Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 421 - HEALTH CARE INFORMATION › Subchapter E - COLLECTION AND RELEASE OF EMERGENCY VISIT DATA › Section 421.71 - 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--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 3MT.
											  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.
(36) 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.
(37) Physician--An individual licensed under the laws of this state to
											  practice medicine under the Medical Practice Act, Occupations Code, Chapter 151 et seq.
(38) Provider--For the purposes of this subchapter, a physician or
											  facility.
(39) Public use data file--For the purposes of this
											  subchapter, a data file composed of encounter or 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.
(40) 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.
(41) 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 §
										421.77(d)
											  of this title. This list does not include all the data elements that are required by the modified ANSI 837
											  Institutional 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).
(42)
											  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, except as authorized by law.
(43) Submission--The transfer of a set of computer records as specified in
											  §
										421.77 of this
											  title that constitutes the event file for one or more reporting hospitals under this subchapter.
(44) 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.
(45) THCIC
											  Identification Number--A string of six characters assigned by DSHS to identify facilities for reporting and
											  tracking purposes. For a facility operating multiple facility locations under one license number and
											  duplicating services at those locations, DSHS will assign a distinguishable identifier for each separate
											  facility location under one license number. The relationship of the identifier to 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 facilities and patient events. 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, operating or other provider providing
											  health care services or treating a patient in a facility and which remains constant across facilities. 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) Universal Resource Locator (URL)--A specific set of ordered characters
											  to identify a unique resource location (address) on the Internet or World Wide Web.
(49) Validation--The process by which a provider verifies the accuracy and
											  completeness of data and corrects any errors identified before certification.