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TITLE 25HEALTH SERVICES
PART 1DEPARTMENT OF STATE HEALTH SERVICES
CHAPTER 421HEALTH CARE INFORMATION
SUBCHAPTER DCOLLECTION AND RELEASE OF OUTPATIENT SURGICAL AND RADIOLOGICAL PROCEDURES AT HOSPITALS AND AMBULATORY SURGICAL CENTERS
RULE §421.67Event Files--Records, Data Fields and Codes
    (E) Service Provider ZIP; and

  (37) Service Provider Secondary Identifier - THCIC 6-digit facility ID assigned to each facility;

   (38) Point of Origin (Source of Admission) (Hospital Emergency Department Visits only); and

  (39) Patient Status (Hospital Emergency Department Visits only).

 (e) Facilities shall submit the following required minimum data set in the following modified ANSI 837 Professional Guide format for all patients for which an event claim is required by a third party payer to be in the ANSI 837 Professional Guide format or CMS-1500 format and required to be submitted under this subchapter. At a facility's option, a facility may choose to submit the required data set listed in subsection (d) of this section. The required minimum data set for the modified (as specified in subsection (c) of this section) ANSI 837 Professional Guide format includes the following data elements as listed in this subsection.

  (1) Patient Name.

    (A) Patient Last Name;

    (B) Patient First Name; and

    (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; and

    (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 (if applicable);

  (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 (Facility Type Code plus Claim Frequency Code);

  (14) Service Date;

  (15) Principal Diagnosis;

  (16) Other Diagnosis Codes - up to 7 occurrences (all applicable);

  (17) Related Cause Code - up to 3 occurrences (if applicable);

  (18) Procedure Codes - up to 50 occurrences (all applicable):

    (A) HCPCS Procedure Modifier 1 (applicable to each submitted Procedure code);

    (B) HCPCS Procedure Modifier 2 (applicable to each submitted Procedure code);

    (C) HCPCS Procedure Modifier 3 (applicable to each submitted Procedure code);

    (D) HCPCS Procedure Modifier 4 (applicable to each submitted Procedure code);

    (E) Charge Amount;

    (F) Unit Code; and

    (G) Unit Quantity;

  (19) Rendering Provider or Rendering Other Health Professional Name (Up to 2 occurrences):

    (A) Rendering Provider or Rendering Other Health Professional Last Name;

    (B) Rendering Provider or Rendering Other Health Professional First Name; and

    (C) Rendering Provider or Rendering Other Health Professional Middle Initial;

  (20) Rendering Provider or Rendering Other Health Professional Primary Identifier (National Provider Identifier) (Up to 2 occurrences);

  (21) Rendering Provider or Rendering Other Health Professional Secondary Identifier (Texas state license number) (if primary identifier not available) (Up to 2 occurrences);

  (22) Total Claim Charges;

  (23) Service Provider Name;

   (24) Service Provider Primary Identifier--Provider Federal Tax ID (EIN) or National Provider Identifier;

  (25) 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; and

     (E) Service Provider ZIP;

  (26) Service Provider Secondary Identifier--THCIC 6-digit Hospital ID assigned to each facility.

 (f) Facilities shall submit the required minimum data set to DSHS for each patient who has one or more of the following revenue codes in this subsection or one or more of the outpatient surgical or radiological procedures (which are covered by the service and procedure categories listed in subsection (g) of this section) for services rendered to the patient in the facility. Facilities operating in the State of Texas shall submit the required data elements as specified in subsection (d) or (e) of this section relating to the revenue codes in this subsection or the procedure codes covered in the service and procedure categories listed in subsection (g) of this section.

  (1) 0320 Radiology--Diagnostic General Classification. (effective 90 calendar days after being published in the Texas Register );

  (2) 0321 Radiology--Diagnostic Angiocardiology;

  (3) 0322 Radiology--Diagnostic Arthrography;

  (4) 0323 Radiology--Diagnostic Arteriography;

  (5) 0329 Radiology--Diagnostic Other Radiology - Diagnostic;

  (6) 0330 Radiology--Therapeutic General Classification;

  (7) 0333 Radiology--Therapeutic Radiation Therapy;

  (8) 0339 Radiology--Therapeutic Other Radiology - Therapeutic;

  (9) 0340 Nuclear Medicine General Classification;

  (10) 0341 Nuclear Medicine Diagnostic;

  (11) 0342 Nuclear Medicine Therapeutic;

   (12) 0343 Nuclear Medicine Diagnostic Pharmaceuticals;

  (13) 0344 Nuclear Medicine Therapeutic Pharmaceuticals;

  (14) 0349 Nuclear Medicine Other Nuclear Medicine;

  (15) 0350 Computed Tomography (CT) Scan General Classification;

  (16) 0351 Computed Tomography (CT)--Head Scan;

  (17) 0352 Computed Tomography (CT)--Body Scan;

  (18) 0359 Computed Tomography (CT)--Other;

  (19) 0360 Operating Room Services General Classification;

  (20) 0361 Operating Room Services Minor Surgery;

  (21) 0369 Operating Room Services Other Operating Room Services;

  (22) 0400 Other Imaging Services General Classification;

  (23) 0401 Other Imaging Services Diagnostic Mammography;

  (24) 0403 Other Imaging Services Screening Mammography;

  (25) 0404 Other Imaging Services Positron Emission Tomography (PET);

  (26) 0409 Other Imaging Services Other Imaging Services;

   (27) 0481 Cardiology Cardiac Catheterization Lab;

  (28) 0483 Cardiology Echocardiology;

  (29) 0489 Cardiology Other Cardiology Services;

  (30) 0490 Ambulatory Surgical Care General Classification;

  (31) 0499 Ambulatory Surgical Care Other Ambulatory Surgical;

  (32) 0500 Outpatient Services General Classification;

  (33) 0509 Outpatient Services Other Outpatient;

  (34) 0610 Magnetic Resonance Technology General Classification;

  (35) 0611 Magnetic Resonance Technology Magnetic Resonance Imaging (MRI)--Brain/Brainstem;

  (36) 0612 Magnetic Resonance Technology Magnetic Resonance Imaging (MRI)--Spinal Cord/Spine;

  (37) 0614 Magnetic Resonance Technology Magnetic Resonance Imaging (MRI)--Other;

  (38) 0615 Magnetic Resonance Technology Magnetic Resonance Angiography (MRA)--Head and Neck;

  (39) 0616 Magnetic Resonance Technology Magnetic Resonance Angiography (MRA)--Lower Extremities;

  (40) 0618 Magnetic Resonance Technology Magnetic Resonance Angiography (MRA)--Other;

   (41) 0619 Magnetic Resonance Technology Other Magnetic Resonance Technology;

  (42) 0760 Specialty Room--Treatment/Observation Room General Classification;

  (43) 0761 Specialty Room--Treatment Room;

  (44) 0762 Specialty Room--Observation Room; and

Cont'd...		 

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