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RULE §421.71Definitions

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.


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