| (a) Hospitals that have not obtained an exemption letter
authorized by §421.81 of this title (relating to Health Care
Facilities Exemptions from Filing Requirements) shall submit discharge
reports, electronically in the file format for inpatient hospital
bills defined by the American National Standards Institute (ANSI),
commonly known as the ANSI ASC X12N form 837 Health Care Claims (ANSI
837 Institutional Guide) transaction for institutional claims and/or
encounters. ANSI updates this format from time to time by issuing
new versions.
(b) DSHS will make detailed specifications for these
data elements available to submitters and to the public.
(c) In addition to the data elements contained in the
ANSI 837 Institutional Guide, DSHS has defined the following data
elements shown in this subsection and as defined the location in the
ANSI 837 Institutional Guide where each element is to be reported.
Data element content, format and locations may change as federal and
state legislative requirements change in regards to Public Law 104-191,
Health Insurance Portability and Accountability Act of 1996 (HIPAA),
as amended, is implemented.
(1) Patient race - This data element shall be reported
at Loop 2300 in the K3 segment as the second numeric value in this
data segment. Acceptable codes are 1 = American Indian/Eskimo/Aleut,
2 = Asian or, Pacific Islander, 3 = Black, 4 = White and 5 = Other
Race. In order to obtain this data, the hospital staff retrieves the
patient's response from a written form or asks the patient, or the
person speaking for the patient to classify the patient. If the patient,
or person speaking for the patient, declines to answer, the hospital
staff is to use its best judgment to make the correct classification
based on available data.
(2) Patient ethnicity - This data element shall be
reported at Loop 2300 in the K3 segment as the first numeric value.
Acceptable codes are 1 = Hispanic or Latino Origin and 2 = Not of
Hispanic or Latino Origin. In order to obtain this data, the hospital
staff retrieves the patient's response from a written form or asks
the patient, or the person speaking for the patient to classify the
patient. If the patient, or person speaking for the patient, declines
to answer, the hospital staff is to use its best judgment to make
the correct classification based on available data.
(3) Other E-codes - These additional E-codes (maximum
of nine (9)) shall be reported in the following ANSI X12N Form 837
locations: Loop 2300, segments, HI05-2, HI06-2, HI07-2, HI08-2, HI09-2,
HI10-2, HI11-2 and HI12-2. (The first E-code is reported in Loop 2300
segment HI04-2).
(4) THCIC Identification Number - This data element
shall be submitted in data segment REF02 of Loop 2010AA or Loop 2010AB
(in the Pay-to provider reported provided the services), or Loop 2310E
(if the Service Facility Provider is submitted).
(d) Hospitals shall submit the required minimum data
set for all patients for which a discharge claim is required by this
title. The required minimum data set includes the following data elements
as listed in this subsection:
(1) Patient Name:
(A) Patient Last Name;
(B) Patient First Name;
(C) Patient Middle Initial;
(2) Patient Address:
(A) Patient Address Line 1;
(B) Patient Address Line 2 (if applicable);
(C) Patient City;
(D) Patient State;
(E) Patient ZIP;
(F) Patient Country (if address is not in the United
States of America, or one of its territories);
(3) Patient Birth Date;
(4) Patient Sex;
(5) Patient Race;
(6) Patient Ethnicity;
(7) Patient Social Security Number;
(8) Patient Account Number;
(9) Patient Medical Record Number;
(10) Claim Filing Indicator Code (Payer Source - primary
and secondary (if applicable for secondary payer source);
(11) Payer Name - Primary and secondary (if applicable,
for both);
(12) National Plan Identifier - for primary and secondary
(if applicable) payers (National Health Plan Identification number,
if applicable and when assigned by the Federal Government);
(13) Type of Bill;
(14) Statement Dates (replaces Statement From and Statement
Thru dates);
(15) Admission / Start of Care:
(A) Admission / Start of Care Date;
(B) Admission / Start of Care Hour;
(16) Admission Type;
(17) Admission Source;
(18) Patient (Discharge) Status;
(19) Patient Discharge Hour;
(20) Principal Diagnosis;
(21) Admitting Diagnosis;
(22) Principle External Cause of Injury (E-Code);
(23) Other Diagnosis Codes - up to 24 occurrences (all
applicable);
(24) External Cause Of Injury (E-Code) - up to 9 occurrences
(if applicable);
(25) Principal Procedure Code (if applicable);
(26) Principal Procedure Date (if applicable);
(27) Other Procedure Codes - up to 24 occurrences (if
applicable);
(28) Other Procedure Dates - up to 24 occurrences (if
applicable);
(29) Occurrence Span Code - up to 24 occurrences (if
applicable);
(30) Occurrence Span Code Associated Date - up to 24
occurrences (if applicable);
(31) Occurrence Code - up to 24 occurrences (if applicable);
(32) Occurrence Code Associated Date - up to 24 occurrences
(if applicable);
(33) Value Code - up to 24 occurrences (if applicable);
(34) Value Code Associated Amount - up to 24 occurrences
(if applicable);
(35) Condition Code - up to 24 occurrences (if applicable);
(36) Attending Physician or Attending Practitioner
Name:
(A) Attending Practitioner Last Name;
(B) Attending Practitioner First Name;
(C) Attending Practitioner Middle Initial;
(37) Attending Practitioner Primary Identifier (National
Provider Identifier, when HIPAA rule is implemented);
(38) Attending Practitioner Secondary Identifier (Texas
state license number or UPIN);
(39) Operating Physician or Other Practitioner Name
(if applicable):
(A) Operating Physician or Other Practitioner Last
Name;
(B) Operating Physician or Other Practitioner First
Name;
(C) Operating Physician or Other Practitioner Middle
Initial;
(40) Operating Physician or Other Practitioner Primary
Identifier (National Provider Identifier, when HIPAA rule is implemented);
(41) Operating Physician or Other Practitioner Secondary
Identifier (Texas state license number or UPIN);
(42) Total Claim Charges;
(43) Revenue Service Line Details (up to 999 service
lines) (all applicable):
(A) Revenue Code;
(B) Procedure Code;
(C) HCPCS/HIPPS Procedure Modifier 1;
(D) HCPCS/HIPPS Procedure Modifier 2;
(E) HCPCS/HIPPS Procedure Modifier 3;
(F) HCPCS/HIPPS Procedure Modifier 4;
(G) Charge Amount;
(H) Unit Code;
(I) Unit Quantity;
(J) Unit Rate;
(K) Non-covered Charge Amount;
(44) Service Provider Name;
(45) Service Provider Primary Identifier - Provider
Federal Tax ID (EIN) or National Provider Identifier (when HIPAA rule
is implemented);
(46) Service Provider Address:
(A) Service Provider Address Line 1;
(B) Service Provider Address Line 2 (if applicable);
(C) Service Provider City;
(D) Service Provider State;
(E) Service Provider ZIP;
(47) Service Provider Secondary Identifier - THCIC
6-digit Hospital ID assigned to each facility.
(e) A hospital shall submit the "POA indicator" for
all diagnosis codes on inpatient claims filed, unless exempted by
this subsection. Exempted hospitals may, but are not required to,
submit POA indicators to DSHS The following hospital types are exempted
from reporting POA indicators to DSHS for the purposes of this subsection:
(1) Critical Access Hospitals (certified by the Secretary
of the United States Department of Health and Human Services as a
critical access hospital under Title 42 United States Code, §1395i-4).
(2) Inpatient Rehabilitation Hospitals (a majority
of the patients are inpatients being rehabilitated).
(3) Inpatient Psychiatric Hospitals (a majority of
the patients are inpatients being treated for psychiatric diseases
or associated conditions).
(4) Cancer Hospitals (a majority of the patients are
inpatients being treated for cancer or associated cancerous conditions).
(5) Children's or Pediatric Hospitals (a majority of
the patients are under the age of 18 and admitted as inpatients).
(6) Long Term Care Hospitals (a majority of the patients
are inpatients being treated for chronic conditions or associated
diseases that require extended stays in a hospital).
(f) For patients which are covered by 42 USC §290dd-2
and 42 CFR Part 2, the hospital shall submit the following patient
identifying information or default values in the specified Record
and Field locations as required by subsection (a) of this section:
(1) Patient Account Number - This alphanumeric patient
control number shall be reported. This number is unique to the institution
and episode of care and will be used by the hospital to review and
certify data.
(2) Last Name - The patient's last name shall be removed
and replaced with "Doe."
(3) First Name - The patient's first name shall be
removed and replaced with "Jane" if female, or "John" if male, and
can include a sequential number (e.g., John1, John2, John3... etc.).
(4) Middle Initial - The patient's middle initial shall
be removed and left blank (space filled).
(5) Date of Birth - "January 1" and the patient's year
of birth shall be reported.
(6) Address - The patient's residence address shall
be removed and replaced with the hospital's street address.
(7) City - The patient's city of residence shall be
removed and replaced with the name of the city where the hospital
is located.
(8) State - The patient's state of residence shall
be reported.
(9) ZIP Code - The patient's ZIP code of residence
shall be removed and replaced with the hospital's ZIP code.
(10) Medical Record Number - The patient's medical
record number shall be reported. This number is unique to the institution
and episode of care and will be used by DSHS to process the claim
data and for the hospital to review and certify the patient's data.
(11) Social Security Number - The patient's Social
Security Number shall be removed and replaced with "999999999."
(12) Statement Dates - The month, day, and year of
the statement from and statement through dates shall be reported as
required. Only the year of service will be retained with the record
after transfer to the DSHS program administering and completing the
processing of the data for the health care data collection system
under Health and Safety Code, Chapter 108.
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| Source Note: The provisions of this §421.9 adopted to be effective August 19, 1997, 22 TexReg 7490; amended to be effective December 29, 1997, 22 TexReg 12494; amended to be effective July 26, 1998, 23 TexReg 7365; amended to be effective February 21, 1999, 24 TexReg 948; amended to be effective July 29, 2001, 26 TexReg 5408; amended to be effective July 6, 2003, 28 TexReg 4915; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; amended to be effective December 27, 2007, 32 TexReg 9683; amended to be effective January 9, 2011, 35 TexReg 9743; amendedto be effective July 5, 2017, 42 TexReg 3373; amended to be effective January 30, 2019, 44 TexReg 429 |
