Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 421 - HEALTH CARE INFORMATION › Subchapter A - COLLECTION AND RELEASE OF HOSPITAL DISCHARGE DATA › Section 421.1 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
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 837
											  Institutional Guide--American National Standards Institute, Accredited Standards Committee X12N, 837 Health
											  Care Institutional Claim Implementation Guide.
(3) Attending
											  Physician--The individual licensed under the Medical Practice Act (Occupations Code, Chapter 151) who would
											  normally be expected to certify and recertify the medical necessity of the services rendered or the licensed
											  health professional primarily responsible for the care of the patient during the hospital episode. For
											  Skilled Nursing Facility (SNF) services, the attending physician is the individual who certifies the SNF plan
											  of care.
(4) Certification Process--The process by which a
											  provider confirms the accuracy and completeness of the encounter data set required to produce the public use
											  data file as specified in §
										421.7 of this title
											  (relating to Certification of Discharge Reports).
(5) 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.
(6) Comments--The notes or explanations submitted by the hospitals,
											  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.
(7) Data format--The sequence or location of data elements in an electronic
											  record according to prescribed specifications.
(8) DSHS
											  --Department of State Health Services.
(9) Discharge--The formal
											  release of a patient by a hospital; that is, the termination of a period of hospitalization by death or by
											  disposition to a residence or another health care provider.
(10)
											  Discharge claim--A set of computer records as specified in §
										421.9 of this
											  title (relating to Discharge Reports--Records, Data Fields and Codes) relating to a specific patient.
											  "Discharge claim" corresponds to the ANSI 837 Institutional Guide term, "Transaction set."
(11) Discharge report--A computer file as defined in §
										421.9 of this
											  title periodically submitted on or on behalf of a Hospital in compliance with the provisions of this chapter.
											  "Discharge report" corresponds to the ANSI 837 Institutional Guide terms, "Communication Envelope" or
											  "Interchange Envelope."
(12) DRG--Diagnosis Related
											  Group
(13) 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.
(14) Edit--An electronic standardized process developed and implemented by
											  DSHS to identify potential errors and mistakes in data elements by reviewing data fields for the presence or
											  absence of data and the accuracy and appropriateness of data.
(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 or other portable data storage media acceptable to the executive
											  director.
(16) Error--Data submitted on a discharge report which
											  are not consistent with the format and data standards contained in this section or with editing criteria
											  established by the executive director, or the failure to submit required data.
(17) Ethnicity--The status of patients relative to Hispanic background.
											  Hospitals shall report this data element according to the following ethnic types: Hispanic or
											  Non-Hispanic.
(18) 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 facility (e.g., Teaching, Acute Care, Rehabilitation, Psychiatric, Pediatric, Cancer, Skilled Nursing,
											  Long Term Acute Care or other Long Term Care Facility). A facility may have more than one indicator.
											  Hospitals may request updates to this field.
(19) Geographic
											  identifiers--A set of codes indicating the public health region and county in which the patient
											  resides.
(20) HCPCS--HCFA's Common Procedure Coding System (HCFA
											  - Health Care Finance Administrations (Now called Centers for Medicare and Medicaid Services)).
(21) Health care facility--A hospital, an ambulatory surgery center
											  licensed under Chapter 243 of the Health and Safety Code, a chemical dependency treatment facility licensed
											  under Chapter 464 of the Health and Safety Code, a renal dialysis center, a birthing center, a rural health
											  clinic or a federally qualified health center as defined by
											  42 United States Code,
											  §1396(1)(2)(B).
(22) HIPPS--Health Insurance Prospective Payment System.
(23) Hospital--A public, for-profit, or nonprofit institution licensed or
											  owned by this state that is a general or special hospital, private mental hospital, chronic disease hospital
											  or other type of hospital.
(24) ICD--International Classification
											  of Disease.
(25) 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.
(26) Institutional Review
											  Board--DSHS' appointees or agent 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 public
											  use data as described in §
										421.46 of this title (relating to
											  Institutional Review Board).
(27) 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 principal procedure or performed the surgical procedure most closely
											  related to the principal diagnosis.
(28) Other exempted
											  provider--A hospital exempt from state franchise, sales, ad valorem, or other state and local taxes that does
											  not seek or receive reimbursement for providing health care services to patients from any source, including
											  the patient or any person legally obligated to support the patient; a third party payer; or Medicaid,
											  Medicare, or any other federal, state or local program for indigent health care.
(29) Other health professional--A person licensed to provide health care
											  services other than a physician. An individual other than a physician who admits patients to hospitals or who
											  provides diagnostic or therapeutic procedures to inpatients. 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 hospital to admit or treat patients.
(30) Patient account number--A number assigned to each patient by the
											  hospital, which appears on each computer record in a patient discharge claim. This number is not consistent
											  for a given patient from one hospital to the next, or from one admission to the next in the same hospital.
											  DSHS deletes or encrypts this number to protect patient confidentiality prior to release of data.
(31) Physician--An individual licensed under the laws of this state to
											  practice medicine under the Medical Practice Act, Occupations Code, Chapter 151.
(32) Present on admission (POA)--Diagnosis present on admission.
(33) Provider--A physician or health care facility.
(34) Provider quality data--A report or reports authored by DSHS on
											  provider quality or outcomes of care, as defined in Health and Safety Code, Chapter 108, created from data
											  collected by DSHS or obtained from other sources.
(35) Public use
											  data file--A data file composed of discharge claims with risk and severity adjustment scores 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 hospital discharge data imposed by
											  statute.
(36) Race--A division of patients according to traits
											  that are transmissible by descent and sufficient to characterize them as distinctly human types. Hospitals
											  shall report this data element according to the following racial types: American Indian, Eskimo, or Aleut;
											  Asian or Pacific Islander; Black; White; or Other.
(37) Required
											  minimum data set--The list of data elements which hospitals are required to submit in a discharge claim for
											  each inpatient stay in the hospital. The required minimum data set is specified in §
										421.9(d)
											  of this title. This list does not include the data elements that are required by the ANSI 837 Institutional
											  Guide to submit an acceptable discharge report. For example: Interchange Control Headers and Trailers,
											  Functional Group Headers and Trailers, Transaction Set Headers and Trailers and Qualifying Codes (which
											  identify which qualify as subsequent data elements).
(38)
											  Research data file--A customized data file, which includes 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. The data elements may be released to a requestor when
											  the requirements specified in §
										421.8 of this title (relating
											  to Hospital Discharge Data Creation) are completed.
(39) Risk
											  adjustment--A statistical method to account for a patient's severity of illness at the time of admission and
											  the likelihood of development of a disease or outcome, prior to any medical intervention.
(40) Service Unit Indicator--An indicator derived from submitted data
											  (based on Bill type or Revenue Codes) and represents the type of service unit or units (e.g., Coronary Care
											  Unit, Detoxification Unit, Intensive Care Unit, Hospice Unit, Nursery, Obstetric Unit, Oncology Unit,
											  Pediatric Unit, Psychiatric Unit, Rehabilitation Unit, Sub acute Care Unit or Skilled Nursing Unit) where the
											  patient received treatment.
(41) Severity adjustment--A method to
											  stratify patient groups by degrees of illness and mortality.
(42)
											  Submission--The transfer of a set of computer records as specified in §
										421.9 of this
											  title that constitutes the discharge report for one or more hospitals.
(43) Submitter--The person or organization, which physically prepares
											  discharge reports for one or more hospitals and submits them to DSHS. A submitter may be a hospital or an
											  agent designated by a hospital or its owner.
(44) THCIC
											  Identification Number--A string of six characters assigned by DSHS to identify health care facilities for
											  reporting and tracking purposes.
(45) Uniform facility
											  identifier--A unique number assigned by DSHS to each health care facility licensed in the state. For
											  hospitals, this will include the hospital's state license number. For hospitals operating multiple facilities
											  under one license number and duplicating services, DSHS will assign a distinguishable uniform facility
											  identifier for each separate facility. The relationship between facility identifier and 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 hospitals and inpatient admissions. 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 or
											  treating a hospital inpatient and which remains constant across hospitals. 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) Validation--The
											  process by which a provider verifies the accuracy and completeness of data and corrects any errors identified
											  before certification.