%      100%    94%      100%     100%     100%     100%      81%     100%       92%
                                 NH NAPLES    98%     100%      100%       97%    100%     100%      98%      96%      99%     100%     100%      100%
                                   NH ROTA   100%     100%      98%       100%    100%     100%     100%      89%     100%     100%      90%       95%
                              NH SIGONELLA   100%     100%      97%        91%    95%       91%     100%     100%     100%     100%     100%       99%
        NATIONAL CAPITAL REGION              92%      100%      98%       99%     98%       99%     100%      99%     98%      100%     92%       98%
                          NNMC BETHESDA       92%     100%      98%       99%      98%      99%     100%      99%      98%     100%      92%       98%
                       NHC PATUXENT RIVER     N/A      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                           NHC ANNAPOLIS      N/A      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                            NHC QUANTICO      N/A      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
          NAVY MEDICINE WEST                 99%      96%       99%       90%     92%       97%     96%       98%     98%      99%      98%       98%
                      NH CAMP PENDLETON      100%      97%      100%      100%    96%      100%      93%      93%     100%     100%      99%      100%
                             NH LEMOORE      100%      99%      100%       98%    99%       96%     100%     100%      99%     100%     100%      100%
                           NMC SAN DIEGO      98%      95%      98%        98%    96%      100%      97%      98%      96%      99%      99%      100%
                     NH TWENTYNINE PALMS     100%      79%      96%        82%    77%       94%      91%     100%      99%     100%      96%       98%
                           NH BREMERTON      100%     100%      100%      100%    100%     100%     100%     100%      96%     100%     100%      100%
                          NH OAK HARBOR       97%     100%      94%       100%    100%     100%     100%     100%      97%      99%      97%       92%
                              NHC HAWAII      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                                NH GUAM      100%     100%      100%      100%    74%       90%     100%     100%     100%     100%      99%      100%
                             NH OKINAWA      100%     100%      100%       33%    95%       98%      96%      98%     100%      95%      98%       96%
                            NH YOKOSUKA      100%      98%      100%       98%    95%       99%      91%      97%      92%      99%      98%       97%

                                   Legend                      95% - 100%
                                                               80% - 94%
                                                                                                                          Navy DQMC 12/17/2011
Updated: 12/8/2010                                             79% and Below
                                                                                                                                  Page 22 of 29
                                                               N/A
   7d. What percentage of completed and current (signed within the past 12 months) DD
           Form 2569s are available for audit (TPC Insurance Info) (APV) (C.7)

                           Reporting Month   Dec 09   Jan 10   Feb 10    Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10   Oct 10    Nov 10
                               Data Month    Oct 09   Nov 09   Dec 09    Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10    Sep 10
                 NAVY                        97%      82%       80%       85%     91%       86%     88%       87%     93%      91%      88%       89%
           NAVY MEDICINE EAST                95%      69%       71%       76%     85%       78%     82%       86%     92%      88%      84%       86%
                             NH PENSACOLA     88%      82%      87%        85%    100%      89%      97%      97%      90%      97%     100%      100%
                           NH JACKSONVILLE    96%      98%      100%      100%    100%     100%     100%     100%     100%      99%     100%       93%
                          NHC GREAT LAKES     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                          NH CAMP LEJEUNE     95%      35%      15%        54%    100%      57%      81%     100%     100%      90%      46%       89%
                          NH CHERRY POINT    100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
           NAVAL HEALTH CARE NEW ENGLAND      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                            NH CHARLESTON     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                              NH BEAUFORT    100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                         NH CORPUS CHRISTI    N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                         NMC PORTSMOUTH       92%       0%      94%        93%    95%      100%      93%      94%     100%      95%      81%       94%
                      NH GUANTANAMO BAY       N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                                 NH NAPLES    N/A      N/A       0%         0%     0%        0%       0%      12%      53%      35%      58%       27%
                                   NH ROTA    N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                              NH SIGONELLA    N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
        NATIONAL CAPITAL REGION              100%     100%      100%      98%     100%      99%     100%      99%     100%     99%      99%       100%
                          NNMC BETHESDA      100%     100%      100%      98%     100%      99%     100%      99%     100%      99%      99%      100%
                       NHC PATUXENT RIVER     N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                           NHC ANNAPOLIS      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                            NHC QUANTICO      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
          NAVY MEDICINE WEST                 97%      91%       86%       91%     95%       92%     93%       87%     92%      92%      92%       90%
                      NH CAMP PENDLETON      100%      88%      77%        73%    98%       98%      95%      87%      96%      78%      79%       95%
                             NH LEMOORE      100%      63%      74%        84%    77%       68%      76%      58%      72%      83%      98%      100%
                           NMC SAN DIEGO     100%      89%      84%        95%    100%      90%     100%      86%      93%      87%      95%       95%
                     NH TWENTYNINE PALMS     100%     100%      100%      100%    100%      96%     100%     100%     100%     100%     100%      100%
                           NH BREMERTON       93%     100%      100%      100%    100%     100%      95%      90%      94%      95%     100%       88%
                          NH OAK HARBOR       87%      95%      92%        93%    96%       90%      85%      89%      92%     100%      71%       54%
                              NHC HAWAII      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                                NH GUAM      100%     100%      73%        93%    97%      100%     100%     100%     100%     100%     100%      100%
                             NH OKINAWA       N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                            NH YOKOSUKA       N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A

                                   Legend                      95% - 100%                                                 Navy DQMC 12/17/2011
                                                               80% - 94%                                                          Page 23 of 29
Updated: 12/8/2010                                             79% and Below
                                                               N/A
7e. What percentage of available, current and complete DD Form 2569s are verified to be
     correct in the Patient Insurance Information (PII) module in CHCS (APV)? (C.7)

                           Reporting Month   Dec 09   Jan 10   Feb 10    Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10   Oct 10    Nov 10
                               Data Month    Oct 09   Nov 09   Dec 09    Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10    Sep 10
                 NAVY                        97%      88%       100%      99%     100%     100%     99%      100%     100%     100%     100%      99%
           NAVY MEDICINE EAST                99%      71%       100%      97%     100%     100%     100%     100%     100%     100%     100%      100%
                             NH PENSACOLA    100%      92%      100%       89%    100%     100%     100%     100%     100%     100%     100%      100%
                           NH JACKSONVILLE   100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                          NHC GREAT LAKES     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                          NH CAMP LEJEUNE     96%      33%      100%       91%    100%     100%     100%     100%     100%     100%     100%      100%
                          NH CHERRY POINT    100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
           NAVAL HEALTH CARE NEW ENGLAND      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                            NH CHARLESTON     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                              NH BEAUFORT    100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                         NH CORPUS CHRISTI    N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                         NMC PORTSMOUTH      100%       0%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                      NH GUANTANAMO BAY       N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                                 NH NAPLES    N/A      N/A       N/A       N/A     N/A      N/A      N/A     100%     100%     100%     100%      100%
                                   NH ROTA    N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                              NH SIGONELLA    N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
        NATIONAL CAPITAL REGION              100%     100%      100%     100%     100%     100%     100%     100%     100%     100%     100%      100%
                          NNMC BETHESDA      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                       NHC PATUXENT RIVER     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                           NHC ANNAPOLIS      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                            NHC QUANTICO      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
          NAVY MEDICINE WEST                 95%      100%      100%     100%     99%      100%     99%       99%     100%     100%     100%      99%
                      NH CAMP PENDLETON      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                             NH LEMOORE       68%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                           NMC SAN DIEGO     100%     100%      100%      100%    94%      100%     100%     100%     100%     100%     100%      100%
                     NH TWENTYNINE PALMS     100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                           NH BREMERTON      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                          NH OAK HARBOR      100%     100%      100%      100%    100%      97%      91%      96%     100%     100%     100%       92%
                              NHC HAWAII      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                                NH GUAM       97%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%      100%
                             NH OKINAWA       N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                            NH YOKOSUKA       N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A

                                   Legend                      95% - 100%                                                 Navy DQMC 12/17/2011
                                                               80% - 94%                                                          Page 23 of 29
Updated: 12/8/2010                                             79% and Below
                                                               N/A
                                   8a. Comparison of reported workload data (C.8a):
                                       # SADR encounters (count) / # WWR visits
                           Reporting Month    Dec 09     Jan 10    Feb 10    Mar 10     Apr 10    May 10    Jun 10   Jul 10   Aug 10   Sep 10   Oct 10   Nov 10
                               Data Month     Oct 09     Nov 09    Dec 09    Jan 10     Feb 10    Mar 10    Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10
                 NAVY                          95%        98%       96%        99%       99%       99%       99%      99%      99%     99%      99%       99%
           NAVY MEDICINE EAST                  98%        99%       94%        99%       100%      100%      99%      99%      99%     99%      99%       99%
                             NH PENSACOLA       99%       96%        99%       98%       100%       99%       99%     99%      99%     98%       98%      99%
                           NH JACKSONVILLE      99%      100%        99%      100%       99%        99%       99%    100%      99%     99%       99%      99%
                          NHC GREAT LAKES       99%      100%        72%       99%       100%       99%       99%     99%      99%     99%       99%     100%
                          NH CAMP LEJEUNE       99%       94%        93%       98%       98%       100%       98%    100%      99%     99%      100%     100%
                          NH CHERRY POINT       99%       99%        99%       99%       99%       100%       99%     99%      99%     99%       99%     100%
           NAVAL HEALTH CARE NEW ENGLAND        99%      100%        99%       99%       100%       99%       99%    100%     100%     98%       99%     100%
                            NH CHARLESTON       98%      100%        99%       98%       99%       100%      100%    100%      99%     100%     100%      98%
                              NH BEAUFORT       98%      100%       100%      100%       100%       99%       99%    100%     100%     100%     100%     100%
                         NH CORPUS CHRISTI      91%       97%        97%       99%       99%        99%       98%     99%      98%     99%       98%     100%
                         NMC PORTSMOUTH        100%      100%       100%      100%       100%      100%      100%    100%     100%     100%      99%      99%
                      NH GUANTANAMO BAY         94%       99%       100%       99%       99%       100%      100%    100%     100%     99%       99%      98%
                                 NH NAPLES      97%      100%        99%      100%       100%      100%       95%     96%      96%     96%       94%      97%
                                   NH ROTA      99%       99%        99%       99%       100%      100%       99%     99%     100%     99%       99%     100%
                              NH SIGONELLA     100%      100%        63%       98%       100%      100%      100%    100%     100%     100%     100%     100%
        NATIONAL CAPITAL REGION                99%        99%       99%        99%       99%       99%       99%      99%      99%     99%      99%      100%
                          NNMC BETHESDA         99%       97%        98%       97%       96%        97%       98%     97%      98%     99%       99%      99%
                       NHC PATUXENT RIVER       98%      100%        99%       99%       99%        99%       99%    100%     100%     100%      99%     100%
                           NHC ANNAPOLIS       100%      100%       100%      100%       100%       98%      100%    100%      97%     99%       99%      99%
                            NHC QUANTICO        98%       99%        99%      100%       100%      100%       99%     99%     100%     99%      100%     100%
          NAVY MEDICINE WEST                   90%        97%       97%        98%       99%       100%      99%      99%      99%     99%      99%       99%
                      NH CAMP PENDLETON         88%       92%        97%       99%       98%        99%       98%    100%      99%     99%       97%     100%
                             NH LEMOORE         98%      100%       100%       99%       100%      100%       99%     98%      99%     100%     100%     100%
                           NMC SAN DIEGO        77%      100%       100%      100%       100%       99%       99%    100%     100%     100%      99%      98%
                     NH TWENTYNINE PALMS        77%       97%        90%       99%       100%      100%      100%    100%      99%     99%       99%      99%
                           NH BREMERTON        100%       99%        99%       99%       100%      100%      100%    100%     100%     100%     100%     100%
                          NH OAK HARBOR         99%      100%        99%       99%       99%       100%      100%     99%     100%     100%     100%      99%
                              NHC HAWAII       100%       99%       100%      100%       99%       100%      100%    100%      99%     99%       99%      99%
                                NH GUAM         73%       89%        88%       91%       95%        99%       92%     96%     100%     89%       96%      97%
                             NH OKINAWA         93%       92%        94%       97%       99%        99%       98%     99%      99%     99%       98%      98%
                            NH YOKOSUKA         99%      100%        98%       99%       97%        99%       99%    100%      99%     100%      99%      99%

                                   Legend                         95% - 100%
                                                                  80% - 94%
Updated: 12/8/2010                                                79% and Below                                                  Navy DQMC 12/17/2011
                                                                  N/A                                                                    Page 24 of 29

                                             * Note: Percentages greater than 100% are converted to less than 100%
                                  8b. Comparison of reported workload data (C.8b):
                                      # SIDR dispositions / # WWR dispositions
                           Reporting Month    Dec 09    Jan 10    Feb 10    Mar 10    Apr 10    May 10    Jun 10     Jul 10   Aug 10     Sep 10   Oct 10   Nov 10
                               Data Month     Oct 09    Nov 09    Dec 09    Jan 10    Feb 10    Mar 10    Apr 10     May 10   Jun 10     Jul 10   Aug 10   Sep 10
                 NAVY                          55%       66%       89%       93%       94%       96%       97%        92%     93%         98%      96%      97%
           NAVY MEDICINE EAST                  83%       87%       97%       99%       94%       95%       97%        92%     95%         98%      94%      96%
                             NH PENSACOLA      100%      100%      100%      100%       93%      90%       90%        87%      91%       100%      59%      81%
                           NH JACKSONVILLE      77%      100%       97%       99%       99%     100%      100%       100%     100%       100%     100%      99%
                          NHC GREAT LAKES       N/A       N/A       N/A       N/A       N/A      N/A       N/A        N/A      N/A        N/A      N/A      N/A
                          NH CAMP LEJEUNE       95%      100%       96%       98%       92%      76%       96%        64%      72%        96%      97%      97%
                          NH CHERRY POINT       N/A       N/A       N/A       N/A       N/A      N/A       N/A        N/A      N/A        N/A      N/A      N/A
           NAVAL HEALTH CARE NEW ENGLAND        N/A       N/A       N/A       N/A       N/A      N/A       N/A        N/A      N/A        N/A      N/A      N/A
                            NH CHARLESTON       N/A       N/A       N/A       N/A       N/A      N/A       N/A        N/A      N/A        N/A      N/A      N/A
                              NH BEAUFORT       99%        0%      100%      100%      100%     100%       97%       100%     100%        98%      98%      93%
                         NH CORPUS CHRISTI      N/A       N/A       N/A       N/A       N/A      N/A       N/A        N/A      N/A        N/A      N/A      N/A
                         NMC PORTSMOUTH         97%       97%       82%       90%       80%      93%      100%       100%      99%       100%     100%     100%
                      NH GUANTANAMO BAY         85%      100%      100%      100%      100%     100%      100%       100%     100%       100%     100%     100%
                                 NH NAPLES      94%      100%      100%      100%      100%     100%      100%       100%     100%       100%      93%      98%
                                  NH ROTA       72%      100%      100%      100%       86%      97%       89%        79%      97%        92%     100%      94%
                             NH SIGONELLA       32%       88%      100%      100%      100%     100%      100%       100%     100%       100%     100%     100%
        NATIONAL CAPITAL REGION                 0%        0%       36%       43%       81%       85%       91%        85%     94%         98%      93%      96%
                          NNMC BETHESDA        0%        0%        36%       43%       81%       85%       91%        85%      94%        98%      93%         96%
                       NHC PATUXENT RIVER      N/A       N/A       N/A       N/A       N/A       N/A       N/A        N/A      N/A        N/A      N/A         N/A
                           NHC ANNAPOLIS       N/A       N/A       N/A       N/A       N/A       N/A       N/A        N/A      N/A        N/A      N/A         N/A
                            NHC QUANTICO       N/A       N/A       N/A       N/A       N/A       N/A       N/A        N/A      N/A        N/A      N/A         N/A
          NAVY MEDICINE WEST                   33%       52%       86%       93%       95%       98%       98%        92%     91%         98%      99%      98%
                      NH CAMP PENDLETON         0%         0%       98%       99%       99%     100%       98%        99%      98%        95%      97%     100%
                             NH LEMOORE        40%         8%       97%      100%      100%     100%      100%       100%     100%       100%     100%     100%
                           NMC SAN DIEGO        0%         0%        0%       92%       98%     100%       99%        99%     100%       100%     100%     100%
                     NH TWENTYNINE PALMS       11%        97%      100%      100%      100%      99%       98%        89%     100%       100%     100%      99%
                           NH BREMERTON        28%        98%       98%       97%      100%      99%       99%       100%     100%        99%      98%      97%
                          NH OAK HARBOR        62%       100%      100%      100%      100%     100%      100%       100%     100%       100%     100%     100%
                              NHC HAWAII       N/A        N/A       N/A       N/A       N/A      N/A       N/A        N/A      N/A        N/A      N/A      N/A
                                NH GUAM        77%        97%       95%       98%       95%     100%       98%       100%      97%        91%     100%      98%
                             NH OKINAWA        58%         0%      100%      100%      100%      99%       95%        98%      99%        99%      98%      95%
                            NH YOKOSUKA        23%        65%       83%       47%       66%      87%       95%        47%      25%        98%      94%      90%

                                   Legend                        95% - 100%
                                                                 80% - 94%
Updated: 12/8/2010                                               79% and Below                                                         Navy DQMC 12/17/2011
                                                                 N/A                                                                           Page 25 of 29


                                             * Note: Percentages greater than 100% are converted to less than 100%
                                  8c. Comparison of reported workload data (C.8c):
                                           # EAS visits / # WWR visits
                           Reporting Month    Dec 09    Jan 10     Feb 10    Mar 10    Apr 10    May 10    Jun 10    Jul 10    Aug 10     Sep 10    Oct 10    Nov 10
                               Data Month     Oct 09    Nov 09     Dec 09    Jan 10    Feb 10    Mar 10    Apr 10    May 10    Jun 10     Jul 10    Aug 10    Sep 10
                 NAVY                          100%      99%       100%      100%      100%      100%      100%       100%      100%      100%       99%      100%
           NAVY MEDICINE EAST                  100%      99%       100%      100%      100%      100%      100%       100%      100%      100%      100%      100%
                             NH PENSACOLA       99%       97%       97%      100%        99%      100%      100%       97%       97%      100%      100%      100%
                           NH JACKSONVILLE     100%      100%      100%      100%       100%      100%      100%      100%      100%      100%       97%      100%
                          NHC GREAT LAKES      100%      100%      100%      100%       100%      100%      100%      100%      100%      100%      100%      100%
                          NH CAMP LEJEUNE      100%      100%      100%      100%       100%      100%      100%      100%      100%      100%      100%      100%
                          NH CHERRY POINT      100%      100%      100%      100%       100%      100%      100%      100%      100%      100%      100%      100%
           NAVAL HEALTH CARE NEW ENGLAND        96%       97%       97%      100%       100%      100%      100%      100%      100%      100%      100%      100%
                            NH CHARLESTON      100%      100%      100%      100%       100%      100%      100%      100%      100%      100%      100%      100%
                              NH BEAUFORT      100%      100%      100%      100%       100%      100%      100%      100%      100%      100%      100%      100%
                         NH CORPUS CHRISTI     100%      100%      100%      100%       100%      100%      100%      100%      100%      100%      100%      100%
                         NMC PORTSMOUTH        100%      100%      100%      100%       100%      100%      100%      100%      100%      100%      100%      100%
                      NH GUANTANAMO BAY         99%      100%      100%      100%       100%      100%      100%      100%      100%      100%      100%      100%
                                 NH NAPLES     100%       98%      100%      100%       100%      100%      100%      100%      100%      100%       98%      100%
                                  NH ROTA      100%      100%      100%      100%       100%      100%      100%      100%      100%      100%      100%      100%
                             NH SIGONELLA      100%      100%      100%      100%       100%      100%      100%      100%      100%      100%      100%      100%
        NATIONAL CAPITAL REGION                100%      100%      100%      100%      100%      100%      100%       100%      100%      100%      100%      100%
                          NNMC BETHESDA        100%      100%      100%      100%       100%      100%      100%      100%      100%      100%      100%      100%
                       NHC PATUXENT RIVER      100%      100%      100%      100%       100%      100%      100%      100%      100%      100%      100%      100%
                           NHC ANNAPOLIS       100%      100%      100%      100%       100%      100%      100%      100%       99%      100%      100%      100%
                            NHC QUANTICO       100%      100%      100%      100%       100%      100%      100%      100%      100%      100%      100%      100%
          NAVY MEDICINE WEST                   100%      99%       100%      100%      100%      100%      100%       100%      100%      100%       97%      100%
                      NH CAMP PENDLETON         99%      100%      100%      100%       100%      100%      100%      100%      100%      100%      100%      100%
                             NH LEMOORE        100%      100%       99%      100%       100%      100%      100%      100%      100%      100%      100%      100%
                           NMC SAN DIEGO       100%      100%      100%      100%       100%      100%      100%      100%      100%      100%      100%      100%
                     NH TWENTYNINE PALMS       100%       97%      100%      100%       100%      100%       96%      100%      100%      100%       72%      100%
                           NH BREMERTON        100%      100%      100%      100%       100%      100%      100%      100%      100%      100%      100%      100%
                          NH OAK HARBOR        100%      100%      100%      100%       100%      100%      100%      100%      100%      100%      100%      100%
                              NHC HAWAII        96%       97%       99%       99%       100%      100%       99%       99%       95%      100%      100%      100%
                                NH GUAM        100%      100%      100%      100%       100%      100%      100%      100%      100%      100%      100%      100%
                             NH OKINAWA        100%       99%      100%      100%       100%      100%      100%      100%      100%      100%      100%      100%
                            NH YOKOSUKA        100%      100%      100%      100%       100%      100%      100%      100%      100%      100%      100%       97%

                                   Legend                         95% - 100%
                                                                  80% - 94%
Updated: 12/8/2010                                                79% and Below                                                         Navy DQMC 12/17/2011
                                                                  N/A                                                                           Page 26 of 29


                                             * Note: Percentages greater than 100% are converted to less than 100%. If 4a is "No", local WAM data should be used.
                                  8d. Comparison of reported workload data (C.8d):
                                      # EAS dispositions / # WWR dispositions
                           Reporting Month    Dec 09    Jan 10    Feb 10    Mar 10     Apr 10   May 10     Jun 10    Jul 10    Aug 10     Sep 10   Oct 10    Nov 10
                               Data Month     Oct 09    Nov 09    Dec 09    Jan 10     Feb 10   Mar 10     Apr 10    May 10    Jun 10     Jul 10   Aug 10    Sep 10
                 NAVY                          100%      100%      100%      100%      100%      100%      100%      100%       100%      100%      100%      100%
           NAVY MEDICINE EAST                  100%      100%      100%      100%      100%      100%      100%      100%       100%      100%      100%      100%
                             NH PENSACOLA      100%      100%      100%      100%      100%      100%      100%       100%       99%      100%      100%       98%
                           NH JACKSONVILLE     100%      100%       99%      100%      100%      100%      100%       100%      100%      100%      100%      100%
                          NHC GREAT LAKES       N/A       N/A       N/A       N/A       N/A       N/A       N/A        N/A       N/A       N/A       N/A       N/A
                          NH CAMP LEJEUNE      100%      100%      100%      100%      100%      100%      100%       100%      100%      100%      100%      100%
                          NH CHERRY POINT       N/A       N/A       N/A       N/A       N/A       N/A       N/A        N/A       N/A       N/A       N/A       N/A
           NAVAL HEALTH CARE NEW ENGLAND        N/A       N/A       N/A       N/A       N/A       N/A       N/A        N/A       N/A       N/A       N/A       N/A
                            NH CHARLESTON       N/A       N/A       N/A       N/A       N/A       N/A       N/A        N/A       N/A       N/A       N/A       N/A
                              NH BEAUFORT      100%      100%      100%      100%      100%      100%      100%       100%      100%      100%      100%      100%
                         NH CORPUS CHRISTI      N/A       N/A       N/A       N/A       N/A       N/A       N/A        N/A       N/A       N/A       N/A       N/A
                         NMC PORTSMOUTH        100%      100%      100%      100%      100%      100%      100%       100%      100%      100%      100%      100%
                      NH GUANTANAMO BAY        100%      100%      100%      100%      100%      100%      100%       100%      100%      100%      100%      100%
                                 NH NAPLES     100%      100%      100%      100%      100%      100%      100%       100%      100%      100%      100%      100%
                                  NH ROTA      100%      100%      100%      100%      100%      100%      100%       100%      100%      100%      100%      100%
                             NH SIGONELLA      100%      100%      100%      100%      100%      100%      100%       100%      100%      100%      100%      100%
        NATIONAL CAPITAL REGION                100%      100%      100%      100%      100%      100%      100%      100%       100%      100%      100%      100%
                          NNMC BETHESDA        100%      100%      100%      100%      100%      100%      100%       100%      100%      100%      100%      100%
                       NHC PATUXENT RIVER       N/A       N/A       N/A       N/A       N/A       N/A       N/A        N/A       N/A       N/A       N/A       N/A
                           NHC ANNAPOLIS        N/A       N/A       N/A       N/A       N/A       N/A       N/A        N/A       N/A       N/A       N/A       N/A
                            NHC QUANTICO        N/A       N/A       N/A       N/A       N/A       N/A       N/A        N/A       N/A       N/A       N/A       N/A
          NAVY MEDICINE WEST                   100%      100%      100%      100%      100%      100%      100%      100%       99%       100%      100%       99%
                      NH CAMP PENDLETON        100%      100%      100%      100%      100%      100%      100%       100%      100%      100%      100%      100%
                             NH LEMOORE        100%      100%      100%      100%      100%      100%      100%       100%      100%      100%      100%      100%
                           NMC SAN DIEGO       100%      100%      100%      100%      100%      100%      100%       100%      100%      100%      100%      100%
                     NH TWENTYNINE PALMS       100%      100%      100%      100%      100%      100%      100%        99%      100%      100%      100%      100%
                           NH BREMERTON        100%      100%      100%      100%      100%      100%      100%       100%      100%      100%      100%      100%
                          NH OAK HARBOR        100%      100%      100%      100%      100%      100%      100%       100%       93%       99%       99%      100%
                              NHC HAWAII        N/A       N/A       N/A       N/A       N/A       N/A       N/A        N/A       N/A       N/A       N/A       N/A
                                NH GUAM        100%      100%      100%      100%      100%      100%      100%       100%      100%      100%      100%      100%
                             NH OKINAWA        100%      100%      100%      100%      100%      100%      100%       100%      100%      100%      100%      100%
                            NH YOKOSUKA        100%      100%      100%      100%      100%      100%      100%       100%      100%      100%      100%       95%

                                   Legend                         95% - 100%
                                                                  80% - 94%
Updated: 12/8/2010                                                79% and Below                                                         Navy DQMC 12/17/2011
                                                                  N/A                                                                           Page 27 of 29


                                             * Note: Percentages greater than 100% are converted to less than 100%. If 4a is "No", local WAM data should be used.
   8e. # of Inpatient Professional Services Rounds SADR encounters (FCC=A***) / # SUM
               WWR (Total Bed days + Total Dispositions) Note: FY10 Goal 80%


                           Reporting Month   Dec 09   Jan 10    Feb 10   Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10   Sep 10   Oct 10    Nov 10
                               Data Month    Oct 09   Nov 09    Dec 09   Jan 10   Feb 10   Mar 10   Apr 10   May 10   Jun 10   Jul 10   Aug 10    Sep 10
                 NAVY                        79%      82%        81%      86%     87%       85%     89%       83%     89%      85%      86%       89%
           NAVY MEDICINE EAST                80%      81%        78%      82%     84%       77%     87%       78%     94%      87%      87%       93%
                             NH PENSACOLA    101%      97%      104%      106%    107%     108%     106%     104%     102%      85%      82%       85%
                           NH JACKSONVILLE   101%     102%      104%      104%    106%     107%     105%     106%     106%     103%     109%      104%
                          NHC GREAT LAKES     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                          NH CAMP LEJEUNE     90%      95%       94%       87%    91%      87%       77%      69%      76%      87%      84%       88%
                          NH CHERRY POINT     N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
           NAVAL HEALTH CARE NEW ENGLAND      88%     100%       84%      100%    95%      100%      94%      92%     100%      67%      88%      100%
                            NH CHARLESTON      0%       0%        0%        0%     0%       0%       N/A     100%     100%       0%       7%       67%
                              NH BEAUFORT     88%      84%       84%       81%    89%      86%       76%      89%      97%      98%      90%       95%
                         NH CORPUS CHRISTI   100%     100%      100%      100%    100%      0%      100%      N/A     225%     229%     180%      142%
                         NMC PORTSMOUTH       75%      79%       79%       81%    84%      79%       81%      82%      84%      81%      81%       83%
                      NH GUANTANAMO BAY       13%      18%       20%       28%    50%      56%       22%       3%      10%      36%      32%       44%
                                 NH NAPLES   102%     101%       84%      106%    100%     99%      100%     100%     102%      98%     102%       99%
                                   NH ROTA   100%     100%       93%      103%    97%      101%     100%      28%      28%      62%      90%      112%
                              NH SIGONELLA    97%     100%       91%       85%    85%      99%      100%      90%      95%      95%      93%       96%
        NATIONAL CAPITAL REGION               8%       8%        11%      16%     18%       34%     33%       32%     29%      29%      58%       41%
                          NNMC BETHESDA       8%       8%        11%      16%      18%      34%      33%      32%      29%      29%      58%       41%
                       NHC PATUXENT RIVER     N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                           NHC ANNAPOLIS      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                            NHC QUANTICO      N/A      N/A       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
          NAVY MEDICINE WEST                 87%      90%        92%     100%     99%      101%     98%       95%     89%      89%      89%       90%
                      NH CAMP PENDLETON      101%      95%       90%      109%    104%     110%     110%     108%     109%     107%     108%      106%
                             NH LEMOORE       98%      96%      102%      100%    103%     101%     104%      98%     102%     100%     102%      100%
                           NMC SAN DIEGO      87%      89%       91%       87%    88%      90%       90%      88%      92%      92%      87%       90%
                     NH TWENTYNINE PALMS      82%      99%       84%      104%    97%      101%      99%      96%      99%      96%      94%      105%
                           NH BREMERTON       96%      99%      100%      100%    99%      105%     103%     105%     101%     101%     106%      100%
                          NH OAK HARBOR       96%     100%      109%      108%    107%     114%     115%     115%     102%     104%     114%      110%
                              NHC HAWAII      N/A      N/A       N/A       N/A     N/A      N/A      N/A      N/A      N/A      N/A      N/A       N/A
                                NH GUAM       26%      37%       52%       84%    83%      91%       97%     107%      96%     100%      90%      110%
                             NH OKINAWA       95%      96%       98%      102%    102%     102%      86%      99%      99%      96%      93%       84%
                            NH YOKOSUKA      103%     101%      100%      104%    104%     99%       81%      37%       5%       8%       6%        8%
                                                                                                                          Navy DQMC 12/17/2011
                                   Legend                      80% - 100%
                                                                                                                                  Page 28 of 29
                                                               79% and Below
Updated: 12/8/2010                                             N/A
 9. (E.4i) # of AHLTA SADR encounters / # of Total SADR encounters. Note: FY10 goal is
                                         80%.


                           Reporting Month   Dec 08   Jan 09    Feb 09   Mar 09   Apr 09   May 09   Jun 09   Jul 09   Aug 09   Sep 09   Oct 09    Nov 09
                               Data Month    Oct 08   Nov 08    Dec 08   Jan 09   Feb 09   Mar 09   Apr 09   May 09   Jun 09   Jul 09   Aug 09    Sep 09
                 NAVY                        92%      94%        92%      94%     94%       95%     94%       94%     94%      93%      95%       94%
           NAVY MEDICINE EAST                93%      94%        93%      93%     93%       94%     94%       93%     93%      93%      94%       94%
                             NH PENSACOLA     95%      94%      94%       95%     94%       95%      95%      94%      95%      94%      95%       95%
                           NH JACKSONVILLE    93%      93%      94%       93%     93%       94%      94%      93%      94%      94%      95%       94%
                          NHC GREAT LAKES     77%      76%      61%       75%     76%       79%      88%      82%      78%      81%      82%       84%
                          NH CAMP LEJEUNE     93%     100%      99%       94%     93%       93%      94%      93%      93%      93%      93%       93%
                          NH CHERRY POINT     99%      99%      99%       99%     99%       99%      99%      99%      99%      99%      99%       99%
           NAVAL HEALTH CARE NEW ENGLAND      98%      98%      98%       99%     97%       99%      99%      99%      97%      97%      98%      100%
                            NH CHARLESTON     97%      98%      96%       96%     96%       96%      96%      97%      97%      97%      97%       98%
                              NH BEAUFORT     80%      85%      84%       82%     86%       86%      87%      86%      84%      80%      83%       83%
                         NH CORPUS CHRISTI    99%      99%      99%       99%     100%     100%      99%      99%     100%     100%      99%       98%
                         NMC PORTSMOUTH       94%      94%      95%       94%     94%       94%      94%      94%      94%      94%      94%       94%
                      NH GUANTANAMO BAY      100%      99%      100%      98%     99%       99%      99%      98%     100%      99%      99%      100%
                                 NH NAPLES    87%      90%      90%       90%     89%       90%      89%      88%      91%      90%      91%       89%
                                   NH ROTA    89%      91%      90%       90%     90%       92%      90%      89%      92%      90%      92%       93%
                              NH SIGONELLA    94%      94%      96%       95%     95%       95%      96%      94%      94%      94%      95%       96%
        NATIONAL CAPITAL REGION              90%      96%        87%      97%     96%       99%     93%       98%     98%      93%      98%       98%
                          NNMC BETHESDA       94%      95%      95%        95%    95%       96%      95%      95%      95%      94%      95%       95%
                       NHC PATUXENT RIVER    100%     100%      100%      100%    100%     100%     100%      99%     100%     100%     100%       99%
                           NHC ANNAPOLIS      70%      87%      54%        99%    88%       99%      77%      98%      95%      81%      96%       96%
                            NHC QUANTICO      96%     100%      100%       95%    100%     100%      98%     100%     100%      97%     100%      100%
          NAVY MEDICINE WEST                 93%      94%        93%      94%     94%       94%     94%       94%     94%      94%      94%       93%
                      NH CAMP PENDLETON       92%      90%       81%       92%    92%       93%      93%      93%      93%      93%      92%       91%
                             NH LEMOORE       99%      99%       98%       99%    99%       99%      99%      99%      99%      99%      99%       99%
                           NMC SAN DIEGO      85%      89%       86%       87%    89%       88%      88%      89%      87%      86%      86%       84%
                     NH TWENTYNINE PALMS      88%      90%       96%       89%    89%       90%      90%      88%      88%      87%      88%       90%
                           NH BREMERTON       89%      91%       93%       93%    90%       92%      92%      91%      92%      91%      93%       85%
                          NH OAK HARBOR       99%      99%       99%       99%    99%       99%      99%      99%      99%      99%     100%      100%
                              NHC HAWAII      99%      99%       99%      100%    100%     100%     100%     100%     100%     100%     100%       99%
                                NH GUAM       93%      96%       97%       96%    97%       97%      98%      98%      98%      99%      99%       99%
                             NH OKINAWA       93%      91%       92%       91%    91%       92%      92%      91%      92%      91%      92%       92%
                            NH YOKOSUKA       93%      92%       93%       93%    93%       94%      93%      92%      93%      93%      94%       93%
                                                                                                                          Navy DQMC 12/17/2011
                                   Legend                      80% - 100%
                                                                                                                                  Page 28 of 29
                                                               79% and Below
Updated: 12/8/2010                                             N/A
            10. What was the number of potential duplicate records in the reporting month?


                           Reporting Month   Dec 08   Jan 09   Feb 09   Mar 09   Apr 09   May 09   Jun 09   Jul 09   Aug 09       Sep 09   Oct 09     Nov 09
                               Data Month    Oct 08   Nov 08   Dec 08   Jan 09   Feb 09   Mar 09   Apr 09   May 09   Jun 09       Jul 09   Aug 09     Sep 09
                 NAVY                         330      202      252      243      168      208      169      181      205          222      208        162
           NAVY MEDICINE EAST                 190      82       154      136      115      143      81        78      108          108      114         90
                             NH PENSACOLA     25       20       11       12       11       26        11       15       10           19       24         9
                           NH JACKSONVILLE     0        0        1        2        2        0         2       0        0            0         0         0
                          NHC GREAT LAKES     10        8        6        3        6        8         9       13       7            3         3         7
                          NH CAMP LEJEUNE     19       12       18       12       16       23       11        16       22           21       23         22
                          NH CHERRY POINT     N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A          N/A      N/A        N/A
           NAVAL HEALTH CARE NEW ENGLAND      13        3        5        3       11        6         7       4        17           16       14         9
                            NH CHARLESTON     67       12       67       67       32       37         0       0        0            0         0         0
                              NH BEAUFORT     N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A          N/A      N/A        N/A
                         NH CORPUS CHRISTI     0        0        0        0        0        0         0       0        0            0         0         0
                         NMC PORTSMOUTH       48       27       42       28       37       41        36       28       47           47       48         40
                      NH GUANTANAMO BAY        3        0        0        0        0        0        0        0        3            0         0         0
                                 NH NAPLES     4        0        4        4        0        0         5       0        0            0         0         0
                                   NH ROTA     0        0        0        2        0        2         0       2        2            0         1         1
                              NH SIGONELLA     1        0        0        3        0        0        0        0        0            2         1         2
        NATIONAL CAPITAL REGION               47       35       37       40       14       28       34       60       60           62        70        46
                          NNMC BETHESDA       47       35       37       40       14       28       34        60       60           62       70         46
                       NHC PATUXENT RIVER     N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A          N/A      N/A        N/A
                           NHC ANNAPOLIS      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A          N/A      N/A        N/A
                            NHC QUANTICO      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A          N/A      N/A        N/A
          NAVY MEDICINE WEST                  93       85       61       67       39       37       54       43       37           52        24        26
                      NH CAMP PENDLETON        1        0        0        0        0        0        0        0        0            0         0         0
                             NH LEMOORE       31       10        3        4        4        4        4        3        7            5         4         6
                           NMC SAN DIEGO      12        9        6       12       11       10       16        11       11           17        8         15
                     NH TWENTYNINE PALMS      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A          N/A      N/A        N/A
                           NH BREMERTON       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A          N/A      N/A        N/A
                          NH OAK HARBOR       N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A          N/A      N/A        N/A
                              NHC HAWAII      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A      N/A          N/A      N/A        N/A
                                NH GUAM       42       46       46       47       24       23       23        23       16           24        1         1
                             NH OKINAWA        0       16        0        0        0        0        0        0        0            0         0         0
                            NH YOKOSUKA        7        4        6        4        0        0       11        6        3            6        11         4




Updated: 12/8/2010
                                                                                                                              Navy DQMC 12/17/2011
                                                                                                                                      Page 13 of 29
   11. I am aware of data quality issues identified by the DQMC Review List and when
             needed, have taken action to improve the data from my facility.


                        Reporting Month   Dec 08   Jan 09   Feb 09    Mar 09   Apr 09   May 09   Jun 09   Jul 09   Aug 09   Sep 09   Oct 09     Nov 09
                            Data Month    Oct 08   Nov 08   Dec 08    Jan 09   Feb 09   Mar 09   Apr 09   May 09   Jun 09   Jul 09   Aug 09     Sep 09
               NAVY                       100%     100%      100%     100%     100%     100%     100%     100%     100%     100%     100%       100%
         NAVY MEDICINE EAST               100%     100%      100%     100%     100%     100%     100%     100%     100%     100%     100%       100%
                         NH PENSACOLA     100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%
                       NH JACKSONVILLE    100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%
                      NHC GREAT LAKES     100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%
                      NH CAMP LEJEUNE     100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%
                      NH CHERRY POINT     100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%
       NAVAL HEALTH CARE NEW ENGLAND      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%
                        NH CHARLESTON     100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%
                          NH BEAUFORT     100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%
                     NH CORPUS CHRISTI    100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%
                     NMC PORTSMOUTH       100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%
                  NH GUANTANAMO BAY       100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%
                             NH NAPLES    100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%
                               NH ROTA    100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%
                          NH SIGONELLA    100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%
      NATIONAL CAPITAL REGION             100%     100%      100%     100%     100%     100%     100%     100%     100%     100%     100%       100%
                        NNMC BETHESDA     100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%
                     NHC PATUXENT RIVER   100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%
                         NHC ANNAPOLIS    100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%
                          NHC QUANTICO    100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%
        NAVY MEDICINE WEST                100%     100%      100%     100%     100%     100%     100%     100%     100%     100%     100%       100%
                  NH CAMP PENDLETON       100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%
                         NH LEMOORE       100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%
                       NMC SAN DIEGO      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%
                 NH TWENTYNINE PALMS      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%
                       NH BREMERTON       100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%
                      NH OAK HARBOR       100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%
                          NHC HAWAII      100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%
                            NH GUAM       100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%
                         NH OKINAWA       100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%
                        NH YOKOSUKA       100%     100%      100%      100%    100%     100%     100%     100%     100%     100%     100%       100%

                                Legend                      95% - 100%
                                                            80% - 94%
Updated: 12/8/2010                                          79% and Below
                                                            N/A




                                                                                                                        Navy DQMC 12/17/2011
                                                                                                                                Page 29 of 29
                           NAVMED WEST
0024   NH CAMP PENDLETON




0028   NH LEMOORE
0029   NMC SAN DIEGO
0030   NH TWENTYNINE PALMS
0126   NH BREMERTON




0127   NH OAK HARBOR
0280   NHC HAWAII




0620   NH GUAM
0621   NH OKINAWA




0622   NH YOKOSUKA
                      NAVMED EAST
0038   NH PENSACOLA
0039   NH JACKSONVILLE
0056   NHC GREAT LAKES




0091   NH CAMP LEJEUNE
0092   NH CHERRY POINT
0100   NAVAL HLTH CLINIC NEW ENGLAND




0103   NH CHARLESTON
0104   NH BEAUFORT




0118   NH CORPUS CHRISTI
0124   NMC PORTSMOUTH
0615   NH GUANTANAMO BAY




0617   NH NAPLES
0618   NH ROTA
0624   NH SIGONELLA
                       NAVMED NCA
0067   NNMC BETHESDA
0068   NHC PATUXENT RIVER




0306   NHC ANNAPOLIS
0385   NHC QUANTICO
                               NAVMED WEST
2a) What percentage of Outpatient Encounters, other than APVs, has been coded within 3 business days of the encounter?
(91%) Information regarding the 3 day mandate has been incorporated into new Provider Orientations, individual Provider
trainings, CMAT meetings, Welcome Aboard Orientation and general reminders. In addition, Outpatient Coding will be
present at the DMS meeting on 22 November and will participate in clinic staff meetings to continue to educate on the
5e) What percentage of completed and current (signed within the past 12 months) DD Form 2569s (TPC Insurance Info) in
Inpatient charts are available for audit? (93%) Patient Admission staff continues to provide training to Active Duty regarding
Admission paperwork. Compliance rate has improved to 93% compared to 89% last month.
6b) What is the percentage of E & M codes deemed correct? (72%) BARJ Area 52 Sports Medicine, BARM Area 13 Sports
Medicine, BGAA Family Practice are all within the 75 percentile of accuracy. BEFA Podiatry is in the 57 percentile of accuracy.
Providers in all clinics are free texting the History of Present Illness which AHLTA recognizes only at the lowest level for the
history component of the 3 key components for an E&M level. Training will need to be done to teach the providers a simple
manual override in AHLTA of one key HPI change from a “1” to a “2” to help correct this situation. This was discussed with
Area 52 and Area 13 in the CMAT meeting 15 November 2010. All areas will receive additional training in this area. Another
major concern and consistent reoccurring trend is the consult versus referrals. All SPEC appointments will default the E&M
code in AHLTA to “consultation”. The majority of these visits are “referrals” which require a problem oriented E&M visit
(new patient or established patient has to be determined also) and not a consult E&M. It places the burden on the provider
6c) What is the percentage of ICD-9 codes deemed correct? (79%) BARJ Area 52 Sports Medicine, BARM Area 13 Sports
Medicine, BGAA Family Practice and BEFA Podiatry are all within the 70-90 percentile of accuracy. BARJ Area 52 Sports
Medicine, BARM Area 13 Sports Medicine, and BEFA Podiatry need to be trained on late effect diagnosis codes. BEFA needs
additional training on aftercare diagnosis codes. The outpatient coding team will work with the AHLTA trainers to have these
codes available on the provider’s templates for easier access. BGAA Family practice needs additional training on pregnancy
6d) What is the percentage of CPT codes deemed correct? (90%) BEFA Podiatry will receive additional input into using 99024
for 90 day global post operative visits and not a problem focused E&M for post operative care.
6E- Percentage of completed and current 2569's): According to the Outpatient Records Division, the reason why the "2569"
forms are not in patients' charts by the time the audit was conducted was due to the TPOCS office keeping records in their
office for an undue amount of time before sending them back to Outpatient records.
12) NEW: Per BUMED direction, the following comment is included regarding
AHLTA-ADM Non Write Back error report:
# of preventable 102 errors: 1022
# of preventable 102 errors corrected: Unknown
# of preventable 102 errors that were not corrected: Unknown
# of 102 errors corrected/# of 102 errors total: Unknown
*The number of corrected errors remain unknown at this time until accurate reports become available. The increase in
errors is due to the fact that in prior month’s error reporting, we were counting the number of patients that had errors. Per
recent guidance from NMW, we are to report the actual number of errors.
# of encounters w/ ADM SADR errors: 167
# of encounters w/ ADM SADR errors corrected: 167
# of encounters w/ ADM SADR errors that were not corrected:0
# of ADM SADR Errors Corrected/# of Encounters with ADM SADR Errors)= 100%
3c-d: DMHRSi percentages of submitted and approved timecard by suspense date were both below 95% for the month of
September. This was due to multiple issues, some of which include training of timecard approvers, training of staff on
templates and correct workstation codes, and submission of timecards and approval of timecards in the appropriate
timeframe. Another contributor to the decreased percentage was moving of staff and assignment of timecard approvers
throughout the MTF. These issues have been addresses and additional training will be provided to staff, and timecard
approvers. DMHRSi Coordinator and Manpower Coordinator have also reviewed and reassigned staff to appropriate
4a: Compliance with TMA or Service level guidelines for timely submission of data for MEPRS/EAS in 45 days was not met for
the month of September due unavailability of military workload data due to outstanding DMHRSi timecards. Authorization
to process was denied because MTF percentage of timecards submitted and approved by suspense date was below 95%. A
drill down to root cause of these deficiencies was done and process improvements are underway to ensure that timecards
are submitted and approved and time lines are met in the future.
4d: MTF Local data shows 100% compliance on daily SADR/ADM transmission. Local data utilized for this metric. Standard
trouble ticket placed for this issue is #: 198688.
5a: MTF Compliance is 93.33%. NMCSD assisted with inpatient audit and found 28/30 records had correct DRG. Training will
be provided on identified issues and proper code usage will be recommended to prevent these errors from re-occurring.
6b: Percentage of Outpatient E&M codes deemed correct for MTF was 80%. This is a training issue and we have notified the
Providers on identified issues and recommend proper code usage to prevent these errors from re-occurring.
6c: Percent of Outpatient ICD-9 codes deemed correct for MTF are 84%. This is a training issue and we have notified the
Providers on identified issues and recommend proper code usage to prevent these errors from re-occurring.
6e: MTF Compliance for complete and current DD Form 2569s available for audit in outpatient records is 77.36% due to audit
total of 82/106 forms with complete and current information. The MTF DQM will continue working closely with the Uniform
Business Office and Patient Administration Staff members to identify the process deficiency to determine why the DD-2569
form is not being administered and signed during the check in process.
8c: Comparison of reported workload data for EAS visits/ number of WWR visits on eDQ states “No Data”. Local MTF data
shows 11,086 EAS visits/ 11,086 WWR visits, 100%. “No Data” comment due to EAS data being transmitted late so WWR is
not pulled in for this calculation. DMHRSi and new MEPRS Coordinators are working together to ensure timelines are met.
8d: Comparison of reported workload data for EAS dispositions/ number of WWR disposition on eDQ states “No Data”. Local
MTF data shows 11,086 EAS visits/ 11,086 WWR visits, 100%. “No Data” comment due to EAS data being transmitted late so
WWR is not pulled in for this calculation. DMHRSi and new MEPRS Coordinators are working together to ensure timelines are
AHLTA write back detected (27)/ AHLTA write back resolved (27) = 100% of errors were resolved.
ADM errors detected (5)/ AMD errors resolved (5) = 100% of errors were resolved.
1.a: EOD reported as less than 95% goal. Action – Validated from local data that near 100% of appointments closed daily
during EOD. EDQ reported compliance of 89% due to NMCSD’s failure to transmit the daily Appt File after an ETU update.
Regular transmissions were reestablished on 8 September and NMCSD has been transmitting Appt File successfully since that
time. NMCSD Trouble Ticket #39536 and Navy Medicine Trouble ticket #356789 were created for this issue.
2.a: OPVs coded within three business days less than 95% goal (Apr 84.9%, May 85%, Jun 85.6%, Jul 86.1%, Aug 89.0%, Sep
90.3%). Action – Continue to steadily improve this metric. Continue to publish weekly report of uncoded records and push
weekly summary report of uncoded records to key personnel including coding staff for updates and corrections.
3.d: Approved DMHRSi timecards less than 95%. Action - DMHRSI system upgrade for weekend of 15 Oct 10 caused
numerous issues for all sites on DMHRSi. Major issues include: Timecards being rejected as an ex-employee and 35,000 cards
in Submitted status being stuck in the system. MHS was working to resubmit all stuck timecards. A work around was sent to
all DMHRSI Timekeepers and Approvers to inform them of issues related to the system upgrade and assist staff members
whose cards had been rejected as an ex-employee. Delinquent lists were sent out to Leadership, so that timecards action
can be taken to get outstanding timecards submitted and approved. NMCSD not authorized to create Sep DMHRSi file per
BUMED authorization report dated 3Nov10 which prevented creation of Sept EAS data. (Impacts items 4.a, 8.c and 8.d)
4.a: MEPRS/EAS data not submitted in 45 calendar days. NMCSD did not meet the BUMED 95% approved timecard
threshold required to create DMHRSi file and related MEPRS/EAS data submission.
5.c: IBWA ICD9 codes less than 95% correct. Action - Diagnosis were incorrect based on the documentation. Specific errors
corrected and one on one guidance/training for the coders completed.
6.b: Outpatient E&M codes less than 95% correct. Action - Two encounters where provider selected E&M were one level
higher than supported by documentation. Coding corrected and guidance on coding reviewed with providers by coding
6.c: Outpatient ICD 9 codes less than 95% correct. Action - Diagnosis coded incorrectly by providers. Coding corrected and
guidance on coding reviewed with providers by coding staff.
6.d: Outpatient CPT codes less than 95% correct. Action - Procedures were coded with no supporting documentation in
record. Coding corrected and guidance on coding/documentation reviewed with provider by coding staff.
6.e: Complete and current DD 2569 in outpatient record less than 95%. Action – Clinic assist visits with follow up audits
continue to be effective in improving compliance with statutory requirements in the clinics visited. Follow up audits found
100% of audited November encounters at Miramar Family Practice clinic had current and complete DD 2569 after assist
visits. Additionally, a draft e-2569 has been created by NMCSD IT dept. Plan for testing e-2569 in selected clinics in Dec 2010
8.a; SADR count is 102% of WWR. Action: MHS trouble ticket # 360126 started per BUMED instruction. Local data shows
SIDR count is 100.6% of WWR. Plan to reevaluate discrepancy after MEPRS dept recalculates WWR as part of planned
reprocessing of Sept EAS data.
8.c: EAS data not available. Local EAS data: EAS Disp (1753)/WWR Disp (1753) = 100%. EAS data was not created for Sept
because NMCSD did not meet the BUMED “Approved Timecard” threshold (95%) required to create DMHRSi file and related
MEPRS/EAS data submission.
8.d: EAS data not available. Local EAS data: EAS Visits (125,417)/WWR Visits (125,414) = 100%. EAS data was not created
for Sept because NMCSD did not meet the BUMED “Approved Timecard” threshold (95%) required to create DMHRSi file and
related MEPRS/EAS data submission.
Per BUMED direction, the following comment is included regarding:
ADM Write Back error report:
# of preventable 102 errors 242
# of preventable 102 errors corrected: 115
# of preventable 102 errors that could not be corrected: 127
# of 102 errors corrected/# of 102 errors total: 115/242 = 48%
Per BUMED direction, the following comment is included regarding:
ADM Deficiency Report:
# of encounters w/ ADM SADR errors= 344
# of encounters w/ ADM SADR errors corrected= 238
# of encounters w/ ADM SADR errors that could not be corrected= 106
# of ADM SADR Errors Corrected/# of Encounters with ADM SADR Errors)= 69%
Of the 242 AHLTA errors created in September, 169 appear to have been created due to an AHLTA software glitch which
stripped the 5th digit off a number of valid ICD9 codes selected by providers. The software glitch occurred during an ICD9
table update on weekend of 25 September and created a spike in AHLTA errors in the last week of September and beginning
of October. NMCSD Trouble ticket 33601 to correct software problem that was deleting the 5th digit, and NMCSD Trouble
Ticket 33604 to create ADM Write back push to electronically correct error in records where V72.31 was changed to invalid
code V72.3. Coding staff working to correct the other codes where the 5th digit was removed using the ADM Write back
2A - What percentage of Outpatient Encounters, other than APVs, has been coded within 3 business days of the encounter?
We had a turnover of Provider, and numerous TAD Providers not closing out records in a timely manner.
2B - What percentage of APVs has been coded within 15 calendar days of the encounter? For this month’s reporting period
we have improved for the Ambulatory Procedure Visits. We addressed this issue last month and we are still working closely
with our scanner and data entry employee to improve our compliance; however it was too late to see more of improvement
for this month’s report. We think we have discovered an issue with the Pre-op appointments utilizing TP APU clinics instead
of the utilizing the Gyn, Surgery, or Ortho clinics. We need to have this issue looked into and then take the appropriate
3C For DMHRSi, what is the percentage of submitted timecards by suspense date? On 10-8-2010 DMHRSi team emailed to
all sites connectivity issues. The system was down for most members for approximately two weeks. The last Pay Period for
DMHRSi affecting the September file ended on 09 OCT 2010. Staff members were not able to successfully log into DMHRSi.
MHS Trouble ticket number: MHSINC000519036 issued on 12 OCT 2010. Unable to access DMHRSi due to IAS/CAC card
issues. IAS Engineer Mr. Tauk Chang of SAIC worked closely with MEPRS Manager to reconfigure IAS (CAC) account. Trouble
ticket closed on 19 OCT 2010. DMHRSi is still not fully operational.
4D - MTF Local data shows 100% compliance on daily SADR/ADM transmission. Local data utilized for this metric. Standard
trouble ticket placed for this issue is #: 198688.
6B - What is the percentage of E & M codes deemed correct? (E & M code must comply with current DoD guidance.) We had
a few providers who had problems with the coding in AHLTA. The AHLTA trainer came in and has worked with these
providers to correct the problems. We also have providers that did not have AHLTA access with meant the encounters were
hand written and harder to read. This has also been corrected.
6C - What is the percentage of ICD-9 codes deemed correct? We had a few providers who had problems with the coding in
AHLTA. The AHLTA trainer came in and has worked with these providers to correct the problems. We also have providers
that did not have AHLTA access with meant the encounters were hand written and harder to read. This has also been
6D - What is the percentage of CPT codes deemed correct? (CPT code must comply with current DoD guidance.) We had a
few providers who had problems with the coding in AHLTA. The AHLTA trainer came in and has worked with these providers
to correct the problems. We also have providers that did not have AHLTA access with meant the encounters were hand
written and harder to read. This has also been corrected.
7B - What is the percentage of ICD-9 codes deemed correct? Providers need to sign up with the Contract Auditor/Trainer to
go over the results of the audits and improve documentation for accuracy.
10A - What was the number of potential duplicate records in the reporting month? Camp Pendleton is our CHCS host site.
While this metric is not applicable to our site we have requested the duplicate report from our host site for review and
ADM Write Back error report:
# of preventable 102 errors: 134
# of preventable 102 errors corrected: 70
# of preventable 102 errors that could not be corrected: 64
# of 102 errors corrected/# of 102 errors total: 70/134 = 52%
ADM Deficiency Report:
# of encounters w/ ADM SADR errors: 325
# of encounters w/ ADM SADR errors corrected: 50
# of encounters w/ ADM SADR errors that could not be corrected: 275
# of ADM SADR errors corrected/# of encounters with ADM SADR errors: 50/325 = 15%
2a. The coding of outpatient encounters continues to be below the BUMED goal of 96%, currently at 94%, holding steady
over the last five months. PLAN: A listing, by provider, of the delinquent ADM coded records is posted daily to the
SharePoint website for each clinic. Each Department Head/Clinic Manager should be consulting this listing to determine
which records are outstanding and assist the providers with completing their encounters.
2c. The coding of the inpatient records within 30 days dropped 1.5% just at the 95% goal. PLAN: Inpatient coders continue to
work all inpatient records within the 30 day requirement.
3c. The DMHRSi timecard reports indicated that 8% of timecards (356) were not in a submitted status and 6% of timecards
(223) were not in an approved status by the due dates. PLAN: The DMHRSi LCA manager will provide a list to the Data
Quality Manager each Friday (started in November), following the end of a timecard period, identifying by name and by
department, the staff with outstanding timecards. This listing will be forwarded to the Directors for dissemination and
action. Plan to see improvement by December DQ Statement.
3d. The DMHRSi timecard reports indicated that 8% of timecards (356) were not in a submitted status and 6% of timecards
(223) were not in an approved status by the due dates. PLAN: The DMHRSi LCA manager will provide a list to the Data
Quality Manager each Friday (started in November), following the end of a timecard period, identifying by name and by
department, the staff with outstanding timecards. This listing will be forwarded to the Directors for dissemination and
action. Plan to see improvement by December DQ Statement.
4a. The MEPRS/EAS transmission was not completed due to the delay in processing the DMHRSi timecards/file. The DMHRSi
timecard reports indicated that 8% of timecards (356) were not in a submitted status and 6% of timecards (223) were not in
an approved status by the due dates. PLAN: The DMHRSi LCA manager will provide a list to the Data Quality Manager each
Friday (started in November), following the end of a timecard period, identifying by name and by department, the staff with
outstanding timecards. This listing will be forwarded to the Directors for dissemination and action. Plan to see improvement
6b. Seven records out of 30, or 23% were assigned an incorrect E&M code. PLAN: The Auditor/Trainers will follow-up with
one-on-one training with the providers/clinic which should decrease the number of coding errors in the next couple of
6e. Six outpatient records out of 20, or 30%, a 25% decrease from the previous month, were without a signed DD2569 in the
non-active duty records. The average for October – August for FY09 was 74% and for FY10 is 82%. PLAN: The Business Office
continues to communicate the importance of a valid DD2569 form; offering additional assistance and training to improve this
7d. The APV record review revealed, one record, out of 16, that was missing a signed DD2569. PLAN: The Business Office
continues to communicate the importance of a valid DD2569 form; offering additional assistance and training to improve this
8c. Local data used due to delay in processing September file (EAS visits 29,384/WWR visits 20,384).
8d. Local data used due to delay in processing September file (EAS dispositions 255/WWR dispositions 255).
Per BUMED, the following comment is included regarding SADR error correction:
ADM Write back error report:
# of preventable 102 errors = 45
# of preventable 102 errors corrected = 45
# of preventable 102 errors that could not be corrected = 0
# of errors corrected/#of 102 errors total = 45/45 = 100%
ADM Deficiency Report:
# of encounters w/ADM SADR error = 18
# of encounters w/ADM SADR errors corrected = 5
# of encounters w/ADM SADR errors that could not be corrected = 0
# of ADM SADR Errors corrected/# of Encounters with ADM SADR errors = 5/5 = 100%
Item 2a - Percentage of Outpatient Encounters other than APV coded within 3 business days is 92% although Tracker report
is showing 100% SADR transmitted and coded. Trouble ticket has been filed to reflect the correct numbers. Ticket number is
Item 6b - Two E&M codes are incorrect. E&M code 99213 was used vice 99212, 99212 vice 99201. Auditor/Coder Liz Tellez
educated the coders after review regarding the correct codes to use.
Item 6c - Four out of forty one have incorrect ICD-9 codes. ICD-9 codes V15.82, V67.09 should not have been used. ICD-9
codes 923.10, 380.89 was used but documentation did not support it. Resolution is the same as Item 6b.
Item 6d - One out of twelve record does not have CPT code and should had been 90809. Resolution is the same as Item 6b.
Item 6e - Three records does not have current DD2569. UBO Lisa Marshall is working with the check-in clerks to identify
which department is not in compliance in collecting DD2569.
Item 7b - Three ICD-9 codes are not correct. ICD-9 codes 229.8, 823.80, 718.81 was used but documentation does not
support it. Resolution is the same as Item 6b.
Item 7c - CPT code 58120 was used vice 29870, 24530 was used vice 24535. Resolution is the same as Item 6b.
Item 7d - Seven out of thirteen records do not have current and updated DD2569. UBO lead will be working with the Surgery
Department to review the packet that is being handed to the beneficiaries before surgery.
Item 7e - One DD2569 was not updated in CHCS. UBO office will ensure that CHCS records are updated when DD2569 are
NEW: Per BUMED direction, the following comment is included regarding:
ADM Write Back error report:
# of preventable 102 errors: 175
# of preventable 102 errors corrected: 175
# of preventable 102 errors that could not be corrected:0
# of 102 errors corrected/# of 102 errors total: 175/175=100%
NEW: Per BUMED direction, the following comment is included regarding:
ADM Deficiency Report:
# of encounters w/ ADM SADR errors= 4
# of encounters w/ ADM SADR errors corrected= 4
# of encounters w/ ADM SADR errors that could not be corrected= 0
# of ADM SADR Errors Corrected/# of Encounters with ADM SADR Errors) 4/4=100%
There were four local ADM Deficiency Report (ADR) errors corrected on 17 November 2010. There are 175 AHLTA Exception
Write back (AEW) errors report received from the host command, Madigan Army Medical Center (MAMC) for the month of
4d)SADR/ADM: The eDQ is expected to be fixed either with the FY11 changes or shortly after. Ticket #198688.
6b)E&M Codes: There were 2 encounters with errors. 1 E&M level was over coded; 1 E&M level was under coded.
6e)DQM Team will re-evaluate current process for ensuring 2569s are updated in patient records and determine if front desk
staff require re-training. Clinic Department Heads will also be re-informed of the importance of this process.
SADR Errors: 0 errors (Errors are addressed by BOD and resolved by respective clinics weekly)
ADM Write Back Error report:
# of preventable 102 errors: 483
# of preventable 102 errors corrected: 449
# of preventable 102 errors that could not be corrected: 34
# of 102 errors corrected/# of 102 errors total: 93%
# of preventable 103 errors: 20
# of preventable 103 errors corrected: 18
# of preventable 103 errors that could not be corrected: 2
# of 103 errors corrected/# of 103 errors total: 18/20 = 90%
2A: POA&M: PAD Head and Assistant Head, will be visiting each of the 10 of 32 clinics identified as below 95% in order to
assist in obtaining a higher level of compliance by working with them to recognize and address areas of concern.
2C: POA&M: The percentage of inpatient records coded within 30 calendar days after discharge has increased from 91% to
94% in the last month. With newly implemented tracker, PAD expects to see an increase in compliance within the next
quarter. CCE updates released at the beginning of new fiscal year placed a significant number of records on hold. This is
expected to cause a temporary drop in compliance with the October reporting month.
6B: POA&M: Outpatient E&M coding accuracy decreased from 75% to 70% during the past month. Audited providers
notified of their audit results and made resources available to them for error correction. Top three errors identified were: 1.
Over coded ESTABLISHED - Medical Decision Making (MDM) (8), 2. EM not required (99499 or blank) (5), 3. Modifier not used
(3). We have requested STI's certified auditors/trainers to provide monthly guidance specific to the errors with clear
instructions on how to correct and prevent future reoccurrences.
6C: POA&M: Outpatient ICD-9 coding accuracy decreased from 97% to 88% during the past month. Audited providers
notified of their audit results and made resources available to them for error correction. The three errors identified are: 1.
Other diagnosis disagreement (5), 2. Primary diagnosis not the reason for the visit (4), and 3. Diagnosis not to maximum level
of specificity (3). We have requested STI's certified auditors/trainers to provide monthly guidance specific to the errors with
clear instructions on how to correct and prevent future reoccurrences.
6D: POA&M: Outpatient CPT coding accuracy increased from 91% to 92% during the past month. Audited providers notified
of their audit results and made resources available to them for error correction. The two errors identified are: 1. Procedure
not coded (5) and 2. Other CPT/HCPCS disagreement (2). We have requested STI's certified auditors/trainers to provide
monthly guidance specific to the errors with clear instructions on how to correct and prevent future reoccurrences.
* AHLTA WRITE BACK ERROR *
(266) Write back errors detected / (0) Write back errors resolved = 0% of
errors were resolved (coding errors that require correcting from "off island" contract coders).
259 of the errors were type 102.
6 of the errors were type 103.
1 of the errors were type 106.
** ADM DEFICIENCY ERROR **
(6) ADM Deficiency errors detected / (1) ADM Deficiency errors resolved =
17% of errors were resolved.
2a. Non-compliance is a result of ADM Write back errors in AHLTA concerning ICD-9 codes. The ticket number is
MHSINC000546268 and it was logged by the SAIC team in the US.
2b. Our APV coder experienced about a week backlog of records to code resulting in several records being non-compliant.
Also 38 test encounters that were recently discovered effecting write back errors.
2c. Reviewing and double checking the status of the results.
5c. Oversight in coding diagnosis code by coder. Corrective action has been identified to maintain attention to detail when
5d. Insufficient documentation by provider. The provider was contacted to discuss discrepancies provider's template has
been updated.
5e. No audit results this month, staff will conduct the audit and verify CHCS reporting next month.
5f. No audit results this month, staff will conduct the audit and verify CHCS reporting next month.
6b. E&M coding accuracy improved greatly from 46% to 80% in Sep. Lead auditor will visit our command in Dec to provide
quarterly training to the providers to continue to improve E&M accuracy.
6c. Coding accuracy has improved from 77% to 82% in Sep. Lead auditor will visit our command in Dec to provide quarterly
training to the providers to continue to improve ICD-9 accuracy.
6d. CPT coding accuracy has decreased from 82% down to 72% in Sep. Along with the lead auditor quarterly training held in
Dec, the command plans to hire two auditor/trainers to assist the providers with CPT coding.
6e. The audit was not performed due to the newly person assigned to conduct the audits was off island. She has been
tasked to complete each audit by the 15th of each month for the correct period.
6f. The audit was not performed due to the newly person assigned to conduct the audits was off island. She has been tasked
to complete each audit by the 15th of each month for the correct period.
7d. The audit was not performed due to the newly person assigned to conduct the audits was off island. She has been
tasked to complete each audit by the 15th of each month for the correct period.
7e. The audit was not performed due to the newly person assigned to conduct the audits was off island. She has been
tasked to complete each audit by the 15th of each month for the correct period.
2a) Compliance reports are generated and sent out to Directors to notify what providers have not met the 3 business day
standard. Business Operations will include Department Heads to list.
2c) USNH Yokosuka was short staff during this time period. USNH Yokosuka is still currently working with NMW on
submitting information for coding and auditing review.
5b) USNH Yokosuka was unable to complete IBWA rounds prior to falling out of the system due to staffing shortage.
5c) USNH Yokosuka was unable to complete IBWA rounds prior to falling out of the system due to staffing shortage.
5d) USNH Yokosuka was unable to complete IBWA rounds prior to falling out of the system due to staffing shortage.
5e) DD 2569 information not provide for this DQ statement. Information was not captured due to shortage of staff.
5f) DD 2569 information not provide for verification check.
6b) Improper documentation submitted, lack of documentation was submitted, and codes being audit were 1, 2, or 4 levels
lower then reported.
6c) Diagnosis that was reported was not correct for first line diagnosis.
6d) Modifiers were not reported. The CPT/HCPCS procedure codes used; supporting documentation and/or coding rules
indicate that a modifier should be assigned.
6e) DD 2569 information not provide for this DQ statement. Information was not captured due to shortage of staff.
6f) Information not provide for verification.
7d) DD 2569 information not provide for this DQ statement. Information was not captured due to shortage of staff.
7e) Information not provide for verification.
8c) Local generated numbers for EAS IV were used 15754.
8d) Local generated numbers for EAS depositions used 152
8e) USNH Yokosuka was unable to complete IBWA rounds prior to falling out of the system due to staffing shortage.
ADM Write Back error report:
# of preventable 102 errors 359
# of preventable 102 errors corrected: 63
# of preventable 102 errors that could not be corrected: n/a
# of 102 errors corrected/# of 102 errors total: 17.5%
In addition there are 45 errors in the 103 status.
In addition there are 10 errors in the 106 status.
In addition there are 3 errors in the 110 status.
ADM Deficiency Report:
# of encounters w/ ADM SADR errors= 8
# of encounters w/ ADM SADR errors corrected= 0
# of encounters w/ ADM SADR errors that could not be corrected= N/A
# of ADM SADR Errors Corrected/# of Encounters with ADM SADR Errors)= 0
                             NAVMED EAST
2c)In- completed documentation and provider signature. NH Pensacola current policy is that all records must be sign by the
provider before they can be coded. The directors, departments, and clinic managers are all educating providers that they
should not be waiting until day 30 before signing these records. Inpatients coded was 71%.
3b)Previous WWR/EAS outliers were cleared up with the exception of Dental. The summary outlier for Dental was corrected
on 18 November 2010. The cause for this outlier/variance was due to the amount of the 4th level N/DMIS 0260 was entered
5a)The DRG accuracy has failed below the metric due to missing records. NH Pensacola staff has attempted to locate these
files through CHCS, MRM, doctors chart room and record room with no success.
NH Pensacola staff has attempted to locate these files through CHCS, MRM, doctors chart room and record room with no
success. DRG accuracy was 90.0 (27/30).
5b)Based on supporting documentation the cause for this to be below threshold was due to an IBWA visit not being coded
by a coder prior to audit and two E/M errors. E&M accuracy was 93.0 (27/29).
5c)ICD-9 coding errors were identified for IBWA coding; only those addressed on each date of service should have been
coded for that date of service (except for discharge). An example: patient was in for UTI and later diagnosed with E-coli; the
E-coli should not have been coded on IBWA rounds prior to the day it was diagnosed. ICD-9 accuracy was 73.0 (72/98).
5d) Non-Obstetrical procedure code was reported when procedure was related to obstetrical condition. CPT accuracy was
94.0 (30/32). On 22 November 2010 NH Pensacola PAD hired an STI inpatient coder to come onboard. We should start to
see an improvement in the DRG, ICD-9, CPT and E&M metric starting January 2011.
5e)Inpatient DD 2569’s was 97.0 (29/30).
6b)One of the cause for this metric not meeting the compliance rate was due to over-coding being identified mainly on
established patients. DOD rule states that the MDM has to be one of the two components used in determining E&M level.
Based on the supporting documentation if the history and exam both meet the documentation requirements of a 99214, the
AHLTA coding calculator will assign a 99214. However, if the MDM only meets the requirements of a 99213, DOD rules states
that the E&M must be down coded to a 99213 based on MDM determining the E&M level. The second cause that was found
by the coders was that non-privileged provider PHA’s coded to either preventive medicine physical E&M codes or preventive
medicine counseling E&M codes. E&M accuracy was 80.0 (209/260)
6c)NH Pensacola auditor/trainer has found the following items that has caused this metric to be below the compliance rate:
several encounters reported diagnosis code V70.0 that should been V72.31 (well woman exam), incorrect extender codes
reported, V68.1 being coded in other than primary diagnosis, coding conditions that are resolved when the patient comes in
for follow-up, aftercare codes not being reported appropriately and diagnoses that should be reported in the order of chief
compliant and/or order of medical decision making complexity. ICD-9 accuracy was 86.0 (362/419)
6d)CPT accuracy was 97.0 (356/366). NH Pensacola is in the process of hiring professional coders to be placed in multiple
outpatient clinics to help address our coding issues and improve coding accuracy we should start to see changes in this
metric around January 2011.
6e) Based on supporting documentation on our outpatient metric for DD Form 2569’s occurred due to the form not being
completed correctly (not signed), dated or not available weather it was an electronic copy, a loose copy, or hard copy. As of
17 November 2010 NH Pensacola has started transitioning to our new process for DD Form 2569’s and has deployed scanner
to the following clinic: Family Medicine, EN & T and Inter Medicine for testing (with insurance cards only). NH Pensacola
UBO office is working on a schedule for deployment of the scanners to the other clinics. Our UBO office has assigned one
person who will start full-time as of 01 December 2010 and she will be responsible for OHI process and insuring that each
clinic has been trained on how to use the scanner, collecting the hard copies of the forms and helping the clinics with any
questions that they may have. This process will be done on a daily basis to ensure that the scanners are being used properly
and that the DD Forms 2569 are being fill out correctly. Outpatient DD 2569’s was 67.0 (72/108).
7c)Documentation shows that NH Pensacola had one procedure that was coded as closed procedure (fracture) when it
should have been coded as an open procedure. CPT accuracy was 99.0 (79/80). All errors are noted and being reviewed
with the APV coder to ensure that documentation and coding references are being followed.
7d)APV DD 2569’s was 100.0 (30/30).
8b)Per Mr. Bush; NH Pensacola current policy is that all records must be signed before the coders can code them. This policy
was put into place when the audit was done by Deloitte. The SIDR report is sent on the first of every month and in some
cases not all records have been signed by the providers in order for the coders complete. SIDR should be 100%
NEW: Per BUMED direction, the following comments is included regarding:
ADM Write Back error report:
# of preventable 102 errors were 314
# of preventable 102 errors corrected: 73
# of preventable 102 errors that could not be corrected:161
# of 102 errors corrected/ # of 102 errors total: 73/314 = 0.23%
Once the coders have completed the error report, the errors are being sent to clinic managers for the provider to let them
know the specific code(s) are no longer valid and to update their favorites list in AHLTA and to get rid of the outdated
NEW: Per BUMED direction, the following comment is included regarding:
ADM Deficiency Report:
# of encounters w/ ADM SADR errors= 3
# of encounters w/ ADM SADR errors corrected= 3
# of encounters w/ ADM SADR errors that could not be corrected=0
# of ADM SADR Errors Corrected/# of Encounters with ADM SADR Errors)=100%
2.a. We have continued to provide reports monthly to the clinic managers to identify open encounters. Although 3 of our
facilities did not meet the metric goal for completing Outpatient encounters within 3 business days, we are currently @
99.7% completion for the month of September, with only 185 incomplete records. An updated POA&M is attached.
2.b. Of the 20 records not coded within the 15 day time frame, nineteen were due to two providers being on leave/TAD. In
spite of not meeting the metric, all APVs except one have been completed for the month of September. POA&M is attached.
3.b. Dental weighted workload was an outlier for the month of September. Mayport Dental Lab did not have all of their
August workload in the August Report and what had not be included for August was added to the September data, resulting
in an outlier. Business rules for ensuring all workload is recorded during the correct month will be discussed with the Dental
5.b E&M - Unable to audit 6 records; 3 had incorrect MEPRS; 1 had incorrect admission date, and 2 encounters were not
flagged for signature and coder was unable to code the additional E&M. Inpatient supervisor will provide training for her
staff on ensuring that the MEPRS code, admission dates and signatures are correct. Auditor/trainer will provide training with
5.c - ICD-9 - Incorrect last digit and additional diagnosis code for attending were not selected. Auditor/trainer will provide
training with coders immediately on ICD-9s.
5.d CPT - Based on documentation, the selection of the procedure codes did not match the ops report. Auditor/trainer will
provide training with coders immediately on CPTS.
5-b-d - Coding supervisor will provide educational feedback to the coder's areas of deficiency with a follow up review 15 days
after training.
5.e - Form 2569 continues to be an issue in the medical records. TPC will continue to provide training and pick up of the
form to be put in the records. Even though we are not meeting the metric, the Command remains number 1 in the Navy for
collections of OHI. The Command will continue work toward collecting as many DD2569s as possible.
6.b - E&M -Four records had incorrect appointment type selected. Since changing appointment types to OPAC, and having to
use the PCM, the clinics are using EST, SPEC, or OPAC, AHLTA disposition defaults to an incorrect E&M code.
6.c - ICD-9 - Out of 45 diagnoses, four were not captured.
6.b & c - A handout for the providers with appointment types and the disposition default will be provided to the providers
with directions on ensuring the E&M is correct before closing the record. Training will be provided to ensure all conditions
treated during the encounter are captured.
6.e - Form 2569 continues to be an issue in the medical records. TPC continues to provide training and pick up of the form to
be put in the records. Even though we are not meeting the metric, the Command remains number 1 in the Navy for
collections of OHI. The Command will continue work toward collecting as many DD2569s as possible.
7.d. Form 2569 continues to be an issue in the medical records. TPC will continue to provide training and pick up of the
form to be put in the records. Even though we are not meeting the metric, the Command remains number 1 in the Navy for
collections of OHI. The Command will continue work toward collecting as many DD2569s as possible.
Inpatient 2569 audit in record - 28/30 = 93%
Outpatient 2569 audit in record - 27/30 = 90%
APV 2569 audit in record - 28/30 = 93%
ADM WRITE BACK ERROR REPORT
Total 102 preventable errors = 977
Total 102 errors corrected = 417        43%
Total 102 errors non-corrected = 560
Total ADM SADR errors = 1,020
Total ADM SADR errors corrected = 443/1020          43%
Total ADM SADR errors not corrected = 577
3.b. Data Load Status - EAS transmission was 1 day late due to an allocation error that needed assistance from higher
authority to correct.
4.a. EAS transmission was 1 day late due to an allocation error that needed assistance from higher authority to correct.
4.d. BUMED TT198688
6.b. 20 of 29 E&M were correct
6.c. 36 of 40 ICD9 were correct
6.d. 30 of 33 CPT were correct
6.e. 4 out of 30 encounters were missing current, complete 2569s
6.f. 26 out of 26 2569 were verified in CHCS
8.c. WWR/EAS 34275/34275 100%
Write Back Error Reports can no longer be provided due to the LCS now being on the MHS domain.
2a) 46,881/42,033=89.66% ER Encounters delayed compliance due to process errors by STI Contract Coders/data entry staff;
process was corrected. Compliance increased for September; anticipate continued compliance for future DQ Statements.
Provider delinquency continues to be addressed by DQM, PAD and Clinic Managers; anticipating increased compliance for
2b) 188/229=82.10% Incomplete documentation, and Provider dictation delinquency decreased timeliness. Directors,
Department Heads and Providers engaged via XO to expedite process.
2c) 573/499=87.10% Incomplete documentation, and Provider dictation delinquency decreased timeliness. Directors,
Department Heads and Providers engaged via XO to expedite process.
3b) MEWACS reviewed; no new Outliers to report.
4d) 100% SADR File Transmission errors continued. BUMED TT#198688 submitted.
5a) 28/30=93% Coder selected the incorrect diagnosis or had the wrong diagnosis as the principal.
5b) 29/30=97%
5c) 71/81=88% None of the diagnoses reported were the correct first-listed diagnosis. (Excludes specificity errors which
should be reported with codes D6-D8.) A diagnosis reported in any one of positions two through fifteen cannot be
substantiated in the supporting documentation. Based upon the supporting documentation, a diagnoses/diagnoses, which
is/are not classified as a complication or co-morbidity, should have been assigned in the third to ninth positions.
5d) 12/14=86% Based upon the supporting documentation, a procedure should not have been reported.
5e) 22/23=96%
5f) 0/0=100% or N/A
CODING CORRECTIVE ACTION: Records and Audit sheets returned to coder with errors, coder to review and submit back to
MRA-Coding Supervisor for justification and correction of codes.
6a) 30/30=100%
6b) 24/32=75% Based upon the supporting documentation, an E&M code should not have been reported. Based upon the
supporting documentation, an additional E&M code should have been reported. The E&M code audited was 1 level below
the reported E&M code. The E&M code audited was 1 level above the reported E&M code. The E&M code audited was 2
6c) 50/58=86% Based upon the supporting documentation, a diagnoses/diagnoses, which is/are not classified as a
complication or co-morbidity, should have been assigned in the third to ninth positions.
6d) 31/41=76% Based upon the supporting documentation, a procedure should not have been reported. Based upon the
supporting documentation, a procedure should have been reported. A CPT code should have been reported versus a HCPCS
6e) 9/11=82% UBO DH and 2569 Coordinator contacted Internal Medicine and APV DH for corrective action to ensure 2569s
are completed/updated for every patient, every appointment. Anticipate continued increase in compliance for future DQ
6f) 0/0=100% or N/A
CODING CORRECTIVE ACTION: Records and Audit sheets will be reviewed and returned to coder with errors, coder to review
and submit back to MRA-Coding Supervisor for justification and correction of codes. Provider coding will be reviewed;
Coders will conduct Provider education/clarification.
7a) 29/29=100%
7b) 90/94=96%
7c) 92/95=97%
7d) 8/9=89% UBO DH and 2569 Coordinator contacted Internal Medicine and APV DH for corrective action to ensure 2569s
are completed/updated for every patient, every appointment. Anticipate continued increase in compliance for future DQ
7e) 1/1=100%
NEW: Per BUMED direction, the following comment is included regarding the ADM Write Back error report(*):
# of preventable 102/103 errors: 584
# of preventable 102/103 errors corrected: 584
# of preventable 102/103 errors that could not be corrected: 0
# of 102 errors corrected/# of 102/103 errors total: 584/584=100%
NEW: Per BUMED direction, the following comment is included regarding the ADM Deficiency Report(*):
# of encounters w/ ADM SADR errors: 60
# of encounters w/ ADM SADR errors corrected: 56
# of encounters w/ ADM SADR errors that could not be corrected: 4
# of ADM SADR Errors Corrected/# of Encounters with ADM SADR Errors): 56/60=93%
* Continuing to coordinate the final DQ, MID, PAD/Coding analysis & correction process.
Additional Issues and Updates
1. Tickets being worked by MHS developers:
a. Duplicate Modifiers Display
MHS – 14219608 – under review
AHLTA 3.3.3.2 - A/P module when user selects a CPT/Procedure, then opens the Procedure Details window via Icon
“Modifiers” selects drop down arrow, duplicate Modifier codes display.
Update: 30 JUN 2010 – Duplicate modifiers still display after CF 9 upgrade. Contacted MHS; passed up to T3 for resolution.
2. AHLTA
a. MedcinCode s 5.1 3rd QRT 2010 IDC upgrade was pushed 10 NOV.
3b. There was one new MEWACS Outliers for our Facility for this reporting period. This Outlier is related to the Personnel
Direct Expenses, which appear to be under-stated for this month's reporting. This decrease is attributable to the removal of
all of the Non-Personal Contract Labor FTE's in DMHRSi. These Contract FTE should not have been reported, because these
Contracts are not based on Hours of Service. For example: Housekeepers under Custodial Services (EFAA).
3c. DMHRSi Timecard Compliance at the time of transmission to the Repository was 100% for a total of 1,324 Timecards.
There were a total of (30) encounters that were reviewed for this month's reporting. The Coding Audit statistics reported
below are based on the interpretations of the NME Auditors. Due to current time constraints we are unable to provide more
detailed analysis at this time. Until that analysis is completed we cannot provide our concurrence with these Audit Findings.
At the completion of our local reviews we will forward the appropriate information to NME at that time.
6b. E/M Statistics are as follows: 22/31 for 71%. According to the comments provided by NME there were instances of
under-coding E&M values, as well as upcoding some E&M values that were not supported by the documentation.
6c. ICD-9 Statistics are as follows: 36/43 for 84%. According to the comments provided by NME there were instances of
improperly ranking the Diagnosis.
6d. CPT Statistics are as follows: 37/42 for 88%. According to the comments provided by NME there were instances of
reporting Procedures Codes that were not supported by the documentation.
6e. Statistics are as follows: 13/16 = 81.25%. There were a total of (16) non-Active Duty encounters, (8) Active Duty and (6)
Occ Med encounters for this DD2569 Audit. We were able to locate all of the applicable Non-Active Duty forms for this
month's Audit except for (3). It has been confirmed that one of our major Clinics had a misunderstanding during this
month's reporting relating to the requirement that all Family Members are required to complete a DD2569. This
misunderstanding has been addressed with the appropriate Clinical Staff.
7b. ICD-9 Statistics are as follows: 39/45 for 87%. According to the comments provided by NME there were instances of
improperly ranking the Diagnosis.
New Metrics Update
ADM Write-Back Errors for this Month's reporting total (363)
# of preventable 102 Errors: 341
# of preventable 102 Errors corrected: 100
# of 103 Errors: 22
# of 103 Errors corrected: 0
Comments from Coding Manager:
The Coding Manager is continuing to work with Mr. Nicholas Cappola our SME on this issue. We have experienced a
decrease of approximately 30% from last month's reported total of (516). We are continuing to work with the Providers and
their Templates to ensure that they are not utilizing inactive codes, as well. We suspect that the majority of these errors are
attributable to ICD-9 Table update disconnects between AHLTA and CHCSI.
ADM Deficiency Report for this Month's reporting period total (1,049), of which 18% or (194) are correctly reflected as an
ADM Deficiency. The Deficiency categories are broken down as follows: NO ADM Record - There are (507) encounters that
are attributable to our Case Management and Referral "E-non-count" Clinics that do not require an ADM record. There are
(194) instances where the encounter has not been processed through the ADM Module of CHCSI. This is most often
attributable to the fact that the encounter has not been coded or it has simply not written back to the ADM Module. No
E&M - There are (348) encounters that carry a 99499 Place Holder E&M value, because they contain a CPT Procedure that
acts as the E&M value. No ICD 9 - There were no instances of this type of error for this month's reporting period. No ICD-9 -
(2a) Compliance improved; King Hall Clinic administrative assistance will be available during shot clinics to ensure timeliness
of coding in AHLTA.
(3b) WWR/EASi outliers: no new outliers
(4d) All NHCNE SADR files were sent on time during September - BUMED TT# 198688.
(6b) NME audited 30 September encounters. The NHCNE Auditor/Trainers will continue to provide focused training to
providers and coding staff in conjunction with local Provider Data Profile reviews and input from NME audits. Coding
(6c) The NHCNE Auditor/Trainers will continue to provide focused training to providers and coding staff in conjunction with
local Provider Data Profile reviews and input from NME audits. Coding accuracy: ICD-9 46/49 = 93.87%
(6d) The NHCNE Auditor/Trainers will continue to provide focused training to providers and coding staff in conjunction with
local Provider Data Profile reviews and input from NME audits. Coding accuracy: CPT 45/55 = 81.81%
(6e) The Deputy Director for Health Services recommended clinic points of contact review the 2569 audits with Medical
Records staff at all NHCNE MTFs. The September 2010 audit for 2569 compliance improved: 85 of the 90 records audited
(94.44%) were compliant. NHCNE Newport: 29 of 30 (96.66%), NBHC Groton: 26 of 30 (86.66%), and NBHC Portsmouth NH:
30 of 30 (100%); NBHC Saratoga Springs is A/D only. Updated 2569 information was entered into CHCS: 83 of 85 (97.64%).
(8a) Compliance Status = R: Count = 20,366 (81.14%); Non-count = 4,733 (18.86%); Source: M2 12/1/10; reported as of
11/22/10. Local numbers: 20,366/20,299 (100.33%).
(8c) NHCNE reprocessed and submitted EASi and WWR on 04 Oct, 25 Oct, and again on 08 Nov; totals submitted 08 Nov:
20,299/20,299 (100%).
10) NHCNE had 9 potential duplicates - there were no actual duplicates.
The following comment is included regarding AHLTA Write Back error report:
# of preventable 102 errors: 124
# of preventable 102 errors corrected: 116
# of preventable 102 errors that could not be corrected: 6
# of 102 errors corrected/# of 102 errors total: 116/124 = 95.16%
The following comment is included regarding ADM Deficiency Report:
# of encounters w/ ADM SADR errors = 0
# of encounters w/ ADM SADR errors corrected = 0
# of encounters w/ ADM SADR errors that could not be corrected = 0
# of ADM SADR Errors Corrected/# of Encounters with ADM SADR Errors)= 0/0 = 100%
2.a: Local data substituted based on an Ambulatory Data Module Compliance Report run daily for September 2010 based on
the three business day rule. 3.b: MEWACS version 16 Nov 10. No new outliers. 6.a: Of the 30 random record pull for audit
2 were reported with no documentation in AHLTA. 6.b: E&M audit indicated 1 encounter without an E&M should have had
one, 1 encounter should have had 2, 1 encounter was under coded, and 2 encounters the documentation didn't support the
E&M selected. See attached POA&M. 24 of 29 (83%) accurate. 6.c: ICD9 audit indicated 5 encounters had omitted ICDs, 1
was not specific enough, and 1 was just in error. See attached POA&M. 43 of 50 (86%) accurate. 6.d: CPT audit indicated 3
encounters did not have supporting documentation, 1 encounter did not have medical necessity documented, and 1 had
omitted code. See attached POA&M. 36 of 43 (84%) accurate. 6.e: A random list of 125 records were reviewed, of which
113 (90.4%) were compliant. The move to our new facility restricted record distribution to clinics to only 4 days in
Per BUMED direction, the following comment is included regarding:
ADM Write Back error report:
# of preventable 102 errors 15
# of preventable 102 errors corrected: 15
# of preventable 102 errors that could not be corrected:0
# of 102 errors corrected/# of 102 errors total: 15/15 =100%
Per BUMED direction, the following comment is included regarding:
ADM Deficiency Report:
# of encounters w/ ADM SADR errors=1
# of encounters w/ ADM SADR errors corrected=0
# of encounters w/ ADM SADR errors that could not be corrected=1
# of ADM SADR Errors Corrected/# of Encounters with ADM SADR Errors)=0/1 = 0%
2c. All charts with the exception of three were coded within 30 days. Four were recoded after the 30 day time period which
causes them to fall out as delinquent on the report.
3b. No new outliers
5a. 30 of 30 codes deemed correct for 100%.
5b. 29 of 30 codes deemed correct for 97%.
5c. 53 of 54 codes deemed correct for 98%.
5d. 29 of 31 codes deemed correct for 94 %. Errors due to code specificity and bundling issues.
6b. 24 of 30 codes deemed correct for 80%. Errors due to new vs established x 2. One level over- coded x 1. One level
under-coded x 1. No supporting documentation to code visit x 2.
6c. 44 of 49 codes deemed correct for 90%. Errors due to omission of e-codes x 2. Routine exams for active duty x 2.
Pregnancy not captured x 1.
6d. 38 of 41 codes deemed correct for 93%. Bundled codes used x 1. No supporting documentation x 2.
6e. Of 4191 opportunities to collect 2569 information, we collected 3453.
7b. 58 of 58 codes deemed correct for 100%.
7c. 95 of 96 codes deemed correct for 99%.
8b. 63 of 68 dispositions for 92.65%. Five charts not coded due to missing documentation.
ADM Write back:
# of preventable 102 errors 7
# of preventable 102 errors corrected: 7
# of preventable 102 errors that could not be corrected:0
# of 102 errors corrected/# of 102 errors total:7/7 =100%
# of encounters w/ ADM SADR errors=2
# of encounters w/ ADM SADR errors corrected=0
# of encounters w/ ADM SADR errors that could not be corrected=2
# of ADM SADR Errors Corrected/# of Encounters with ADM SADR Errors)=0
2.a: What percentage of Outpatient Encounters, other than APVs, has been coded within 3 business days of the encounter?
Using the Coding Standards Compliance Ad Hoc from CHCS, there were 5,744 encounters coded out of 6,287 encounters
within 3 business days. The coding staff is monitoring this metric and giving feedback to the providers and clinic managers on
a daily basis. The coding staff is also providing one on one training with the providers as needed.
4.b: N/A - no longer need to report SIDR for external facility.
4.d: SADR/ADM - Daily - We transferred 150 of 155 SADRs on time. DMIS 0656 has been disestablished, 30 SADRs are
showing in the total number as being missing but should be excluded. Ref BUMED TT 198688
6.b-d: The coding audit was done by a contractor at NME. In the first audit completed by NME, some of the discrepancies
noted are subjective. The site disagrees with the interpretation of the guidelines for some of the auditor applied codes.
6.b: What is the percentage of E & M codes deemed correct? Of the 30 Records reviewed there were 30 E/M codes used
with 24 codes being accurate resulting to a 80% accuracy rate. Of the six E&M errors the auditor identified, four were
questioned for the level of E&M increase from 99213 to a 99214.
6.c: What is the percentage of ICD-9 codes deemed correct? Of the 30 records reviewed there were 49 ICD-9 codes used with
37 codes being accurate resulting to a 76% accuracy rate. 12 diagnosis codes were changed or added. Of these twelve, seven
were questioned against coding guidelines.
6.d: What is the percentage of CPT codes deemed correct? Of the 30 Records reviewed there were 37 CPT codes used with
37 codes being accurate resulting to a 100% accuracy rate.
6.e: What percentage of completed and current (signed within the past 12 months) DD Form 2569s (TPC Insurance Info, OHI
forms) are available for audit? 30 names were generated from CHCS for auditing; 10 charts had a current OHI form signed;
59%, 7 charts did not have a current OHI form. 12 names were active duty and are excluded and 1 name was a member not
having a medical record on file (Transferred). Training is being conducted with the front desk staff on the importance of the
8.b/d: NHCCC is currently engaged in an external resource sharing agreement for inpatient services at a civilian facility. No
longer reporting admissions/dispositions.
8.e: Number of Inpatient Professional Services Rounds SADRs encounters (FCC=A***) / number of SUM WWR (Total Bed
Days + Total Dispositions). When we run the SADR's and the WWR we are showing 12 IPS rounds and 12 WWR (9 bed days +
3 dispositions). Trouble ticket INC000000359346 filed.
Per BUMED direction, the following comment is included regarding:
ADM Write Back error Report:
# of preventable 102 errors - 13
# of preventable 102 errors corrected: 2 the other 11 errors within the data range were already correct in CCA, CHCS, and
AHLTA - as per our coding supervisor.
# of preventable 102 errors that could not be corrected:0
# of 102 errors corrected/# of 102 errors total: 13/13 =100%
ADM Deficiency Report:
# of encounters w/ ADM SADR errors=2
# of encounters w/ ADM SADR errors corrected=2
# of encounters w/ ADM SADR errors that could not be corrected=0
# of ADM SADR Errors Corrected/# of Encounters with ADM SADR Errors)=2/2
Question 2 (a): 88.17% (August 2010, 89.89%) The Outpatient Coding, IMD, and the Data Quality staff are working with clinic
managers to increase compliance. The total number of tickets open currently for CHCS/ AHLTA issues is 1,150. There are 40
tickets that address ADM Write-back issues. The new ticket numbers are listed.
NMC, PORTSMOUTH 53531 10/25/10
NMC, PORTSMOUTH 536202 10/25/10
NMC, PORTSMOUTH 539269 10/27/10
NMC, PORTSMOUTH 551775 11/5/10
NMC, PORTSMOUTH 562851 11/15/10
Question 3 (c): 89% (August 2010, 91%) Throughout the month current employee timecards were rejected by the DMHRSi
system with the following message: “This timecard has been rejected because this person is an ex-employee for all of the
time for which you have approved this timecard.” Those timecards had to be resubmitted causing duplicate work for
personnel Command wide. The MHS DMHRSi POC, Curtis Shelton, resubmitted 511 NMCP timecards for the month of
September and the LCA staff has no way to track the number of resubmissions they did.
Question 3 (d): 91% (August 2010, 95%) Throughout the month current employee timecards were rejected by the DMHRSi
system with the following message: “This timecard has been rejected because this person is an ex-employee for all of the
time for which you have approved this timecard.” Those timecards had to be resubmitted causing duplicate work for
personnel Command wide. The MHS DMHRSi POC, Curtis Shelton, resubmitted 511 NMCP timecards for the month of
September and the LCA staff has no way to track the number of resubmissions they did.
Question 4 (d): 100% (August 2010, 100%) SADR transmission is an automated process that transmits daily. If the
transmission fails the system retransmits until it is successful. Reference BUMED Trouble Ticket # 198688
Question 5 (a): DRG 25/30 for 83% (August 2010, 90%). Individual training is ongoing for the inpatient coders.
Question 5 (c) ICD9-CM 58/63 for 92% (August 2010, 100%) One IPS encounter was cancelled in error. Training for the coders
is ongoing.
Question 5 (e) DD Form 2569 18/18 for 100%.
Question 6 (b): E&M 23/32 for 72%,(August 2010,73%) The Coder /Auditor is on board at NME and the goal is to see steady
improvement as the auditor becomes more imbedded in the process. The Data Quality Manager has contacted NMCSD via
the regional Data Quality Manager to obtain best practices for coding compliance.
Question 6 (c): ICD-9 55/63 for 87%,(August 2010,72%) The Coder /Auditor is on board at NME and the goal is to see steady
improvement as the auditor becomes more imbedded in the process. The Data Quality Manager has contacted NMCSD via
the regional Data Quality Manager to obtain best practices for coding compliance.
Question 6 (d): CPT 30/38 for 79%,(August 2010, 87%) The Coder /Auditor is on board at NME and the goal is to see steady
improvement as the auditor becomes more imbedded in the process. The Data Quality Manager has contacted NMCSD via
the regional Data Quality Manager to obtain best practices for coding compliance.
Question 6 (e): DD Form 2569 4/18 for 22% (August 2010, 20%) Training for front desk employees is held monthly. A POA&M
is in place and a TPC representative attends every Data Quality Assist Team visit to explain the importance of the DD Form
Question 7 (b), (c) ICD-9 49/50 for 98%, CPT 102/104 for 98%.
Question 7 (d) DD Form 2569 15/16 for 94% (August 2010, 81%). Training for front desk employees is held monthly. A
POA&M is in place and a TPC representative attends every Data Quality Assist Team visit to explain the importance of the DD
NEW: Per BUMED direction, the following comment is included regarding:
ADM Write Back error report:
# of preventable 102 errors: 1,088
# of preventable 102 errors corrected: 1,088
# of preventable 102 errors that could not be corrected: 0
# of 102 errors corrected/# of 102 errors total: 1,088/1,088 = 100%
NEW: Per BUMED direction, the following comment is included regarding:
ADM Deficiency Report:
# of encounters w/ ADM SADR errors=91
# of encounters w/ ADM SADR errors corrected=88
# of encounters w/ ADM SADR errors that could not be corrected=3
# of ADM SADR Errors Corrected/# of Encounters with ADM SADR Errors) 88/91=97%
1A. This fall out is due to technical difficulties in granting AHLTA access to a visiting provider.
2A. Coding timelines has decreased significantly. Efforts have increased to ensure notification of the Chain of Command of
delinquent encounters.
2B. Local numbers reflect 1 APV was not cancelled, leaving it in an un-coded/pending status, and 1 APV did not make the 15
day timeline.
4A. BUMED ref TT#198688.
5A. 32/32
5B. 21/21
5C. 35/40 ICD-9 coder were deemed correct. Issues identified were lack of specificity, wrong dx code utilized or dx was not
5D. 19/21 CPT codes were deemed correct. Errors identified were 1 CPT code not coded and 1 CPT utilized was not the best
5E. 5/6 – A newborn’s record did not contain a 2569, but the mother’s record did have a 2569.
5F. 5/5
6B. 15/24 E&M codes were deemed correct. E&M discrepancies were mainly due to over and under coding.
6C. 34/39 ICD-9 codes were deemed correct. Errors identified were lack of use of E and V codes.
6D. 28/31 CPT codes were deemed correct. 3 procedure codes were coded and should not have been reported because they
were included, by definition of the procedures, within one other procedure reported on the same encounter., i.e. double
coded due to using a global code.
6E. 24/30 – 3 of the 6 identified were patients that have not been seen at NH GTMO within the past 3 years, but still reside
on base. These patients will be required to complete a 2569 at their next appointment.
6F. 24/24
7B. 11/11
7C. 33/36 CPT deemed correct. CPT errors were due to lack of supporting documentation or usage of the incorrect
7D. 2/2
7E. 2/2
8E. The Special Category Residents (SCR) for Guantanamo Bay are considered long-term care patients and only require
weekly rounds vice daily rounds for regular inpatient admissions. Local reports show all standard inpatient rounds and
weekly SCR rounds were coded within the 30 day timeline providing an overall coding compliance of 100% during this
ADM Write-Back error report
# of preventable 102 errors - 8
# of preventable 106 errors - 7
ADM Deficiency Report
# of encounters w/ ADM SADR errors - 0
2a) Completion of ADMs continues to be a problem. We are still working with issues with provider co-signing off technicians
work at our Capodichino Clinic. Considerable improvement should be seen with the November 2010 data. The Directors of
our non-compliant clinics are actively involved in assuring that encounters are being coded in within the 72 hour deadline.
2c) There were issues with two TAD providers (5 encounters). These providers had been entered into CHCS but were not in
CCE due to technical problems. The problem was resolved in the middle of October 2010. MHS trouble ticket#
3b) MEWACS was reviewed. No new outliers present. Previous outliers addressed on prior DQ statements.
4d) Naples had SADR gaps for 5 days in the reporting month of September due to ETU upgrade. Metric should read 25/30 =
Inpatient:
5a) Number of correct MS-DRGs/Total number of MS-DRGs = 30/30 = 100%
5b) Number of correct E&M codes/Total number of E&M codes = 29/29 = 100%.
5c) Number of correct ICD-9 codes/Total number of ICD-9 codes = 77/77= 100%.
5d) Number of correct CPT codes/Total number of CPT codes = 19/19 = 100%.
5e) Number of complete and current DD2569s/number of Non-Active duty records audited = 3/6 = 50%. Decreased
compliance is due to staff turnover creating a gap in continuity of our collection process. Training is ongoing for all of the
clinic staff. Expect increase in compliance on next DQ statement.
5f) 3/3 = 100%. Outpatient: CCE Audit tracking Report is not working correctly. MHS trouble ticket submitted;
MHSINC000587891. For this reporting month, only two clinics were used for the audit.
Outpatient
6a) Number of encounters available/Number of requested encounters = 30/30 = 100%.
6b) Number of correct E&M codes/Total number of E&M Codes = 30/30= 100%.
6c) Number of correct ICD-9 codes/Total number of ICD-9 codes = 54/58 = 93%. Code V45.69 (post-op visit) should have
been added to encounter. Documentation should state the date of surgery and which post-op visit it is. (2 encounters). On
active duty patient's eye exam, extender code must be used as first code, V70.5 2 vice V72.0 (2 encounters).
6d) Number of correct CPT codes/Total number of CPT codes = 28/55 = 51%. Data entry error on 1 encounter, 992004
entered vice 99204. Diabetic indicator, S3000, was missing on 3 retinal eye exams encounters. CPT procedures sequence
was not correct on 24 encounters. The procedure with the highest RVU should be coded first.
6e) Number of complete and current DD2569/number of Non-Active duty records audited = 1/18= 6%. Decreased
compliance is due to staff turnover creating a gap in continuity of our collection process. Training is ongoing for all of the
clinic staff. Expect increase in compliance on next DQ statement.
6f) 1/1 = 100%
APV:
7a) 30/30 documentation available = 100%.
7b) Number of correct ICD-9 codes/Total number of ICD-9 codes = 78/80 = 98%.
7c) Number of correct CPT codes/Total number of CPT codes = 105/105 = 100%.
7d) Number of complete and current DD2569/number of Non-Active duty records audited = 4/15 = 27%. Decreased
compliance is due to staff turnover creating a gap in continuity of our collection process. Training is ongoing for all of the
clinic staff. Expect increase in compliance on next DQ statement.
7e) 4/4 = 100%
NEW: Per BUMED direction, the following comment is included regarding AHLTA Write Back error report:
# of preventable 102 errors: 9
# of preventable 102 errors corrected: 9
# of preventable 102 errors that could not be corrected: 0
# of 102 errors corrected/# of 102 errors total: 9/9=100%
NEW: Per BUMED direction, the following comment is included regarding ADM Deficiency Report:
# of encounters w/ ADM SADR errors = 21
# of encounters w/ ADM SADR errors corrected= 15
# of encounters w/ ADM SADR errors that could not be corrected= 6
# of ADM SADR Errors Corrected/# of Encounters with ADM SADR Errors)= 71%
2.a: 3-day coding completion is generally improving. Recent efforts to improve this appear to be working based on local data.
2.c: 3 of 36 dispositions were not coded within 30 days. Of the 3 only 1 was actually coded but coded late. The other two
were placed on review hold in CCE due to download of 2011 codes. All dispositions have been on review hold up until 15
November when the proper codes were loaded. The records on hold are now being coded but many will be late due to this
3.b: One not previously addressed MEWACS outlier was caused by a disposition at the end of the month that had lab work
that got accounted to the wrong month. The exact details are still being researched.
General coding comments: The command continues to work on improvement of coding accuracy. At the strategic planning
offsite the Board of Directors designated data quality including a specific emphasis on coding accuracy as an annual goal
team for FY11 which will greatly increase the emphasis on improvement in this area. The specific breakdown of error types is
not available this month because the coding audit which was performed at NME did not contain the reason codes that
Coding details:
5.a: Actual numbers: 30 / 30 = 100%
5.b: Actual numbers: 12 / 12 = 100%
5.c: Actual numbers: 20 / 23 = 87%
Causes: NME failed to provide any information other than the final numbers for IPSR so no further comments can be made.
Resolution: Provider training.
5.d: Actual numbers: 9 / 9 = 100%
6.a: Actual numbers: 30 / 30 = 100%
6.b: Actual numbers: 23 / 30 = 77%
Causes:
99211 instead of 99499 (Based on the documentation, coding Social Work Encounters should follow MHS guidance in
Appendix E 1.2. Social work is non count and will be assigned 99499 for the E/M Service Code. Appropriate G code will be
assigned based upon the visit and documentation supplied.) 5 records.
99205 instead of 99499 (Based on the documentation, an E/M error has been identified. NO E/M code would be required for
this visit.) 1 record.
99245 instead of 99499 (Based on the documentation an E/M error has been identified. The documentation did not support
use of a consultation code. Additionally, the patient was self referred to the MH clinic.) 1 record.
Resolution: Provider training.
6.c: Actual numbers: 36 / 45 = 80%
Causes:
Coded V63,2, should be V49.89_9
Coded V61.9, should be V49.89_9
Missing code V70.5_9
Coded V62.9, should be V46.89_9
Coded V65.49_9, should be V46.89_9
Missing code V62.29
Coded V62.9, should be V46.89_9
Coded V71.09, should be V70.5_6
Missing code V79.1
Resolution: Provider training.
Actual numbers: 36 / 45 = 80%
6.d: Actual numbers: 32 / 44 = 73%
Causes:
Missing code G9012
Missing code G9012
Coded 90806, should be 90801
Missing code G9012
Missing code G9012
Missing code G9012
Inappropriate use of 90801
Missing code 90801
Missing code H0005
Missing code H0024
Missing code 90806
Coded 90885 and 90889, should have been 90806
Resolution: Provider training.
7.a: Actual numbers: 24 / 24 = 100%
7.b: Actual numbers: 36 / 40 = 82%
Causes:
Missing code 530.81
Missing code 305.1
Missing code 272.4
Missing code V16.0
Resolution: Provider training.
7.c: Actual numbers: 83 / 87 = 95%
DD2569 general comments: The DD2569 collection process is now operational. A total of 1206 forms have been collected as
of 18 Oct. The need to ensure complete training to staff who man check-in desks on an occasional basis has been identified.
The use of the OHI yellow card is being added to the existing process to improve compliance and ease impact on patients.
Calculations for DD2569 metrics are as follows:
5.e: Actual numbers: 10 / 26 = 38.5%
Causes: Incomplete collection of forms by staff.
Resolution: Training and feedback to staff involved.
5.f: Actual numbers: 10 / 10 = 100%
6.e: Actual numbers: 5 / 5 = 100%
6.f: Actual numbers: 2 / 5 = 40%
Causes: Incomplete entry of forms into CHCS by staff.
Resolution: Training and feedback to staff involved.
7.d: Actual numbers: 9 / 11 = 81.8%
Causes: Incomplete collection of forms by staff.
Resolution: Training and feedback to staff involved.
7.e: Actual numbers: 5 / 9 = 55.6%
Causes: Incomplete entry of forms into CHCS by staff.
Resolution: Training and feedback to staff involved.
8.b: As mentioned for item 2.c the two "missing" dispositions were on review hold due to code update issues in CCE. The
new codes have been loaded so they are now being coded and will transmit on the November SIDR.
NEW: Per BUMED direction, the following comment is included regarding AHLTA Write Back error report:
# of preventable 102 errors: 25
# of preventable 102 errors corrected: 15
# of preventable 102 errors that could not be corrected: 10
# of 102 errors corrected/# of 102 errors total: 15 / 25 = 60%
NEW: Per BUMED direction, the following comment is included regarding ADM Deficiency Report:
# of encounters w/ ADM SADR errors = 5
# of encounters w/ ADM SADR errors corrected = 4
# of encounters w/ ADM SADR errors that could not be corrected = 1
# of ADM SADR Errors Corrected/# of Encounters with ADM SADR Errors)= 4/5 = %80
AHLTA write back and ADM SADR errors not corrected were not corrected due primarily to inadequate AHLTA/CHCS staffing.
The available staff was completely overwhelmed by direct provider support and thus could not expend time in correction of
these errors. The new AHLTA trainer has just checked onboard (19 Nov) and a temporary AHLTA/CHCS technician has been
provided by SAIC so better progress with correction of these problems is expected. October and November are expected to
show a dramatic increase in these errors for the same reasons. Correction of AHLTA templates (supported by the temporary
AHLTA trainer) should occur during late November and December.
Comments (format and content in accordance with NME DQ guidance):
2b. 21/22= 95.45% Total APVs performed for the month of September are twenty one. Although one APV was cancelled, it
was still in the system counting against the total numbers.
3b. No new MEWACS outliers.
4d. Navy-wide technical issue (BUMED), refer to TT#198688.
5a. 22/23= 96%. Starting November 2010 all Data Quality audits have been performed by NME. Several discrepancies have
been noticed and presented to Ms. C. Shelor for actions. Thirty Inpatient Records were scanned and submitted for audit but
only twenty three were returned. One DRG error was erroneously considered by the auditor because the procedure
mentioned in the comments was performed during the APV episode and not during the admission.
5b. 29/31=94% Two out of thirty one E&M codes were incorrect. Documentation didn’t support codes assigned.
5c. 66/86=77% Twenty out of eighty six diagnoses were errors. Nine codes were not supported by the provided
documentation, five diagnoses were not coded, five were not the principle diagnoses and one was not coded to maximum
5e. 2/25=8% Two out of twenty five Inpatient records had a complete and updated DD2569. (See Plan of Action for details)
After an analysis of dates and times of September admissions, it has been noticed that about 50% were admitted after hours,
25% over the weekend and the remaining 25% during regular hours. Also noted that only pre-scheduled admissions (hence
patients coming to Medical Records to be pre-admitted) tend to have the DD 2569 forms, therefore , all admissions will be
performed by the admitting physician or the ward personnel.
5f. 2/2=100%
6a-d. Audit performed by NME. Results are not posted because they have not been received yet.
6e. 4/9=44% Four out of nine outpatient records had a complete DD2569. (See Plan of Action for details)
6f. 4/4=100%
7a. 21/21=100%
7b. 74/77=96%
7c. 72/73=99%
7d. 13/13=100%
7e. 13/13=100%
NEW: Per BUMED direction, the following comment is included regarding:
ADM Write Back error report:
# of preventable 102 errors: 46
# of preventable 102 errors corrected: 46
# of preventable 102 errors that could not be corrected: 0
# of 46 errors corrected/# of 46 errors total: 46/46: 100%
NEW: Per BUMED direction, the following comment is included regarding:
ADM Deficiency Report:
# of encounters w/ ADM SADR errors: 55
# of encounters w/ ADM SADR errors corrected: 55
# of encounters w/ ADM SADR errors that could not be corrected: 0
# of ADM SADR Errors Corrected/# of Encounters with ADM SADR Errors): 100%
                              NAVMED NCA
DQ Data Month Reviewed: SEPTEMBER, 2010:
The following comments are items reflected above as non-compliant [<95%] for November 2010 Data Quality Statement:
2a: Outpatient Coded Encounters: SEPT-84% [AUG-85%/JULY-85%/JUNE-83%]. This is a 3-day timeliness snap-shot that
reflect September 3-day coding compliance. This metric historically hovers around 85%. NNMC DQ Manager continues to
spool and identify in-completed ADMs. This list is sent to all NNMC Clinic Managers with encounter information that is very
easy to identify and fix, as applicable. Records are updated and re-transmitted once corrected. However, NNMC 3-ADM
timeliness continues to be non-compliant <95%. The AHLTA coding is getting done, however, other system glitches like CHCS
write back and ADM Deficiency error codes are causing the compliance errors to be below normal.
2b: APV Completion: SEPT-90% [AUG-84%/JUL-95%/JUNE-92%]. APV Coders were moved back to coding APV records which
increased by 6%. Additional Coders are being sort by PAD to fill in the coding gaps.
2c: SIDR coding completion within 30 days: SEPT 91% [AUG-89%/JUL-88%/JUN-71%]. Upward trend noted. PAD continues to
work to get this metric caught up.
3b: MEWACS Reviewed-No new discrepancies/outliers noted from last report. Old issues still showing up: WWR-EASIV
Outliers: FM1 and FM2, FY10 variance for Carderock. FM1, 6.8%; FM2, 5.6%. This is probably the result of inadvertently
transmitting WWR files for those months while NNMC were troubleshooting SIDR-WWR difference. NNMC however
regenerated Oct 09-May 10 WWR-WAM recently. The numbers matched... 73 for FM1 and 90 for FM2. So once we
5d: SEPT 69% [AUG-95/JUL-99%/JUN-100%]: Inpatient/IWBA Lead coder found missing CPT codes for Round visits. This is a
manual coding process where the coders abstract documentation from Eccentrics and manually enter the codes in CHCS
ADM. Coders were made aware of errors. This metric have been averaging >95% but dipped to 69% this reporting month.
6b: Outpatients E&M: SEPT 51% [AUG-92%JULY-83%/JUNE 63%]: This metric has taken a downward trend from 92% to 51% [-
41%]. PAD will be looking and giving feedback to providers and clinics that were audited. Providers will be notified of audit
results. Looking at the audited spreadsheets: 35 E&M codes were reviewed with 18 correctly match. Reasons for errors are:
Up-coding and Down-coding for the E&M selections.
6c: Outpatient ICD codes: SEPT 93% [AUG-96%/JUL-100%/JUNE-95%]:This metric has always maintained >95% accuracy
except for this reporting month. ICD codes were documented in AHLTA but not to the specificity of the diagnosis. Providers
were notified by Coders of errors.
6d: Outpatient CPT Code: SEPT 82%. [AUG-88%/JULY-88%/JUNE-73%]. Majority of errors were missing CPT codes that were
not coded but documented in AHLTA. Providers of audited records were notified and instructed to always select the
appropriate CPTs when documented. Coders continue to find missing CPT codes that were documented but not selected in
AHLTA. AHLTA Trainers will intervene in this process.
6e: What percentage of completed and current DD Form 2569s (TPC Insurance Info) is available for audit? SEPT 30% [AUG-50
JULY-50%/JUNE 40%] an increased in collection of DD2569 does not mean that percentages of this metric will increase due to
the random sampling that is conducted. NNMC collects DD2569's every day, however, a copy may or may not make it down
to Outpatient Records room and placed in the outpatient record. Ex: Pharmacy DD2969 collections will not make it down to
outpt records room because 99% of them are Civilian scripts and records may or may not be here. I conducted these audits
myself to ensure that the form is not missed. This scenario will potentially increase collections but not necessarily this metric.
I have started placing a blank DD2569 in Outpatient records with the hope that it will be completed on the patient's next
visit. NNMC continues to struggle with this individual metric because the sample records audited for coding may or may not
yet have the required form. UBO office continues to receive completed forms daily to maximize TPC billing and collection. DQ
8e: Number of Inpatient Professional Services SADR rounds that were completed by the attending provider/service: 41%
[AUG 58%-JULY-29%/JUNE-29%]. The IBWA coders have now moved from a different location to the Patient Admin area
where the records are kept and will be coding from the completed hard copy chart rather than looking up notes in Essentris.
This metric has moved back down by 17%.
NEW: Per BUMED direction, the following comment is included regarding:
ADM Write Back error report:
# of preventable 102 errors= 2,140
# of preventable 102 errors corrected= 2,109
# of preventable 102 errors that could not be corrected= 31
# of 102 errors corrected/# of 102 errors total: 2109/2140=99%
Once the coders have completed the 102 error report, an e-mail is sent to the providers to let them know the specific code(s)
are no longer valid and to update their Favorites List in AHLTA and to get rid of the outdated code. This seems to be
working very well for NNMC.
Note: 31 Appointments could not be found in CHCS.
NEW: Per BUMED direction, the following comment is included regarding:
ADM Deficiency Report:
# of encounters w/ ADM SADR errors=101
# of encounters w/ ADM SADR errors corrected=44
# of encounters w/ ADM SADR errors that could not be corrected=57
# of ADM SADR Errors Corrected/# of Encounters with ADM SADR Errors)
=44/101=44%...DQ Manager successfully spooled and captured this new report for the second time. It includes other error
codes which are new to the Coders. There identified error codes were: 218(19),222(29),229(1),236(6),251(29),258(13) &
259(5). Note: 57 of these errors requires a trouble ticket to be submitted because the providers are no longer at NNMC.
Additional Note from PAD Lead Coder:
"Due to the size of the Write Back Error Report (2140), plus required audits and ADM Deficiency Errors to be completed,
along with our day to day responsibilities, it is very difficult to complete/fix the AHLTA problems. This is a lot of duplication
of effort. I am sure that with the loading of the 2011 ICD-9 codes, this situation is only going to get worse".
2a)The Comptroller held an in-service on 10 Nov 2010 with the Family Practice and Flight Medicine providers to discuss
closing out encounters within 3 business days as well as E&M and ICD-9 coding accuracy. Mental Health, Primary Care
Dahlgren, Occupational Health Indian Head, and Hearing Conservation Indian Head were 16%, 89%, 81%, and 57% compliant
for September 2010, respectively. The Comptroller has scheduled an in-service with the Mental Health Clinic providers and
OIC of the Branch Medical Clinics to develop and instill the practice of closing out encounters within 3 business days. The XO
3b) MEWACS was reviewed.
4d) 4d is to be answered 100%
6b) E/M Coding is at 94% this month. Out of 30 Records Audited; there were 31 total E/M codes; 29 of these were correct. 1
case should have had and additional E/M code based upon the supporting documents (E11). 1 case the E/M code audited
was 1 level above the reported E/M code (E6). PAX September 2010 - 17 102 errors/ 17 102 errors corrected.
Per Ms. Perry Lead Coder: ADM Deficiency Report: 1-218 Error; 1-222 Error; 2- 259 Errors; Corrections Pending
Ms. Perry, our only GS coder, left 19 November2010. She did complete early December's Audit for the month of October.
The Regional Coder, Ms. Robyn Williams, will be asked to assist Patuxent River with DQ Auditing for our DQ Commanders
Statements if necessary depending on when we get a new coder onboard.
3b. OUTLIERS: An outlier currently exists for the month of September. Total expenses increased by approximately 50% from
the prior month. This may be attributed to the fiscal year end supply & equipment orders. Increase totaled $609,067: Earl
Primary care 200K, Annapolis 250K, Philadelphia 146K and Lakehurst 20K.
4d. eDQ auto-populated to 127%, manual adjustment made to 100% per regional DQ manager.
6b. E&M coding for month of September is 73%, down from the 85% reported last month. Previous coding POA&M has
resulted in increased scores for other coding metrics. E&M coding may require additional measures and training. Command
leadership is fully aware of this issue.
6c. ICD9 coding is at 90%, which is lower than the EDQ required 95%. While this is a drastic improvement from previous
months, additional training and audits will be utilized to ensure that these metrics continue to increase.
ADM Write back Errors: Coder received a total of 234 write back errors from the region, 229 were completed (97.86%).
Suspected spike in number of write back errors this month is due to recent AHLTA 3.3 upgrade. Many encounters did not
cross over and/or had no code associated with them at all. A majority of these visits are noted to be "Well-Woman" visits.
NHC Annapolis coder is working diligently to complete the remaining 5 encounters.
ADM Deficiency Report: For there month of September there are currently 4 errors with a 251 code. correction pending.
Downtime Scheduled/Date Time(s) Systems Affected
17-19Sep10 8hrs AHLTA
Unscheduled/Date Time(s) Systems Affected
08Sep10 .25 hrs AHLTA degrade
22Sep10 .75hrs AHLTA degrade
6 % Scheduled; 1 % Unscheduled Degrade; TOTAL % downtime/degrade reported
MHS Ticket Submission
Ticket # Issue Date opened Date Closed
481970 Pt. IEN discrepancy 9/14/10 10/14/10
486861 Pt. w/o facility identifiers in AHLTA 9/17/10 10/21/10
488595 Patient sponsor update request 9/20/10 10/20/10
488826 Patient FMP/demographics update 9/20/10
488834 Patient FMP/demographics update 9/20/10
488837 Patient merge request 9/20/10 10/25/10
6. b) Coding Audit: We are trending towards the right direction, for August we were at 73% and for September we are
reporting 90%. POA&M in place. Coding is one of our FY11 Annual Strategic Goals, we will conduct a Lean Six Sigma project,
anticipated start date is January 2011 with a completion date of June 2011.
6. c) POA&M in place. Coding is one of our FY11 Annual Strategic Goals, we will conduct a Lean Six Sigma project, anticipated
start date is January 2011 with a completion date of June 2011.
ADM Error Metric: Quantico 8 102 errors identified/7 102 errors corrected.
ADM Deficiency Report:
August (9) 236 Errors/Aug (x) Errors corrected. (3) 222 Errors/(x) 222 errors corrected.
Sept:(21) 236 Errors/(12) Errors corrected. (4) 222 Errors/(2) 222 errors
corrected.
A. Currently still working on to complete the errors.
Comments by Command:
NH Pensacola           4,6         #
NH Jacksonville        4,6         1
NH Corpus Christi      3,4,6       2
NH Sigonella           3,4         3
NH Beaufort                        4
NH Guantanamo Bay      4           5
NH Naples              3,4,6,15    6
NH Rota                4,6         7
NH Charleston                      8
NMC Portsmouth         4,6         9
NHC Great Lakes        16         10
NHC New England        4,6        11
NH Camp Lejeune        3,4,6      12
NH Cherry Point        4,6        13
NHC Annapolis          4,         14
NNMC Bethesda          4,6        15
NHC Quantico           4          16
NHC Pax River          3,4        17
NMC San Diego          4,6,16
NH Twenty Nine Palms   3,4         3
NH Lemoore             3,4,6,16    4
NH Oak Harbor          4,6         5
NH Camp Pendleton      4,6         6
NH Bremerton           4,6,16      9
NH Guam                4          15
NHC Hawaii             6,9        16
NH Yokosuka            4,5
NH Okinawa             4
                                                Comment Code
Comment
Process Improvement Plan in place to correct EOD Processing deficiencies (Question 1)
Unable to complete financial reconciliation due to incorrect data in the financial reconciliation website
Technical difficulties causing non-transmission of SADR data (Question 3d)
Training and other measures being conducted to correct coding deficiencies
Coding issues reported due to staffing availability issues
Plan of Action developed to increase compliance with DD2569 (Question 6e)
Command staff working with site on appropriate Plan of Action and Milestones
Experiencing difficulties with CHCS/CHCS II
Experiencing difficulties with the DQMC Community Website
Late release of software by TMA
TPOCS data does not match the CCE database and is under investigation by RITPO.
CCE deployment delayed and working with RITPO to resolve
Data transmission issues between CHCSI and AHLTA compromise metrics.
Remote coding contract is in progress of implementation.
Experiencing issues with Coding Compliance Editor (CCE)
Unable to process EASIV (Question 3, 4)
External Resource Sharing issue requiring resolution (Question 2b)

Technical difficulties causing non-transmission of SADR data (Question 3d)
Training and other measures being conducted to correct coding deficiencies
Coding issues reported due to staffing availability issues
Plan of Action developed to increase compliance with DD2569 (Question 6e)
Experiencing difficulties with the DQMC Community Website
Experiencing issues with Coding Compliance Editor (CCE)
Unable to process EASIV (Question 3, 4)

								
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