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) Ambulatory Surgical Care Data--Data for events
associated with facility services, which require surgery to be performed
in an operating room on an anesthetized patient.
(3) Ambulatory surgical center--An establishment licensed
as an ambulatory surgical center under the Texas Health and Safety
Code, Chapter 243.
(4) Anesthetized patient--For the purposes of this
subchapter, an outpatient who receives an anesthetic (a substance
that reduces sensitivity, feeling, or awareness to pain or bodily
sensations or renders the patient unconscious) prior to surgical services
from a hospital or ambulatory surgical center.
(5) ANSI 837 Institutional Guide--American National
Standards Institute, Accredited Standards Committee X12N, 837 Health
Care Institutional Claim Implementation Guide.
(6) ANSI 837 Professional Guide--American National
Standards Institute, Accredited Standards Committee X12N, 837 Health
Care Professional Claim Implementation Guide.
(7) APC--Ambulatory Payment Classification.
(8) 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 visit and classify patients with similar
clinical characteristics.
(9) 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.
(10) 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 or surgical
and radiological categories specified in §421.67(f) or §421.67(g)
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.
(11) 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 §421.66
of this title (relating to Certification of Compiled Event Data).
(12) 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.
(13) 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).
(14) 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.
(15) Data format--The sequence or location of data
elements in an electronic record according to prescribed specifications.
(16) DSHS--Department of State Health Services.
(17) 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.
(18) 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 portable data storage media
acceptable to DSHS.
(19) Emergency Department--Department or room within
a hospital as determined by federal or state law for the provision
of emergency health care.
(20) Emergency Department Data--Events associated with
hospital services in an emergency department or emergency room.
(21) Error--Data submitted on a event file which are
not consistent with the format and data standards contained in this
subchapter or with auditing criteria established by DSHS.
(22) 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.
(23) Event--The medical screening examination, triage,
observation, diagnosis or treatment of a patient within the authority
of a facility.
(24) Event claim--A set of computer records as specified
in §421.67 of this title relating to a specific patient. "Event
claim" corresponds to the ANSI 837 Institutional Guide and ANSI 837
Professional Guide term, "Transaction set."
(25) Event file--A computer file as defined in §421.67
of this title periodically submitted on or on behalf of a facility
in compliance with the provisions of this subchapter. "Event File"
corresponds to the ANSI 837 Institutional Guide and ANSI 837 Professional
Guide terms, "Communication Envelope" or "Interchange Envelope."
(26) Facility--For the purposes of this subchapter,
a facility is a hospital or ambulatory surgical center, required to
report under the Texas Health and Safety Code, Chapter 108 and this
subchapter.
(27) 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., Hospital based ambulatory
surgical unit and hospitals with an emergency department or emergency
room) and ambulatory surgical centers. A facility may have more than
one indicator.
(28) Geographic identifiers--A set of codes indicating
the health service region and county in which the patient resides.
(29) 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.
(30) HIPPS--Health Insurance Prospective Payment System.
(31) Hospital--A public, for-profit or nonprofit institution
licensed as a general or special hospital (25 TAC §133.2(21))
of this title, or a hospital owned by the state.
(32) ICD--International Classification of Disease.
(33) 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 outpatient
event public use data.
(34) 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.
(35) Other health professional--A person licensed to
provide health care services other than a physician. 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, and podiatrists who are authorized
by the facilities to examine, observe or treat patients.
(36) 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.
(37) Outpatient or patient--For the purposes of this
subchapter, a patient who receives surgical or radiological services
from an ambulatory surgical center, or a patient who receives surgical
or radiological services from a hospital and is not admitted to a
hospital for inpatient services. Outpatients include patients who
receive one or more services covered by the revenue codes or surgical
and radiological categories that are specified in §421.67(f)
or §421.67(g) of this title, which may occur in the emergency
department, ambulatory care, radiological, imaging or other types
of hospital units. Outpatient includes a patient who is transferred
from an ambulatory surgical center to another facility or a hospital
patient who is under observation and not admitted to the hospital.
(38) 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.
(39) Physician--An individual licensed under the laws
of this state to practice medicine under the Medical Practice Act,
Occupations Code, Chapter 151 et seq.
(40) Provider--For the purposes of this subchapter,
a physician or facility.
(41) Public use data file--For the purposes of this
subchapter, a data file composed of 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.
(42) 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.
(43) Radiological procedures--For the purposes of this
subchapter, diagnostic procedures performed on a patient using radiant
energy devices (Projection Radiology (for example - X-ray), Computed
Tomography, or other ionizing radiation) or diagnostic radioactive
material or other non-ionizing imaging devices (e.g., Magnetic Resonance
Imaging, Nuclear Medicine devices (for example Positron Emission Tomography),
Sound Imaging devices (for example Ultrasound or Echocardiography),
Thermal imaging devices, Diagnostic Light imaging devices (for example
- diagnostic photography, endoscopy, and fundoscopy) and other diagnostic
imaging devices.
(44) Rendering provider or rendering other health professional--For
the purposes of reporting on the modified ANSI 837 Professional Guide,
the physician or other health professional who performed the surgical
or radiological procedure on the patient for the event. In the case
where a substitute provider (locum tenans) is used, that physician
or other health professional shall be submitted as specified in this
subchapter. For purposes of this definition, the term "provider" is
not limited to only a physician or facility as defined in paragraphs
(26), (36), and (40) of this subsection.
(45) 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 §421.67(d) and (e) of this title. This list does not include
all the data elements that are required by the modified ANSI 837 Institutional
Guide or modified ANSI 837 Professional 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).
(46) 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.
(47) Submission--The transfer of a set of computer
records as specified in §421.67 of this title that constitutes
the event file for one or more reporting hospitals under this subchapter.
(48) 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.
(49) Surgical procedure--For the purposes of this subchapter,
an invasive procedure that penetrates or breaks the skin or other
patient tissue (in vivo) for the purpose diagnosing, evaluating, analyzing,
monitoring or treating a patient.
Cont'd... |
