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--American National Standards Institute.
(3) ANSI 837 Institutional Guide--American National
Standards Institute, Accredited Standards Committee X12N, 837 Health
Care Institutional Claim Implementation Guide.
(4) APC--Ambulatory Payment Classification.
(5) APG--Enhanced Ambulatory Patient Grouper--A prospective
payment system (PPS) for ambulatory patient care developed by 3M™.
The APGs provide information regarding the kinds and amounts of resources
utilized in an outpatient emergency visit and classify patients with
similar clinical characteristics.
(6) Audit--An electronic standardized process developed
and implemented by DSHS to identify potential errors and mistakes
in file structure format or data element content by reviewing data
fields for the presence or absence of data and the accuracy and appropriateness
of data.
(7) Certification File--One or more electronic files
(may include reports concerning the data and its compilation process)
compiled by DSHS that contain one record for each patient event which
has at least one procedure covered in the revenue codes specified
in §421.77(e) of this title (relating to Event Files--Records,
Data Fields and Codes) submitted for each facility under this subchapter
during the reporting quarter and may contain one record for any patient
event occurring during one prior reporting quarter for whom additional
event claims have been received.
(8) Certification Process--The process by which a provider
confirms the accuracy and completeness of the certification file required
to produce the public use data file as specified in §421.76 of
this title (relating to Certification of Compiled Event Data).
(9) 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.
(10) Clinical Classifications Software--A classification
system that groups diagnoses and procedures into a limited number
of clinically meaningful categories developed at the United States
Department of Health and Human Services, Agency for Healthcare Research
and Quality (AHRQ).
(11) Comments--The notes or explanations submitted
by the facilities, 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.
(12) Data format--The sequence or location of data
elements in an electronic record according to prescribed specifications.
(13) DSHS--Department of State Health Services.
(14) 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.
(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, magnetic, or other portable data storage
media acceptable to DSHS.
(16) Emergency Department--Department or room within
a hospital or freestanding emergency medical care facility as determined
by federal or state law for the provision of emergency health care
services.
(17) Emergency Visit Patient or patient--For the purposes
of this subchapter a patient who receives services in the emergency
department or emergency room of the health care facility. Emergency
Visit Patients include patients who receive one or more services,
which occur in the emergency department or emergency room of the healthcare
facility.
(18) ESRD--End Stage Renal Disease.
(19) Error--Data submitted on an event file which are
not consistent with the format and data standards contained in this
subchapter or with auditing criteria established by DSHS.
(20) Ethnicity--The status of patients relative to
Hispanic background. Facilities shall report this data element according
to the following ethnic types: Hispanic or Non-Hispanic.
(21) Event--The medical screening examination, triage,
observation, diagnosis or treatment of a patient within the authority
of a facility that occurs as result of an outpatient emergency visit.
(22) Event claim--A set of computer records as specified
in §421.77 of this title relating to a specific patient. "Event
claim" corresponds to the ANSI 837 Institutional Guide term, "Transaction
set."
(23) Event file--A computer file as defined in §421.77
of this title periodically submitted on or on behalf of a facility
in compliance with the provisions of this subchapter. "Event File"
that corresponds to the ANSI 837 Institutional Guide terms, "Communication
Envelope" or "Interchange Envelope."
(24) Facility--For the purposes of this subchapter,
a facility is a hospital or freestanding emergency medical care facility
required to report under the Texas Health and Safety Code, Chapter
108 and this subchapter.
(25) 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 hospital (e.g., Acute Care Hospital,
Children's Hospital, Cancer Hospital, or Freestanding Emergency Medical
Care Facility. A facility may have more than one indicator.
(26) Geographic identifiers--A set of codes indicating
the health service region and county in which the patient resides.
(27) HCPCS--Healthcare Common Procedure Coding System
of the Centers for Medicare and Medicaid Services. This includes the
"Current Procedural Terminology" (CPT) codes (maintained by the "American
Medical Association" (AMA)), which are "Level 1" HCPCS codes.
(28) Hospital--A public, for-profit, or nonprofit institution
licensed as a general or special hospital as defined in §133.2(21)
of this title (relating to Definitions), or a hospital owned by the
state.
(29) ICD--International Classification of Disease.
(30) 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.
(31) IRB--Institutional Review Board--composed of DSHS'
appointees or agents 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 emergency
visit public use data.
(32) 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 surgical or radiological
procedure most closely related to the principal diagnosis.
(33) Other health professional--A person licensed to
provide health care services other than a physician. "Other health
professional" is an individual other than a physician who provides
diagnostic or therapeutic procedures to patients. The term encompasses
persons licensed under various Texas practice statutes, such as psychologists,
chiropractors, dentists, nurse practitioners, nurse midwives, physicians
assistants and podiatrists who are authorized by the facilities to
examine, observe or treat patients.
(34) Other Provider--For the purposes of reporting
on the modified ANSI 837 Institutional Guide, the physician, other
health professional or facility as reported on a claim, who performed
a secondary surgical or a primary or secondary radiological procedure
on the patient for the event, if they are not reported as the operating
or other physician or the facility. In the case where a substitute
provider (locum tenens) is used, that physician or other health professional
shall be submitted as specified in this subchapter.
(35) Outpatient Emergency Visit--For the purposes of
this subchapter, events associated with services in an emergency department,
emergency room, or a freestanding emergency medical care facility.
(36) Patient account number--A number assigned to each
patient by the facility, which appears on each computer record in
a patient event claim. This number is not consistent for a given patient
from one facility to the next, or from one admission to the next in
the same facility. DSHS will delete or encrypt this number to protect
patient confidentiality prior to release of data.
(37) Physician--An individual licensed under the laws
of this state to practice medicine under the Medical Practice Act,
Occupations Code, Chapter 151 et seq.
(38) Provider--For the purposes of this subchapter,
a physician or facility.
(39) Public use data file--For the purposes of this
subchapter, a data file composed of encounter or event claims 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 data imposed by statute.
(40) Race--A division of patients according to traits
that are transmissible by descent and sufficient to characterize them
as distinctly human types. Facilities shall report this data element
according to the following racial types: American Indian, Eskimo,
or Aleut; Asian or Pacific Islander; Black; White; or Other.
(41) Required minimum data set--The list of data elements
for which facilities may submit an event claim for each patient event
occurring in the facility. The required minimum data sets are specified
in §421.77(d) of this title. This list does not include all the
data elements that are required by the modified ANSI 837 Institutional
Guide to submit an acceptable event file. For example: Interchange
Control Headers and Trailers, Functional Group Headers and Trailers,
Transaction Set Headers and Trailers and Qualifying Codes (which identify
or qualify subsequent data elements).
(42) Research data file--A customized data file, which
may include the data elements in the public use file and may include
data elements other than the required minimum data set submitted to
DSHS, except those data elements that could reasonably identify a
patient or physician, except as authorized by law.
(43) Submission--The transfer of a set of computer
records as specified in §421.77 of this title that constitutes
the event file for one or more reporting hospitals under this subchapter.
(44) Submitter--The person or organization, which physically
prepares an event file for one or more facilities and submits them
under this subchapter. A submitter may be a facility or an agent designated
by a facility or its owner.
(45) THCIC Identification Number--A string of six characters
assigned by DSHS to identify facilities for reporting and tracking
purposes. For a facility operating multiple facility locations under
one license number and duplicating services at those locations, DSHS
will assign a distinguishable identifier for each separate facility
location under one license number. The relationship of the identifier
to the name and license number of the facility is public information.
(46) Uniform patient identifier--A unique identifier
assigned by DSHS to an individual patient and composed of numeric,
alpha, or alphanumeric characters, which remains constant across facilities
and patient events. The relationship of the identifier to the patient-specific
data elements used to assign it is confidential.
(47) Uniform physician identifier--A unique identifier
assigned by DSHS to a physician or other health professional who is
reported as attending, operating or other provider providing health
care services or treating a patient in a facility and which remains
constant across facilities. The relationship of the identifier to
the physician-specific data elements used to assign it is confidential.
The uniform physician identifier shall consist of alphanumeric characters.
(48) Universal Resource Locator (URL)--A specific set
of ordered characters to identify a unique resource location (address)
on the Internet or World Wide Web.
(49) Validation--The process by which a provider verifies
the accuracy and completeness of data and corrects any errors identified
before certification.
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