Connecticut Administrative Code › Title 19a - Public Health and Well-being › 167g - FY 1990 Hospital Budget Review › FY 1991 and Subsequent Years Hospital Budget Review › Section 19a-167g-94 - The uniform reporting of discharge abstract and billing data

Current through July 10, 2024
For the purpose of sections 3, 4, 5, 8, 12, 18, and 29 of
				  public act 89-371, and section 11 of public act 90-134, the following section
				  shall be used to report discharge abstract and billing data in fiscal year 1991
				  and thereafter. The provisions of this section shall supersede the provisions
				  of 19a-165q-2 of the integrated prospective payment system regulations.
(a)
Definitions.
For the purpose
				of this section and except as otherwise noted, the following words and phrases
				are defined below:
(1) "Agent" means a person
				or entity which has entered into an agreement or contract with the commission
				to perform administrative, processing, management, analytical, evaluative, or
				other related services with the data collected pursuant to this
				section.
(2) "Current
				hospitalization" or "hospitalization being recorded" refers to that episode of
				hospitalization defined by the patient's admission and discharge dates and the
				medical record number and patient control number associated with that episode.
				All the data being submitted by the hospital concerning the patient's
				hospitalization relate to this episode of hospitalization.
(3) "Discharge" is defined according to
				subdivision
				19a-167g-55(b)
				(22).
(4) "Patient identification"
				means the unique designation or number assigned to each patient within a
				hospital that distinguishes by itself the medical record of an individual
				patient from the medical record of all other patients in that
				institution.
(5) "Patient control
				number" means the unique designation or number assigned by the hospital to each
				patient's individual hospitalization that distinguishes by itself the medical
				and billing records of that hospitalization.
(6) "Date of birth" means the month, day, and
				year on which the patient whose hospitalization is being recorded was
				born.
(7) "Date of admission" means
				the month, day, and year on which the patient whose hospitalization is being
				recorded was admitted to the hospital.
(8) "Date of discharge" means the month, day,
				and year on which the patient whose hospitalization is being recorded was
				discharged from the hospital.
(9)
				"Sex" means a designation of the patient as:
designation
code
(A) Male
=M
(B) Female
=F
(C) Not determined
=U
The category "not determined" may only be used in rare
				  instances where the sex of the patient either has not been or cannot be
				  determined at the time of discharge.
(10) "Zip code" means the zip code of the
				post office where the patient customarily receives mail. If the patient resides
				outside the United States or its territories, the zip code shall be
				"99998."
(11) "Race" means a
				designation of the patient according to the categories listed below. For the
				purpose of reporting this information to the commission as part of this data
				set, each category is assigned the numeric codes listed below:
category
code
(A) White
=1
(B) Black
=2
(C) American Indian/Eskimo/Aleut
=3
(D) Hawaiian/Pacific Islander
=4
(E) Asian
=5
(F) Other Non-white
=6
(G) Unknown
=0
(12)
				"Ethnicity" refers to the patient's cultural origin. The patient must be
				classified into one of the categories of ethnicity listed below. For the
				purpose of reporting this information to the commission as part of this data
				set, each ethnic category is assigned the numeric codes listed below:
category
code
(A) Spanish origin/Hispanic
=1
(B) Non-Spanish origin/Non-Hispanic
=2
(13)
				"Previous admission" refers to the length of time between the date of admission
				for the hospitalization being recorded and the date of discharge for the
				patient's most recent previous inpatient hospitalization. For the purpose of
				reporting this information to the commission as part of this data set, the
				categories of previous admission are assigned the numeric codes listed below:
category
code
(A) Less than 31 days
=1
(B) More than 30 but less than 61
							 days
=2
(C) More than 60 but less than 91
							 days
=3
(D) More than 90 but less than 181
							 days
=4
(E) More than 180 days
=5
(F) No previous hospitalization
=6
(G) Unknown
=7
(14)
				"Hospital ID code" refers to the last four digits of the hospital's Medicare
				provider number for the unit from which the patient was discharged for the
				hospitalization being recorded.
(15) "Attending practitioner" means the
				physician, surgeon, homeopath, dentist, podiatrist, chiropractor, osteopath, or
				psychologist who was primarily responsible for the patient's care during the
				hospitalization being recorded. The attending practitioner will be designated
				by the hospital using the unique code established pursuant to subsection (e) of
				this section.
(16) "Operating
				practitioner" means the physician, surgeon, homeopath, dentist, podiatrist,
				chiropractor, osteopath, or psychologist who performed the principal procedure
				during the hospitalization being recorded. The operating practitioner will be
				designated by the hospital using the unique code established pursuant to
				subsection (e) of this section.
(17) "Principal diagnosis and secondary
				diagnoses" refer to diagnoses that affect the hospitalization being recorded.
(A) "Principal diagnosis" refers to the
				condition which is established after study to be chiefly responsible for the
				admission of the patient to the hospital.
(B) "Secondary diagnoses" refers to those
				conditions, exclusive of the principal diagnosis, which exist at the time of
				the patient's admission or which develop subsequently to the admission and
				which affect the patient's treatment or length of stay for the hospitalization
				being recorded. Diagnoses which are associated with an earlier hospitalization
				and which have no bearing on the current hospitalization shall not be recorded
				as secondary diagnoses.
(18) Procedures and procedure days.
(A) "Procedure" means a significant procedure
				that is surgical in nature; carries a procedural or anesthetic risk; or
				requires specialized training or special facilities or equipment.
(B) "Procedure day" refers to the day on
				which the procedure was performed. The procedure day equals the number of days
				after the admission date on which the procedure was performed. If the procedure
				was performed on the date of admission, then the procedure day = 0.
(C) "Principal procedure" means that
				procedure most closely related to the principal diagnosis which is performed
				for the definitive treatment of the patient.
(i) The principal procedure cannot be a
				procedure which has been performed for a diagnostic or exploratory purpose only
				or to resolve a complication, unless these are the only types of procedures
				performed on the patient during the hospitalization being recorded.
(ii) "Complication" is defined in this
				section as any diagnosis other than the principal diagnosis.
(D) "Other procedures" means other
				significant procedures in addition to the principal procedure. These are to be
				reported with the procedure day on which the procedure was performed.
(19) "Admission status" describes
				the circumstances associated with the patient's admission and will be limited
				to the following:
circumstance
code
(A) Physician Referral
1
(B) Clinic Referral
2
(C) HMO Referral
3
(D) Transfer from a Hospital
4
(E) Transfer from a Skilled nursing
							 facility
5
(F) Transfer from another health care
							 facility
6
(G) Emergency room
7
(H) Court/law enforcement
8
(I) Newborn
9
(20)
				"Discharge status" means a designation associated with the circumstances of the
				patient's discharge and will be limited to the following:
designation
code
(A) Home
01
(B) Transferred to another short term
							 hospital
02
(C) Transferred to a skilled nursing
							 facility
03
(D) Transferred to an intermediate care
							 facility
04
(E) Transferred to another type of
							 institution
05
(F) Discharged to home health service
06
(G) Left against medical advice
07
(H) Expired
20
(21)
				"Expected principal source of payment" means that payment source that was
				expected at the time the data set was completed to provide the primary share of
				the payment for the hospitalization being recorded. These sources will be
				limited to the following:
payment
							 source
code
(A) Self pay
A
(B) Worker's Compensation
B
(C) Medicare
C
(D) Medicaid
D
(E) Other Federal Program
E
(F) Commercial Insurance Company
F
(G) Blue Cross
G
(H) CHAMPUS
H
(I) Other
I
(J) Title V
Q
(K) No Charge
R
(L) HMO
S
(M) PPO
T
(22)
				"CHAMPUS" is defined in 19a-167g-55 (b) (13).
(23) "Title V" means the Maternal and Child
				Health Services Block Grant as provided under Title V of the Social Security
				Act.
(24) "HMO" and "PPO" refer to
				alternative delivery systems and are defined in 19a-167g-55 (b) (3).
(25) "Birthweight" means the weight in grams
				of a newborn infant recorded at birth. This value must be coded if the
				admission status is newborn.
(26)
				"Total revenue center charges" means the total charges appearing on the
				patient's bill. This amount should correspond to revenue code "001" on a
				standard UB-82 bill.
(27) A "group
				of revenue data elements" means an individual, distinct revenue code and its
				corresponding units of service and charges for the hospitalization being
				recorded. One group of revenue data elements consists of the revenue center
				code, its units of service, and its total charges.
(28) "UB-82 data" refers to those uniform
				billing data elements generated by hospitals for the purpose of billing
				hospital charges to patients for services rendered after September 30, 1984.
				These data elements are contained on a "UB-82 form" which is that version of
				the Uniform Hospital Billing Form promulgated by the National Uniform Billing
				Committee, established by the American Hospital Association, as from time to
				time amended. The UB-82 form has also been adopted as Health Care Financing
				Administration (HCFA) Form 1450 pursuant to Sections 1814 (a) (1) and 1871 of
				the federal Social Security Act.
(29) "Discharge abstract" refers to those
				items of medical and demographic information which are normally available in
				the patient's medical record and which may be abstracted from that medical
				record as data elements. The discharge abstract for the hospitalization being
				recorded summarizes the important clinical features of that patient's
				hospitalization. For the purpose of this section, the items of medical and
				demographic information referred to by the term "discharge abstract data" are
				data elements numbered 4, 6-12, 14-15, 17-18 on record type 2, items numbered
				4, 6-14 on record type 3, and items numbered 4, 6-8, 10-11, 13-14, 16-17,
				19-20, and 22-23 on record type 4 of subsection (h) (8), below. Some of these
				items may also be found on the patient's UB-82 billing form. These data
				elements may also be part of the UB-82 data.
(30) A "test tape" is defined as the
				submission of a sample of a hospital's discharge abstract and billing data set
				as part of the initial submission of data pursuant to subsection (b) (5) or for
				the purpose of testing technical changes made by the hospital which affect the
				submission of its discharge abstract and billing data set on computer tape. The
				test tape shall conform exactly to all the technical specifications provided
				for in this section. The sample of the data set contained on a hospital's test
				tape shall not exceed one-twelfth (1/12) of that hospital's total discharges
				for fiscal year 1989.
(31) Reports.
(A) A "report" is defined as data or
				information extracted or prepared from the data collected under this section or
				section 19a-165q-2 of the commission's regulations. This includes data derived
				from other sources when such data are combined with the data collected under
				this section. The report may be presented in any form, either on paper or
				contained in computer-accessible files on-or offline on magnetic media, such as
				magnetic tapes, disks, or drums.
(B) If a report, either by itself or in
				combination with another report, can identify an individual patient or
				practitioner either by personal identification code, by name, or by a
				combination of data elements, then it will be considered
				"confidential."
(C) If a report,
				either by itself or in combination with another report, cannot identify an
				individual patient or practitioner either by personal identification code, by
				name, or by a combination of data elements, then it will be considered
				"nonconfi-dential."
(32)
				"Data element" means an individual category of data taken from a discharge's
				medical record or hospital bill (UB-82 data). Data elements to be filed
				pursuant to this section are prescribed in subsection (h) (9), and, when
				appropriate, are defined in subsection (a).
(33) "Data record" refers to a 282-byte array
				of a computer file containing data elements specific to a hospital or to
				individual discharges from a hospital. Six types of data records shall be filed
				by a hospital pursuant to this section. They are referred to as data record
				type 1 through data record type 6. These data record types are described in
				subsections (h) (4) and (h) (9).
(34) "Data set" refers to the complete set of
				data records filed by a hospital for a reporting period. The data set shall
				contain the discharge abstract and billing data for each individual discharged
				from that hospital during the reporting period. The data set shall be composed
				of one header record (data record type 1), one trailer record (data record type
				6) for each hospital, and a group of data records (data record types 2 through
				5, inclusive) for each individual discharged from that hospital. These data
				records shall include the data elements prescribed in subsection (h)
				(9).
(35) "Payer identification"
				means the code number or the payer name which identifies the payer organization
				from which the hospital expects at the time of discharge some payment for the
				bill. Up to three payer organizations shall be reported in order of their
				expected contributions to the payment of the hospital bill.
(36) "Estimated responsibility" means the
				amount estimated by the hospital at the time of discharge to be paid by the
				indicated payer.
(37) "Deductible"
				means that amount estimated by the hospital at the time of discharge to be
				applied to the patient's deductible amount for the indicated payer.
(38) "Coinsurance" means that amount
				estimated by the hospital at the time of discharge to be applied to the
				patient's coinsurance amount for the indicated payer.
(39) A "report cell" means the intersection
				of a row and column of data elements in a report.