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 421.7 - Certification of Discharge Reports

Current through Reg. 49, No. 28; July 12, 2024
(a) Within five months after the end of each reporting quarter, DSHS shall
											  compile one or more electronic data files for each reporting hospital using all discharge claims received
											  from each hospital. The file shall have one record for each patient discharged during the reporting quarter
											  and one record for any patient discharged during one prior reporting quarter for whom additional discharge
											  claims have been received. This file will include all data submitted by the hospital, which DSHS intends to
											  use in the creation of the public use data file. The data files, including reports and any additional
											  information returned to the hospital, allows the hospital to provide physicians and other health
											  professionals the opportunity to review, request correction of, and comment on records of discharged patients
											  for whom they are shown as "attending" or "operating or other." DSHS shall determine the format and medium in
											  which the quarterly file will be delivered to hospitals.
(b) The
											  chief executive officer or chief executive officer's designated agent of each hospital shall indicate whether
											  the hospital is certifying or not certifying the discharge encounter data specified in subsection (a) of this
											  section, sign and return the form corresponding to the discharge report for each quarter using forms supplied
											  by DSHS. The certification form may be signed by a person designated by the chief executive officer and
											  acting as the officer's agent. Designation of an agent does not relieve the chief executive officer of
											  personal responsibility for the certification. If the chief executive officer or chief executive officer's
											  designated agent does not believe the quarterly file is accurate, the officer shall provide DSHS with
											  detailed comments regarding the errors or submit a written request (on a form supplied by DSHS) and provide
											  the data necessary to correct any inaccuracy and certify the file subject to those corrections being made
											  prior to the deadlines specified in this subsection. Corrections to certification discharge data shall be
											  submitted on or prior to the following schedule: Quarter 1- October 1; Quarter 2- January 1; Quarter 3- April
											  1; and Quarter 4- July 1. Chief Executive Officers or designees that elect not to certify shall submit a
											  reasoned justification explaining their decision to not certify their discharge encounter data and attach the
											  justification to the certification form. Election to not certify data does not prevent data from appearing in
											  the public use data file. Data that is not corrected and submitted by the deadline may appear in the public
											  use data file.
(c) The signed certification form shall represent
											  that:
(1) policies and procedures are in place within the hospital's
											  processes to validate and assure the accuracy of the discharge encounter data and any corrections submitted;
											  and
(2) all errors and omissions known to the hospital have been
											  corrected or the hospital has submitted comments describing the errors and the reasons why they could not be
											  corrected; and
(3) to the best of their knowledge and belief, the
											  data submitted accurately represents the hospital's administrative status of discharged inpatients for the
											  reporting quarter; and
(4) the hospital has provided physicians
											  and other health professionals a reasonable opportunity to review and comment on the discharge data of
											  patients for which they were reported in one of the available physician number and name fields provided on
											  the acceptable formats specified in §
											421.9 of this
											  title (relating to Discharge Reports--Records, Data Fields and Codes) (for example, "attending physician" or
											  "operating or other physician" as applicable). The physicians or other health professionals may write
											  comments and have errors brought to the attention of the chief executive officer or the chief executive
											  officer's designated agent and the chief executive officer or the chief executive officer's designated agent,
											  shall address any comments by the physicians or other health professionals.
(5) if the chief executive officer or the officer's designee elects not to
											  certify the discharge encounter data for a specific quarter, a written justification of any unresolved data
											  issues concerning the accuracy and completeness of the data at the time of the certification shall be
											  included on the certification form. Discharge data that has been edited, returned to hospital and is not
											  certified may be released and published in the public use data file.