The following words and terms, when used in this subchapter,
shall have the following meanings, unless the context clearly indicates
otherwise.
(1) Accurate and Consistent data--Data that has been
edited by DSHS and subjected to provider validation and certification.
(2) ANSI 837 Institutional Guide--American National
Standards Institute, Accredited Standards Committee X12N, 837 Health
Care Institutional Claim Implementation Guide.
(3) Attending Physician--The individual licensed under
the Medical Practice Act (Occupations Code, Chapter 151) who would
normally be expected to certify and recertify the medical necessity
of the services rendered or the licensed health professional primarily
responsible for the care of the patient during the hospital episode.
For Skilled Nursing Facility (SNF) services, the attending physician
is the individual who certifies the SNF plan of care.
(4) Certification Process--The process by which a provider
confirms the accuracy and completeness of the encounter data set required
to produce the public use data file as specified in §421.7 of
this title (relating to Certification of Discharge Reports).
(5) Charge--The amount billed by a provider for specific
procedures or services provided to a patient before any adjustment
for contractual allowances, government mandated fee schedules or write-offs
for charity care, bad debt or administrative courtesy. The term does
not include co-payments charged to health maintenance organization
enrollees by providers paid by capitation or salary in a health maintenance
organization.
(6) Comments--The notes or explanations submitted by
the hospitals, physicians or other health professionals concerning
the provider quality reports or the encounter data for public use
as described in the Texas Health and Safety Code, §108.010(c)
and (e) and §108.011(g) respectively.
(7) Data format--The sequence or location of data elements
in an electronic record according to prescribed specifications.
(8) DSHS--Department of State Health Services.
(9) Discharge--The formal release of a patient by a
hospital; that is, the termination of a period of hospitalization
by death or by disposition to a residence or another health care provider.
(10) Discharge claim--A set of computer records as
specified in §421.9 of this title (relating to Discharge Reports--Records,
Data Fields and Codes) relating to a specific patient. "Discharge
claim" corresponds to the ANSI 837 Institutional Guide term, "Transaction
set."
(11) Discharge report--A computer file as defined in §421.9
of this title periodically submitted on or on behalf of a Hospital
in compliance with the provisions of this chapter. "Discharge report"
corresponds to the ANSI 837 Institutional Guide terms, "Communication
Envelope" or "Interchange Envelope."
(12) DRG--Diagnosis Related Group.
(13) EDI--Electronic Data Interchange--A method of
sending data electronically from one computer to another. EDI helps
providers and payers maintain a flow of vital information by enabling
the transmission of claims and managed care transactions.
(14) Edit--An electronic standardized process developed
and implemented by DSHS to identify potential errors and mistakes
in data elements by reviewing data fields for the presence or absence
of data and the accuracy and appropriateness of data.
(15) Electronic filing--The submission of computer
records in machine readable form by modem transfer from one computer
to another (EDI) or by recording the records on a nine track magnetic
tape, computer diskette or other portable data storage media acceptable
to the executive director.
(16) Error--Data submitted on a discharge report which
are not consistent with the format and data standards contained in
this section or with editing criteria established by the executive
director, or the failure to submit required data.
(17) Ethnicity--The status of patients relative to
Hispanic background. Hospitals shall report this data element according
to the following ethnic types: Hispanic or Non-Hispanic.
(18) Facility Type Indicators--An indicator that provides
information to the data user as to the type of facility or the primary
health services delivered at that facility (e.g., Teaching, Acute
Care, Rehabilitation, Psychiatric, Pediatric, Cancer, Skilled Nursing,
Long Term Acute Care or other Long Term Care Facility). A facility
may have more than one indicator. Hospitals may request updates to
this field.
(19) Geographic identifiers--A set of codes indicating
the public health region and county in which the patient resides.
(20) HCPCS--HCFA's Common Procedure Coding System (HCFA
- Health Care Finance Administrations (Now called Centers for Medicare
and Medicaid Services)).
(21) Health care facility--A hospital, an ambulatory
surgery center licensed under Chapter 243 of the Health and Safety
Code, a chemical dependency treatment facility licensed under Chapter
464 of the Health and Safety Code, a renal dialysis center, a birthing
center, a rural health clinic or a federally qualified health center
as defined by 42 United States Code, §1396(1)(2)(B).
(22) HIPPS--Health Insurance Prospective Payment System.
(23) Hospital--A public, for-profit, or nonprofit institution
licensed or owned by this state that is a general or special hospital,
private mental hospital, chronic disease hospital or other type of
hospital.
(24) ICD--International Classification of Disease.
(25) Inpatient--A patient, including a newborn infant,
who is formally admitted to the inpatient service of a hospital and
who is subsequently discharged, regardless of status or disposition.
Inpatients include patients admitted to medical/surgical, intensive
care, nursery, subacute, skilled nursing, long-term, psychiatric,
substance abuse, physical rehabilitation and all other types of hospital
units.
(26) Institutional Review Board--DSHS' appointees or
agent who have experience and expertise in ethics, patient confidentiality,
and health care data who review and approve or disapprove requests
for data or information other than the public use data as described
in §421.46 of this title (relating to Institutional Review Board).
(27) Operating or Other Physician--The "physician"
licensed by the Texas Medical Board, or "other health professional"
licensed by the State of Texas who performed the principal procedure
or performed the surgical procedure most closely related to the principal
diagnosis.
(28) Other exempted provider--A hospital exempt from
state franchise, sales, ad valorem, or other state and local taxes
that does not seek or receive reimbursement for providing health care
services to patients from any source, including the patient or any
person legally obligated to support the patient; a third party payer;
or Medicaid, Medicare, or any other federal, state or local program
for indigent health care.
(29) Other health professional--A person licensed to
provide health care services other than a physician. An individual
other than a physician who admits patients to hospitals or who provides
diagnostic or therapeutic procedures to inpatients. The term encompasses
persons licensed under various Texas practice statutes, such as psychologists,
chiropractors, dentists, nurse practitioners, nurse midwives, and
podiatrists who are authorized by the hospital to admit or treat patients.
(30) Patient account number--A number assigned to each
patient by the hospital, which appears on each computer record in
a patient discharge claim. This number is not consistent for a given
patient from one hospital to the next, or from one admission to the
next in the same hospital. DSHS deletes or encrypts this number to
protect patient confidentiality prior to release of data.
(31) Physician--An individual licensed under the laws
of this state to practice medicine under the Medical Practice Act,
Occupations Code, Chapter 151.
(32) Present on admission (POA)--Diagnosis present
on admission.
(33) Provider--A physician or health care facility.
(34) Provider quality data--A report or reports authored
by DSHS on provider quality or outcomes of care, as defined in Health
and Safety Code, Chapter 108, created from data collected by DSHS
or obtained from other sources.
(35) Public use data file--A data file composed of
discharge claims with risk and severity adjustment scores which have
been altered by the deletion, encryption or other modification of
data fields to protect patient and physician confidentiality and to
satisfy other restrictions on the release of hospital discharge data
imposed by statute.
Cont'd... |
