25 TAC §§1301.11-1301.19
The Texas Health Care Information Council proposes new §1301.11-1301.19,
concerning the collection and release of hospital discharge data. Specifically,
the sections define terms used in the collection and release of hospital
discharge data; establish rules for collection of hospital discharge data;
establish rules for filing discharge reports; establish rules for exemptions
from filing requirements; establish rules for acceptance of discharge reports
and correction of errors; establish rules for certification of discharge
reports; establish rules for hospital discharge data release; and establish
rules for discharge reports, including records, data fields, and codes. These
new rules will facilitate implementation of the statewide health care data
collection system mandated by the Legislature in House Bill Number 1048,
of the 74th Legislature, codified in Title 2, Health and Safety Code, §108.1-108.15,
to collect health care charges, utilization data, provider quality data,
and outcome data to facilitate the promotion and accessibility of cost-effective,
good quality health care.
The Texas Health Care Information Council has determined that for the first
five-year period the sections are in effect there will be fiscal implications.
The costs to state government may average up to $450,000 per year. A portion
of these costs may be recaptured through revenues generated by user fees
for products produced through implementation of these rules. The revenues
to be generated through user fees are expected to be positive but as yet
undetermined. There will be no fiscal implications for local governments
except to the extent that local governments operate hospitals that are required
to submit data per these rules.
The Council has also determined that for each year of the first five years
the sections are in effect, the public benefits anticipated as a result of
enforcing and administering the sections will be public access to hospital
discharge data regarding health care charges, utilization data, provider
quality data, and outcome data to facilitate the promotion and accessibility
of cost-effective, good quality health care; to provide an information and
data source for providers, consumers, purchasers, and policy makers alike;
to promote informed decision making in providing, utilizing, and purchasing
health care and for developing and implementing health care policy throughout
the state; and to provide a means of benchmarking throughout the state to
promote continuous quality improvement by providers to ensure good quality,
accessible health care to the citizens of Texas.
There will be additional, marginal costs to providers as they will be required
to provide data on all, as opposed to most, patients admitted to their hospitals
and the information required is expanded. Few, if any, of the hospitals required
to submit data under this rule can be classified as small businesses. The
potential for these increased costs have been mitigated by utilizing formats
and processes currently in existence and through integration and consolidation
with other health care data systems. Under the proposed rule, all hospitals
shall file discharge reports by electronic filing (tape, diskette or modem)
unless the hospital receives an exemption letter from the Council. The following
findings were utilized by the council when writing these rules.
(1) Electronic filing of UB-92 bills with payors by hospitals is the normal
business practice in the hospital industry.
(2) Electronic filing of UB-92 bills with payors by hospitals offers significant
economic advantages to hospitals and payors in reducing errors, reducing
processing costs and speeding payments.
(3) Available computer software and service bureaus usually make electronic
filing of UB-92 bills more economical than filing paper UB-92 forms for most
hospitals.
(4) Hospitals with the capability to electronically file UB-92 bills with
any payor usually have the capability to electronically file discharge files
with the council for all patients discharged.
(5) Electronic filing of discharge reports by hospitals to satisfy the
council's data collection requirements is less costly for the council and
less costly for most hospitals than filing paper UB-92 forms.
The Texas Department of Health, Texas Hospital Association, Blue Cross/Blue
Shield, health data organizations in 17 states, and 46 hospitals within the
State of Texas were contacted for information regarding provider costs in
providing data and information required on uniform billing (UB) form 92 (the
format required by these rules). These entities reported a range of costs,
from 2 to 3 cents per discharge up to 75 cents per form submitted. For providers
that have discharge data bases which are similar to that required for completion
of the UB form 92 and which are fully computerized, the cost averages 2 to
3 cents per patient discharged from the hospital; for those that have systems
which are not fully computerized or which do not maintain data bases similar
to that required for completion of the UB form 92, the cost averages 50-55
cents per hospital discharge; and for those that have little or no computer
support and process all claims manually, the cost increases to about 75 cents
per hospital discharge. To the extent that hospitals are not currently collecting
all of the data required by these rules, they may incur additional costs.
Similarly, to the extent that hospitals utilize outside vendors, they may
incur additional costs. As a consequence, the financial impact will be most
significant on small hospitals with little or no automated data processing
capability. For all of the hospitals required to submit data under these
rules within the State of Texas, the total cost is expected to be approximately
$326,000 per year. There is no anticipated effect on local employment.
Comments on the proposed rules may be submitted to Nelda P. Wray, M.D.,
M.P.H., Chairperson, Texas Health Care Information Council, 4900 North Lamar,
OOL-3407, Austin, Texas, 78751-2399, (512) 424-6492. Comments will be accepted
for 30 days following publication of this proposal in the
Texas Register
. In addition, a public hearing on the proposed sections
will be held at 9:00 a.m., Monday, March 3, 1997, in the Brown-Heatly Building,
Room 1410, 4900 North Lamar, Austin, Texas 78751-2399.
A previous version of this proposed rule was published in the August 23,
1996, issue (21 TexReg 7939). Prior to that date, copies of the proposed
rule were mailed to all Texas hospitals and other interested parties by the
council. A public hearing was held on August 26, 1996, in Austin at which
nine people presented oral testimony. During the 30 day comment period following
publication of the proposed rule, written comments were received from 53
individuals and organizations. Members of the council have also met informally
with representatives of affected interest groups to receive additional input.
Individuals and organizations presenting testimony at the public hearing
were: Mr. Ed Berger representing the Seton Health Network, Mr. John Bergin
representing St. Joseph's Regional Health Center, Dr. Earl Matthew representing
the Texas Medical Association, Mr. Bob Tippens representing Scott & White
Hospital and Texas HIMA, Ms. Ann Heiligenstein representing the Conference
of Catholic Health Facilities, Ms. Pam McNutt representing Methodist Hospitals
of Dallas, Mr. Jay Sherler representing the Providence Health Center, Mr.
Joe DaSilva representing the Texas Hospital Association, and Mr. Gary Barton
representing HCIA.
Individuals and organizations submitting written comments during the comment
period were: Dennis Newquist (Abilene Regional Medical Center); Gerry Brueckner
(Baylor Center for Restorative Care); Mark Hood (Baylor Medical Center at
Grapevine); Ronald L. Boring (Baylor/Richardson Medical Center); Joel Allison
(Baylor University Medical Center); David P. Brown (Citizens Medical Center);
Michael Morris (Coleman County Medical Center); Russell Meyers (Columbia
Bayshore Medical Center); Richard Harwell (Columbia Navarro Regional Hospital);
Sally Jeffcoat (Columbia Spring Branch Medical Center); Norman Powers (Comptroller
of Public Accounts); Earl B. Matthew, M.D. (Texas Medical Association); Gary
D. Brock (Baylor Medical Center at Garland); Robert A. Pascasio (Memorial
Hospital); Judy Huffman (Good Shepherd Medical Center); John Haas (Greater
San Antonio Hospital Council); John Froehlich (HCIA), Christy Francis (Hemphill
County Hospital); Buddy Edwards (Hillcrest Baptist Medical Center); Ken Blankenship,
Robert O. Langland, E.L. Langley, Marilyn Keene-Milligan, Elizabeth R. Propp,
and H.J. Macfarland (Irving Healthcare System); John Hornbeak (Methodist
Healthcare System); Ann Timpe-Brennan and Lisa L. Dahm (Memorial Hospital
System); Pamela G. McNutt (Methodist Hospitals of Dallas); Judy Novak (Park
Plaza Hospital); Kent A. Keahey (Providence Health Canter); Robert M. Tippens
(Scott & White); W. Edward Berger (Seton); Gail M. Oberta and Mary Klock
(Shoal Creek Hospital); Monty McLaurin (St. Joseph's Hospital and Health
Center); Susan Rudd Wynn, M.D. (Tarrant County Medical Society); Jim Biltz
(Tenet HealthSystem); David R. Smith, M.D. (Texas Department of Health);
Jack Harrington (Texas Department of Mental Health and Mental Retardation);
Robert M. Tippens (TX HIMA); Jim Houdek, Joe DaSilva and Hugh Lamensdorf,
M.D. (Texas Medical Association); James Houdek (Texas Hospital Association);
Terry Boucher (Texas Osteopathic Medical Association); Todd Brown (Texas
Workers' Compensation Commission); John Mendelsohn. M.D. (The University
of Texas MD Anderson Cancer Center); James C. Guckian, M.D. (The University
of Texas System); J. Michael Lee (Baylor Medical Center-Ellis County); Richard
J. Hausner, M.D. (Harris County Medical Society); Joanne Turnbull (Hermann
Hospital); Richard D. Arnold (Medina Community Hospital and Medical Clinics);
John G. Bergin (St. Joseph's Services Corporation); Don A. Beeler (St. Michael
Health Care Center); John A. Guest (University Health System); and Di M.
Dooley (Wilford Hall Medical Center).
The council's hospital discharge data committee discussed the comments
at its October 24, 1996, meeting in Houston. The full council discussed the
comments and voted on responses to the comments and associated changes to
the proposed rule at its meetings on October 28 and November 25, 1996, in
Austin. The council determined that sufficient modifications to the proposed
rule were required that it would be inappropriate to move to final adoption
of a rule without withdrawing the initial proposed rule and publishing a
revised proposed rule for public review and comment. Therefore at the January
27, 1997, meeting the council formally withdrew the August 26 proposed rule
from further consideration.
In order to document the council's decisions regarding the development
of this rule, it has prepared a response to the comments received on the
August 26 proposed rule and incorporates them into this preamble. Section
references in this response are to the August 26 version of the proposed
rule.
Comments Related to Specific Sections of the August 26 Proposed Rule
Section 1301.11 Definitions. The Council accepted comments from the Texas
Department of Health (TDH) regarding the need to include TDH in the rule
definitions and to conform the definitions of "physicians" and "providers"
to those found in the statute. Accepting these comments required creation
of another term, "Other Health Professionals," to cover persons who are not
"physicians" as defined in the statute, but who may be reported by providers
as having admitted or treated patients in certain circumstances.
Concerns were expressed by the Texas Department of Mental Health and Mental
Retardation that federal statutes and regulations restricting the release
of information on psychiatric and substance abuse patients might prevent
hospitals from supplying information on these patients, and thus require
changes in the definition of "Inpatient." The council has secured an opinion
from TDH legal counsel that no change is necessary to comply with federal
law. The relevant law (42 U.S.C. §290dd-2) does not restrict disclosure
of records "to qualified persons for the purpose of conducting scientific
research, management audits, financial audits or program evaluation...."
In the opinion of legal counsel, THCIC comes within this category.
Section 1301.12(b) Number of Discharge Records per Patient. The proposed
rule called for one discharge record per patient. This requirement would
require hospitals to do additional data processing in four circumstances:
(1) for live deliveries where only one UB-92 is currently generated with
the mother as patient, the hospital would be required to generate a second
discharge record for the newborn; (2) for patients where the hospital issues
interim bills and a final bill, the hospital would be required to create
a single consolidated discharge record; (3) for patients moved from an acute
care bed to a DRG-exempt unit the hospital would be required to create a
single consolidated discharge record; and (4) for patients for which the
hospital does not currently generate a bill because of a judgment by the
hospital that no payment will occur, the hospital will be required to generate
a discharge record when they might not have generated a UB-92. Multiple hospitals
objected to the additional data processing required by these aspects of the
proposed rule as increasing their costs and being otherwise burdensome. The
council responds to these comments as follows:
The proposed rule has been revised to eliminate the requirement that the
hospital create a separate discharge record for a healthy newborn if a separate
bill was not required by the payor. The council believes that the data elements
requested are sufficient to allow the council to create separate discharge
records for healthy newborns where necessary. On this point, the revised
rule requires the hospital to submit the data in the form required by the
payor.
The proposed rule has been revised to eliminate the requirement that for
patients where the hospital has issued interim and final bills that those
bills be consolidated into a single discharge record. Under the revised rule
the council will accept interim and final discharge records and will make
the necessary consolidations to produce a single discharge record for analytical
purposes. On this point, the revised rule requires the hospital to submit
the data in the form required by the payor.
One hospital asked how hospitals were to report patients who were served
in the acute care portion of a hospital and were then transferred to a DRG-exempt
unit of that hospital. Such units could be skilled nursing units, psychiatric
units, comprehensive medical rehabilitation units or long-term care units.
The answer depends upon the payor. The majority of these patients are Medicare
patients. Medicare requires that the hospital bill separately for the patient's
acute care admission and for the admission to the DRG-exempt unit. The hospital
should therefore submit to the council a separate discharge record for the
admission to each unit or facility. The council will use the data elements
on both records to assign a unique patient identifier to provide a clear
picture of the overall inpatient episode. Other payors may require the hospital
to provide a single bill for the total stay. If so, the hospital would provide
the council with one discharge record. We believe the data elements on the
record (e.g. revenue codes, conditions and occurrence codes, etc.) will allow
proper interpretation of the data for analytical purposes. This approach
will minimize any data processing burden on the hospitals. The council has
also provided that for each patient record on the public data tapes that
acute and subacute care days will be separately reported.
The council does not agree with the comments of numerous hospitals who
commented that hospitals should not be required to submit discharge records
on self-pay and charity care patients for whom a UB-92 had not been sent
to any payor. Some hospitals indicate that such patients are 15% to 25% of
their total patients. One hospital commented that it currently uses a vendor
to take its data and process the data to the HCFA 1450 format. The hospital
pays the vendor a charge per record reformatted. At present only records
to be billed electronically are sent to the vendor. Using the vendor to prepare
records for the council on patients not currently billed electronically will
increase payments to the vendor and hence increase hospital costs. The particular
hospital indicates this would increase the number of records processed by
its vendor by 20-25%. First, we do not believe that the generation of the
required data elements in the proposed rule will, in fact, generate substantial
additional expenses for hospitals. The required data elements are ones that
hospitals must collect on all patients regardless of payment source (e.g.
name, age, diagnosis, procedures, attending physician, disposition at discharge,
detailed charges, etc.). These data are utilized for quality assurance, scheduling,
medication management and many other operational functions of the hospital.
Hospitals do not have one data system for insured patients and a separate
data system for uninsured patients. In creating a bill or discharge record
for a hospital inpatient, the hospital's data system draws data elements
from various data systems in the hospital. The billing system may filter
out patients for whom no payor has been identified, but the data is there
to create the bill. In fact, many uninsured patients receive bills for inpatient
hospital services and the hospital obtains partial, if not total, payment
from these patients. The additional expense is likely to be limited to a
small additional charge per record from a vendor .
Even if the creation of discharge records for uninsured or charity care
patients does generate incremental expense for hospitals, the council believes
the expense is justified by the benefit of having a complete data base for
the hospital and for the community in which the hospital operates. The Legislature
mandated the council to "...develop a statewide health care data collection
system to collect health care charges, utilization data, provider quality
data, and outcome data to facilitate the promotion and accessibility of cost-effective,
good quality health care." (§108.006) We cannot carry out this mandate
by looking only at the health service delivered to insured patients when
we know that Texas has one of the highest percentages of uninsured patients
of any state. We note that the private discharge data system operated by
the Texas Hospital Association requires participating hospitals to submit
discharge records on all patients.
However, the council believes that it is necessary to specify what data
elements are required for each patient. Therefore the council has revised
the proposed rule to require submission of a minimum data set (MDS) on all
patients. The data elements in this minimum data set closely follow the recommendations
of the Texas Hospital Association, with some additional elements necessary
for the assignment of unique patient and physician identifiers. The revised
rule also requires the submission to the council of all other UB-92 data
elements for a patient submitted by the hospital to a third party payor.
The council requests that hospitals provide specific, quantitative comments
on any incremental data processing problems or financial costs they would
incur because of this requirement to submit discharge records on patients
for which they do not currently prepare a UB-92 for a payor.
Section 1301.12(c) Provisions Requiring Electronic Filing of Discharge
Records. Some hospitals objected to the requirement that discharge records
be filed electronically unless the council granted an exemption based on
the hospital's inability to file electronically. One commenter suggested
the rules as proposed exceeded the council's statutory authority. The council
declines to revise the proposed rule in response to these comments. House
Bill 1048 clearly gives the council the legal authority to require electronic
submission of data in most cases. In §108.009(a) the council is instructed
by the Legislature that "The data shall be collected...using electronic data
processing, if available. Later in §108.009(I), the Legislature instructs:
"The council shall develop by rule reasonable alternate data submission procedures
for providers that do not possess electronic data processing capacity." The
council interprets §108.009 to require us to collect hospital discharge
data by electronic means whenever possible, but to define alternative means
for hospitals that do not possess the necessary capacity. §1304.13 of
the proposed rule defines three methods of filing discharge reports: (1)
tapes or diskette, (2) by electronic data interchange and (3) on paper forms.
We have therefore complied with the statute by defining alternative submission
procedures for those who cannot file electronically.
This leaves the question of determining which hospitals do not possess
electronic data processing capacity. We defined the criteria for answering
the question in §1301.15(a)(3). We defined the procedures for a hospital
to show it did not possess the capacity to file electronically in §1301.15(b).
None of the comments suggested that the criteria or the exemption process
were unreasonable or suggested alternatives. We believe the proposed rule
follows the statute and requires no revision.
The council reaffirms its findings that electronic filing is the most economical
means of data submission for both hospitals and the council. The council
requests that hospitals provide specific, quantitative comments on any incremental
data processing problems or financial costs they would incur because of this
requirement to submit discharge records electronically rather than on paper.
The council further requests that if hospitals disagree with the exemption
criteria that they explain their disagreement and suggest alternative criteria.
Section 1301.12(d) For a summary and discussion of the comments received
on the prescribed data submission format see comments related to §1301.19.
Section 1301.12(g) Review of Hospital Documents and Records. The council
wishes to clarify that it has no intention of routinely inspecting hospital
documents and records. The reviews covered by this section of the proposed
rule would occur only when necessary to verify the accuracy and/or completeness
of data submitted by a hospital. One commenter suggested that the council
pay the cost of copying any hospital records it requested pursuant to §1301.12(g).
The Texas Hospital Association (THA) suggested that this section more closely
track the statutory language in §108.007(a) regarding the role of the
Texas Department of Health (TDH). Another noted that any reviews of medical
records could be costly to the hospital and impose an administrative burden.
This section of the proposed rule complies with the statute. Any review of
records by the council is in the nature of an audit of the hospital for the
enforcement of the statute and the verification of the data. We do not believe
it is customary for the State to pay for copies of records in this situation
and decline to do so. On the other hand, the council does not propose to
charge a hospital for the time or expense of state employees required to
conduct a review. We believe the proposed rule provides the "reasonable rules
and guidelines" mentioned in the statute. We believe the reference to TDH
refers to TDH's duty under §108.008(b)(1) and (2) to assist the council
as part of an interagency contract and need not be mentioned in the rule.
Section 1301.13(a) and (b) Schedule for Filing Discharge Reports. One hospital
requested that the deadline for submission of the discharge records for a
calendar quarter be extended from two months to three months. Several hospitals
did not believe they could provide the initial data submission for discharges
during the fourth quarter of 1996 because of set-up requirements and a lack
of final rule from the council. THA commented that the statute requires the
council to test systems for collection of data and to proceed in stages to
build the statewide data system. THA recommended that all of 1997 be considered
a test period for development of systems. Another hospital requested that
hospitals be given a minimum of six months from the time the rules are adopted
to prepare to collect the required data.
The council agrees there is a need to build the data system in phases and
to test the system. The first phase is the collection of hospital discharge
data. We have delayed collection of hospital outpatient and emergency room
data and data from other outpatient facilities until this part of the system
is operational. We have made provisions for the orderly testing of the system.
We cannot begin to test until we have data to test.
The council has revised the proposed rule to provide that no hospital will
be required to submit any data until a minimum of 90 days after the effective
date of the rule. As test data the proposed rule now requires hospitals to
submit a minimum of 30 days and a maximum of 90 days of discharges occurring
in the period January 1 to March 31, 1997. The test data must be submitted
within 90 days after the effective date of the rule or by May 30, 1997, which
ever occurs later. This data will be used only for internal testing. To prevent
its release no public use data file will be created from this data (See §1301.18(c)(1)(C)).
Data for test purposes is drawn from patient discharges occurring in the
first quarter of 1997. Data for discharges occurring in the second quarter
of 1997 will not be collected for testing or actual reporting purposes.
The council has further revised the proposed rule to begin collection of
discharge data for ultimate release with discharges occurring on or after
July 1, 1997. To provide additional time for testing prior to release of
public use data, §1301.18(c)(1)(D) provides that data for the third
quarter of 1997 will not be released until data for the fourth quarter of
1997 is available which would be in August 1998. This appears to offer ample
opportunity for testing and development of the system while not unnecessarily
delaying availability of data to state government and the public.
The rule should not require significant information system modifications
by hospitals. As revised, the rule requires hospitals to submit for insured
patients the social security number and only those data elements already
required by the payors on each specific discharge. For uninsured patients,
the revised rule requires only the minimum data set (MDS). The rule does
not require the collection of race and ethnicity on discharges before January
1, 1998. (See discussion under §1301.19.) Therefore for discharges during
all of 1997, hospitals are being asked to submit National Uniform Billing
Committee standard data elements in the HCFA National Standard Format. The
only additional data element is the patient social security number
In arriving at the requirement that hospitals submit and certify their
discharge records by 60 days after the end of the quarter, the council consulted
with the National Association of Health Data Organizations regarding the
practices in other states operating similar hospital discharge collection
systems. The 60 day period appears reasonable.
Section 1301.13(d) Civil Penalties for Failure to File. The statute at
§108.014(b) states, "A person who fails to supply available data under
Sections §108.009 and §108.010 is liable for a civil penalty of
not less than $1,000 or more than $10,000 for each act of violation. Several
commenters felt the mention of civil penalties in the rules was harsh and
not consistent with the cooperative environment that the council seeks to
develop with health care providers. The council included these references
to civil penalties to give fair notice to all concerned of the Legislature's
action. The application of such penalties is not automatic. The statute provides
that the attorney general would seek such penalties only at the request of
the council. The council has no intention of resorting to enforcement actions
except as a last resort when all other efforts to obtain cooperation and
compliance with the rules have failed. We are mindful that at the start of
every data collection program like this there is much trial and error. We
are interested in fixing problems, not in fixing blame.
Section 1301.14(a) Magnetic Media. One hospital requested that tape cartridges
be listed as an acceptable medium. The council believes the use of certain
tape cartridges are accommodated under §1301.14(a)(1)(C). There are
many types of tape cartridges and similar storage devices and we need to
be sure we have the hardware to read what a hospital chooses to send.
Section 1301.14(a) - (c) Notice of changes in instructions for filing Discharge
Reports. Several commenters requested 90 days notice of changes in council
procedures instead of the 30 days notice in the proposed rule. This change
has been made in the revised rule.
Section 1301.15(a)(1) Exemption as a Rural Provider. Several commenters
objected to the section of the proposed rule that requires a hospital to
apply for exemption as a rural provider. The commenters observed that the
council should be able to use census data to determine which hospitals were
eligible for this exemption and notify the hospitals rather than requiring
them to file exemption requests.
The council agrees that it can make an initial determination of which hospitals
qualify for exemption as a rural provider as new census data becomes available.
An initial determination has been made by the State Census Data Center at
Texas A&M University. The results will be published by the council. The
rule will be revised to indicate that the executive director will make this
determination at least annually and notify hospitals as to who is and is
not exempt as a rural provider. Hospitals that lose the exemption will be
required to begin submitting data for discharges occurring in the next reporting
period that begins 90 days or more after the date of notice of loss of the
exemption. The council will maintain a procedure where a hospital which believes
it has been erroneously denied this exemption can appeal the determination.
Section 1301.15(b) Information Considered by the council in Appeals of
Exemption Decisions. One commenter objected to the provision of the exemption
appeals procedure whereby in an appeal of the decision of the executive director
to the council it will consider only information presented to the executive
director. We disagree with this comment. If the hospital has additional information
relevant to its exemption that the executive director has not seen, it should
first be submitted to the executive director, not to the council. The executive
director may change his/her mind on the basis of the additional information,
eliminating the need for the council to consider the matter.
Section 1301.16(d) Documentation of Edits. One commenter requested that
all edits and acceptance criteria to be applied to discharge reports be incorporated
into the text of the rule. The council declines to do so. We do not believe
this is practical or required by the Administrative Procedures Act. As stated
in the proposed rule we will make copies of all edits and error messages
available to hospitals. We will revise the rule to provide computer code
only if it is the property of the council.
Section 1301.17(a) Certification of Discharge Reports. Several hospitals
commented that the hospital CEO or CFO should not be responsible for certification
of the accuracy and completeness of discharge reports. Some indicated the
council lacked the statutory authority to require such a certification. We
disagree with these comments. We believe §108.007(a) provides the necessary
authority. As with other governmental filings we believe a top executive
officer of the organization should provide the certification so that there
is awareness and accountability by top management. The council has revised
the proposed rule by deleting the second sentence.
Section 1301.17(b) Opportunity for Physician Review of Hospital Discharge
Records. The Texas Medical Association (TMA) commented that the proposed
rule provides the hospital the opportunity to review and verify discharge
data, but does not provide the admitting and treating physicians the same
opportunity. We have revised this section to require the hospital to provide
all their physicians a reasonable opportunity to review the discharge records
prior to certification and to file comments along with the certification
if a physician disagrees with the hospital concerning the accuracy of a discharge
record.
Section 1301.18(b)(5) and (10) Masking of Admission and Discharge Dates.
The Texas Workers' Compensation Commission (TWCC) commented that the removal
of actual admission and discharge dates from the public use data tape would
reduce its utility and recommended leaving exact dates in place. The council
declines to accept this comment in order to protect patient confidentiality.
Admission and discharge dates will be replaced by length of stay on the public
use data tape and a code for day of the week of the admission. Procedure
dates will be replaced by day of stay. Patient birth date will be replaced
by age. The user will know in which quarter of what year the discharge occurred.
Based on the experience of other state health data commissions, we believe
the data, with these substitutions remains very useful and patient confidentiality
is enhanced.
Section 1301.18(b)(7) Inclusion of Uniform Patient Identifier on the Public
Use Data File. Based on the analysis of comments regarding the inclusion
of the uniform patient identifier on the public use data file (see as follows),
the council has determined that §108.013(c)(1) precludes us from including
the uniform patient identifier in the public use data file because any hospital
could use it to deduce the identity of a patient and track the care of that
patient at other facilities. While §108.013(b) of the statute seems
to suggest that the council give providers access to uniform patient identifiers
and have them assign them, we do not intend to do so. Rather, the council
intends to generate the list of uniform patient identifiers and match them
to newly received discharge records to protect patient confidentiality. We
do not believe §108.013(c)(1) precludes the council from utilizing the
uniform patient identifier in analysis performed by the council.
Section 1301.18(b)(12) Inclusion of Uniform Physician Identifier on Public
Use Data File. Several hospitals commented that there was only one physician
at their hospital performing certain procedures and that even if an arbitrary
code was utilized that the physician could be easily identified from that
code. The commenters expressed concern that confidentiality promised to physicians
in the statute may be compromised by the release of physician identifiers
through public use data files or through council reports. The council acknowledges
the problem raised by the comment. The statute under §108.011(c) requires
the council to assign a Uniform Physician Identifier rather than identify
a physician by name. Section §108.013(c) then provides that "Unless
specifically authorized by this chapter, the council may not release and
a person or entity may not gain access to any data...that could reasonably
be expected to reveal the identity of a...physician...." Assuming there are
situations where a physician's identity could be deduced from the Uniform
Physician Identifier, the only specific authorization is found in §108.010(h)
which provides: "A quality outcome data report...must identify the physician
by the uniform physician identifier...."
Given the public use data file as specified in the proposed rule, any hospital
could deduce the Uniform Physician Identifiers for all physicians on its
medical staff, thus revealing their identity and enabling the hospital to
track the physician's activities at other hospitals. Therefore we will revise
the proposed rule to exclude the uniform physician identifier from the public
use data file.
Section 1301.18(c)(1) Release of Public Use Data Tapes. Numerous commenters
opposed the release of public use data files and/or statistical compilations
based on those files. The objections to release of the public use data file
to the public apply whether or not the records include quality adjustment
factors. A separate set of objections were made to the release of public
use data files without quality adjustment factors. The public use data file
is often referred to in the comments as "raw data," as if it had not been
edited, verified or modified to protect confidentiality. There is concern
that the data would be used by unspecified members of the public to produce
invalid and misleading analysis that could be used to damage the reputation
or competitive position of hospitals and physicians. There were several suggestions
that release of public use data tapes either exceeded the statutory authority
of the council or was outside the understandings arrived at between legislators
and affected stakeholders during negotiations over the statute during the
1995 session.
The council disagrees with the characterization of the public use data
file as "raw data." The public use data file will consist of discharge records
which have passed the acceptance criteria and edits established by the council.
It will consist of discharge records which have been reviewed by the submitting
hospital and certified in writing by the CEO or CFO of the hospital as accurate
and complete. This certification will come after the hospital's medical staff
has been afforded an opportunity to review and correct records on which they
are shown as the admitting or treating physician. The public use data file
will have been modified only as necessary to meet statutory provisions for
confidentiality and to allow risk and severity adjustment. If deemed necessary,
the council will have conducted an audit of the discharge records against
the hospital's medical record. By no means can one characterize the public
use data file as "raw data." The council believes the procedures contained
in the proposed rule satisfy the statutory requirement that "The council
shall adopt procedures to verify the accuracy of the data before a report
containing the data is released to the public."§108.011(d).
The council disagrees with the comments suggesting that such release is
not authorized by the statute. The overall thrust of the statute is to make
the data collected by the council available to anyone who wants it subject
only to specific confidentiality provisions protecting the identity of patients
and physicians. The statute makes it a duty of the council to "assure that
data collected is made available and accessible to interested persons." §108.006(a)(6).
This can best be accomplished by release of a public use data file so that
any interested person who wishes can review and analyze the data. The statute
also requires that "The council shall promptly provide data to those requesting
it, subject to the restrictions on access to council data prescribed by §108.010
and §108.013." §108.011(a). The council is aware of business, labor,
educational, research and professional organizations who will request copies
of a public use data file or statistical compilations based on that file.
The council sees nothing in §108.010 or §108.013 that would restrict
this access.
The provisions of the statute concerning confidentiality and general access
to data reinforce the view that the council has the obligation to create
public use data files from the hospital discharge data and make these files
available to the public. The council is required to use data received by
the council for the benefit of the public and to make determinations on requests
for information in favor of access. The information received by the council,
once modified to protect patient and physician confidentiality as required
by the statute, is subject to the open records act. §108.013(a).
There have been suggestions that the council create different levels of
access to the public use data file for different types of users. For example
anyone might have access to a subset of the data elements on the public use
data file, but only qualified researchers would be given access to the full
public use data file; perhaps after review of their research plans. This
is the practice in some states (e.g. California). Other states make their
public use data file available to anyone who wants it and pays the established
fee (e.g. Florida). Both approaches have been in operation for several years
allowing us to observe the results. The council declines this suggestion
because we do not believe that the statute allows us to create different
classes of users. The statute requires that "The council shall promptly provide
data to those requesting it, subject to the restrictions on access to council
data prescribed by §108.010 and §108.013." §108.011(a). Thus
any data that is available to any member of the public is available to all
members of the public. The council is not allowed to restrict access based
on the qualifications of the person or entity requesting the data, or on
the purposes for which that person or entity requests the data. Further,
we decline the suggestion because we are unable to find examples of harm
to any individual caused by giving the public full access to the public use
data file.
No commenter has cited any example of any instance where the release of
public use data files in other states where such data has been available
for many years has resulted in any harm to any provider or any confusion
or misdirection of any consumer. Examples cited of controversial uses of
data were the HCFA hospital mortality reports, reports of CABG outcomes published
by the states of New York and Pennsylvania and a recent report published
by the Florida Agency for Health Care Administration. All of these are reports
prepared by government agencies, with severity adjustment, review by all
providers and all other safeguards. None of these reports were the result
of release of public use data files to the public. In fact, most private
use of public use data files in other states is internal use of the data
by hospitals, employers, insurance carriers and benefit consultants which
never results in a published report available to the public. Medical or other
scientific research based on public use data files are normally subjected
to extensive professional peer review before any publication in a professional
journal.
Section 1301.18(c) Release of Public Use Data File Containing Less Than
One Year of Data. One commenter objected to the initial release of public
use data for only six months because this data file would miss seasonal fluctuations,
might have limited numbers of records from small providers and might misrepresent
the frequency of rare conditions and procedures. The council disagrees that
these are reasons to totally withhold data from the public. We agree that
these are valid cautions which should be included in all documentation accompanying
the data until a full year is available. However, there are other uses of
the data for which we believe six months is adequate (e.g. patient origin
and destination patterns, hospital market shares for major diagnostic classifications).
Since the statute requires us to resolve policy decisions in favor of public
access we do not intend to with hold data that is valid for some common uses
because the volume of data may not be sufficient for other uses.
Section 1301.18(c) Format for Public Use Data File. One commenter correctly
noted that the public use data file will not be the same as the format in
which the data was submitted and requested that the rule specify the format
for the public use data file. We disagree with this comment. We do not believe
the Administrative Procedures Act requires this sort of information to be
adopted in a rule. We note that the Texas Department of Health (TDH) has
not adopted rules specifying the format of each and every publication and
data file it makes available to the public. The format of the public use
data file is a matter to be dealt with in the council's internal procedures.
Once established, the council will make the format information available
to the public.
Section 1301.18(d) Release of Public Use Data Files Without Quality Adjustment
Factors. Numerous commenters expressed concern that hospital discharge data
would be released through public use tapes and through requests to the council
for statistical tabulations without severity adjustment measures. Some commenters
believe it is beyond statutory authority or legislative intent to release
data without severity adjustment. There is concern that the data without
severity adjustment could be misleading to users and would be used by unspecified
members of the public to produce invalid and misleading analysis that could
be used to damage the reputation or competitive position of hospitals and
physicians. The commenters request that no hospital discharge data be released
without severity adjustment scores.
The council will not release any public use data tapes without risk and
severity adjustment scores from the risk and severity adjustment systems
adopted by the council.
We expect to meet soon with the technical advisory committee named by the
council to assist with this process. We have the work of other states which
have recently selected severity adjustment programs (e.g. Utah, Florida)
on which to build. We anticipate seeking the assistance of an outside contractor
to provide the analysis and other staff work in support of the selection
process. While we anticipate having to extend the January 1, 1997 deadline
for selection of a system, as allowed by statute, we anticipate the selection
process can be completed in 1997.
Any severity adjustment system will be a embodied in a computer program
that creates one or more severity adjustment scores based on an analysis
of patient-specific and facility specific data elements collected from hospitals
under this proposed rule. Once the severity adjustment program is selected
it will therefore be possible to apply it to all hospital discharge records
that have already been collected by the council. Thus any public use data
released in August 1998 will include severity adjustment scores that have
been thoroughly reviewed and commented upon by all interested parties.
Section 1301.18(f) Provision of copies of Provider-specific Data Requests.
One hospital requested that in addition to monthly notice of requests that
the executive director's summary should provide list the data requested.
This seems unnecessary. All requests for statistical compilations will be
in writing and will be maintained by the council for two years. Any person
may request a copy of any data request filed.
Section 1301.18(g) Written Comments from Providers. Several commenters
noted that the rule did not explicitly provide for release of provider comments
on the data along with release of a public use data file or a statistical
compilation prepared from that file. We agree that such procedures are necessary.
We will revise the proposed rule by adding subsection (g) to require the
executive director to provide all comments submitted by providers relating
to any data released.
Section 1301.19(a) Data Format. Comments were received from many hospitals
that the format for data submission was non-standard and would require substantial
reprogramming of computer systems on the part of Texas hospitals requiring
extensive lead time and subjecting them to great expense. The commenters
generally requested that hospitals be able to submit data in whatever form
they chose, leaving it to the council to translate the data to a standard
format. Other comments were received from TDH suggesting that the format
in the proposed rule did not correspond to current ANSI-X.12, Medicare or
Medicaid formats.
In response to these comments, the council conferred with the Texas Health
Information Network (THIN), the electronic bill clearinghouse which is a
subsidiary of Blue Cross Blue Shield of Texas (BCBST). THIN receives electronically
approximately 60 million health claims per year, including Medicare claims,
the majority being from Texas hospitals and physicians. Based upon information
obtained from THIN, the council intends to require data to be submitted by
Texas hospitals in a standard format which is the same as that in the proposed
rule, with minor changes. The reasons for this decision are as follows:
The data format in the proposed rule is the National Standard Format defined
by the Health Care Finance Administration for the electronic submission of
inpatient hospital bills covering the UB-92 data set (HCFA 1450 flat file,
version 4.0).
We will revise the proposed rule to adopt the HCFA format by reference.
We will revise the proposed rule to allow hospitals to submit data in the
current or immediately preceding HCFA format.
The data format maps the UB-92 data elements and provides unused fields
for additional data elements. The council recognizes that some hospital personnel
who work with the UB-92 are unfamiliar with the HCFA 1450 data format. The
council will make available to anyone requesting it a crosswalk between the
elements and the HCFA 1450 format.
No reprogramming of existing hospital data systems is necessary for most
hospitals to submit UB-92 data in this data format. The council requests
that any hospital that does not have the capability, internally or through
a current vendor, to electronically submit inpatient bills in the HCFA 1450
format to identify itself through a comment and explain what cost it would
incur to add this capability.
Because the National Standard Format is promulgated by the federal government,
the council is able to adopt this format by reference and make provision
for automatic incorporation of revisions by the federal government. WE can
also increase reporting flexibility by agreeing to accept the current version
or the immediately previous version of the National Standard Format.
The council does intend to modify the data format in the proposed rule
in the following ways. First, the proposed rule required the patient's social
security number to be reported at Record 30, Field 07. This field is defined
"Certificate/Social Security Number/Health Insurance Claim/ Identification
Number." For some patients the social security number of the insured party
would normally appear here. For other patients, the hospital would have to
over write another data item in preparing data for the council. To eliminate
this inconvenience, the patient's social security number will be reported
at Record 70, Field 28. This field is currently not assigned to any data
element. Second, it is possible that a commercial clearing house will be
contracted by TDH with the concurrence of the council to perform data collection
and editing services. To distinguish records submitted to a clearinghouse
for payment from records submitted for reporting to the council, an appropriate
code will be reported at Record 01, Field 20.8, Position 183.
Section 1301.19(c) Definition of Data Elements. Comments were received
from the Texas Department of Health and from various hospitals that the proposed
rule did not adequately define data elements contained in §1301.19.
Generally we disagree with these comments because in the proposed rule the
data element definitions follow each field. The commenters did not cite specific
data elements which they felt were ambiguous or undefined. With a few exceptions
discussed as follows, the definitions of data elements that are part of the
UB-92 data set are taken verbatim from the National Uniform Billing Data
Element Specifications by the National Uniform Billing Committee as published
in the latest version of the Texas UB-92 Manual available at the time the
proposed rule was published.
Since the publication of the proposed rule, the Congress has passed and
the President has signed into law the Health Insurance Portability and Accountability
Act of 1996 (P.L. 104-191). Section 1171(c)(3) extended a formal consultative
role to the National Uniform Billing Committee and imposed requirements on
the Secretary of the Department of Health and Human Services relative to
the use of standards published by National Uniform Billing Committee (NUBC)
in carrying out her duties under the act. We note that HCFA is a member of
the NUBC and substantially influences its decisions. The Texas State Uniform
Billing Committee is an extension of NUBC and does not unilaterally modify
its standards. Further, in creating the council the Legislature specifically
instructed it to use standards established by the NUBC to the maximum extent
possible. Therefore the council believes it can adopt by reference the Texas
UB-92 Manual and its future revisions as a source of definitions of data
elements not otherwise defined in the council's rules. These revisions have
been incorporated in the proposed rule.
The data elements included in the proposed rule that are not part of the
UB-92 data set and thus are not covered in the National Uniform Billing Data
Element Specifications are THCIC facility identifier, THCIC Uniform Payor
Identification Number, source of payment code, patient's social security
number, race and ethnicity. (Note that insured's social security number is
utilized in the UB-92 data set as the default value for commercially insured
patients where a policy ID number is unavailable. See Form Locator 60.)
The council has determined that it is not necessary to require hospitals
to supply the THCIC Facility or Payor Identifiers for each discharge. With
other data elements that hospitals normally submit to payors the council
can assign these identifiers to each discharge record and reduce the burden
on the hospitals. Therefore hospitals would enter in the fields where the
proposed rule called for these identifiers the data normally submitted to
the payor on that patient.
For race (Record 20, Field 2) and ethnicity (Record 20, Field 26) the current
definitions specified by the United States Census Bureau were printed in
the proposed rule.
The proposed rule utilized a set of codes for "source of payment code"
(Record 30, Field 04) which was a modification of a code set utilized by
Blue Cross Blue Shield of Texas. The BCBST code set did not include a category
for self-pay and did not distinguish all categories of HMO patients. In developing
the code set in the proposed rule the council looked to the code set currently
in use by the State of Florida in its hospital discharge system and blended
the two code sets. We note that the BCBST can be extended to capture all
the necessary categories and we have revised the code set in the proposed
rule. We have identified the necessary categories and we have revised the
code set as shown in §1301.19(c)(4). We have deferred assignment of
single letter codes to these categories until adoption of the final rule.
The Texas Medical Association indicated there was a problem in requiring
the reporting of bills on workers' compensation patients in a standard format
because the Texas Workers' Compensation Commission requires the use of non-standard
CPT codes for services. The council is aware of the variation on the standard
CPT-4 code set adopted by the Texas Workers' Compensation Commission in its
latest Medical Fee Guideline. We do not believe this will be a problem with
regard to the hospital discharge data system because procedures on inpatient
hospital bills for workers' compensation patients utilize ICD-9 procedure
codes. The variance from standard CPT-4 codes only affects bills for outpatient
services which are beyond the scope of the proposed rule.
Section 1301.19(c) Required data elements. The proposed rule stated that
all data elements were required unless otherwise indicated. Other than comments
on collection of social security number, race and ethnicity, we received
no comments during the formal comment period concerning which data elements
should be required and which should not. However, there have been numerous
comments that the data requested in the proposed rule was excessive and burdensome.
We have revised the proposed rule to identify a minimum set of data elements
that are required for all patients, regardless of insurance or payment status.
In deciding which data elements to require we have considered the lists of
required data elements utilized by the current THA patient discharge system
and by other state hospital discharge systems. We have considered the data
elements required in order to calculate severity adjustment scores. We have
considered the minimum data elements required for use of the data by employers,
health care providers and public health researchers.
Beyond the required minimum data set for each patient, the rule requires
the hospital to submit on each patient all information submitted to the payor(s)
for that patient. This data should not be thought of as optional. However,
because it will differ from patient to patient, the lack of any data element
beyond the minimum required data set will not prevent the discharge record
from being included in the council's data base or in the public use data
file.
Section 1301.19(e)(3) Patient Data - Collection of Patient Name. One commenter
indicated its policy was to redact patient names and replace them with patient
account numbers or medical record numbers before releasing data. The collection
of patient names is necessary in order to assign a uniform patient identifier
that will enable patients to be tracked across multiple admissions to multiple
facilities. A patient account or medical record number is unique to the hospital
that assigns it and cannot assist in linking a discharge record to another
for the same patient. The council believes it has statutory authority to
require hospitals to submit this data, just as the Texas Workers' Compensation
Commission has for many years, after taking fully into account state and
federal confidentiality requirements. We also believe the statute and proposed
rules establish sufficient safeguards to patient confidentiality which will
be observed by the council in the implementation of its information systems.
Section 1301.19(e)(3) Patient Data - Collection of Social Security Number.
Many hospitals objected to the requirement that hospitals collect the patient's
social security number. They further objected to identifying the reason no
social security number was available for patients without one. Some said
this would require additional work by hospital staff. Others said requesting
it might be offensive to the patient for various reasons, including it as
an attempt to screen out aliens. Hospitals also said the social security
number should not be collected because it was not part of the UB-92 data
set. The council does not accept these comments.
We believe that almost all hospitals routinely collect the social security
number from all patients that have one and enter it into their data systems.
No hospital claimed it did not. The objection therefore appears to be more
one of releasing the data to collecting it.
We do not believe the statute restricts the council to collection of data
elements that are part of the UB-92 data set where the additional data sets
are within the general statutory authority of the council to collect. We
read the intent of the statute as encouraging us to use UB-92 definitions
for data elements found in that data sets rather than creating new definitions
which could be confusing.
The council believes the use of the social security number as a patient
identifier has become so routine in health care that few, if any, patients
could sincerely claim to be offended by the request for this data. We have
revised the instructions on what to do if the patient has no social security
number because they are not a U.S. resident by taking advantage of the Special
Condition code added to the newest edition of the Texas UB-92 Manual, "Patient
is non-U.S. Resident" (Form Locator 24-30(25)).
The council understands that social security numbers are not universally
available or reliable. However, the council believes that in order to analyze
patterns of inpatient hospital use, including transfers, readmissions and
movement between acute and non-acute hospital units that it must do its best
to construct a uniform patient identifier as defined in the statute §108.002(15)).
The council believes that while the social security number is not sufficient
standing alone as the uniform patient identifier, that it is extremely valuable
as one of several patient data elements that can be used together to create
usable identifiers. Thus, the council believes that the benefits of requiring
reporting of the patient's social security number, or the reason it is unavailable,
outweigh the costs.
The social security number is part of the minimum data set. The rule requires
that the hospital supply either a social security number or a code indicating
the reason a number is unavailable. A discharge record would be rejected
only if the field was blank or contained invalid characters.
Section 1301.19(e)(3) Patient Data - Collection of Race and Ethnicity Data.
Many hospitals objected to the requirement that they be required to collect
and report race and ethnicity data on patients. Some objected to the lack
of clear definitions of the terms. Some objected to the lack of clear instructions
on whether the patient was to be asked to classify himself or herself or
whether the hospital staff person was to be required to make a judgment.
Some objected that the council did not have statutory authority to collect
data elements that were not part of the UB-92 data set. Some felt patients
might find the question offensive. Some objected that collecting this information
would require reprogramming of data systems, revision of forms and retraining
of staff; all at significant expense to the hospitals. One hospital objected
that the request for or availability of this data might lead to claims of
discrimination.
The code sets for race and ethnicity used in the proposed rule are the
standard code sets of the U.S. Census Bureau. It is the intention of the
council to revise its code sets for these data elements in the future to
be uniform with the Census Bureau. The proposed rule has been revised to
clarify that initially the patient, or the person speaking for the patient,
is to be asked to make the classification in response to questions from hospital
staff. If the patient declines to answer, the hospital staff person is instructed
to make the classifications using their best judgment based on available
information. If the hospital uses its best judgment, the council has no intention
of disputing that judgment. The revised language also provides a statement
whereby the hospital may inform the patient that the questions are required
by the State of Texas.
The council disagrees with the comment that it lacks statutory authority
to require reporting of race and ethnicity as part of the hospital discharge
data system. In §108.009(h) we are required to coordinate data collection
with the data collection formats used by hospitals and other providers. The
NUBC is cited as an example of the publisher of one such format. We note
that we have complied with this requirement for data elements defined by
the NUBC. However, §108.009(a) gives the council the authority to require
reporting of those data it deems appropriate. We are not limited to the UB-92
data set. We would only be outside our statutory authority if the statute
forbade us from requiring hospitals to report a data element or if the data
element had no reasonable relationship to legislated mission of the council.
We do not believe either condition puts us outside our statutory authority
with regard to race and ethnicity.
We believe the benefits to the State of collecting data on race and ethnicity
outweigh the costs to the hospitals of collecting them. There is a well developed
literature that has shown statistically significant differences in the health
care provided to racial and ethnic groups for similar medical conditions,
even after controlling for insurance status. Some of the differences in health
care appear to affect outcomes, while others do not. We believe availability
of this data will potentially assist the State in making cost-effective,
good quality health care accessible to all Texans.
We disagree that patients will find these questions offensive. The questions
have become extremely common. Similar questions appear on census questionnaires,
employment applications, certain banking applications, school enrollment
applications and vital statistics records. We believe most persons who are
members of racial and ethnic minority groups understand the purpose of the
questions is to enable government to monitor the actions of various organizations
in the community to detect and prevent discrimination.
Unlike social security number, the council acknowledges that race and ethnicity
are not part of the UB-92 data set and are not routinely collected by hospitals
at present. Time and expense will be required to reprogram computers and
train hospital staff to collect this data. In order to prevent the collection
of these two data elements from delaying commencement of the overall hospital
discharge data system, we have revised the proposed rule to require collection
of these data elements on patient discharged on or after January 1, 1998.
This delay will also give the 1997 Legislature the opportunity to provide
the council guidance on this matter as it sees fit.
Comments not Related to Specific Sections of the Proposed Rule
Duplication of Texas Hospital Association Patient Discharge System. One
hospital commented that the proposed rule would duplicate the efforts of
THA and also duplicate efforts of the Houston and Dallas Business Groups
on Health to build discharge data bases. The commenter suggests coordination
to create one quality and outcomes reporting initiative.
We believe a purpose of the statute is to create a hospital discharge data
base as part of a broader health care information system that, subject to
patient and physician confidentiality provisions, is available to all members
of the public. None of the hospital discharge data bases mentioned by the
commenter are available to the public as public use data files. All are owned
and controlled by private organizations who have not made them generally
available to the public and have not proposed to do so.
We see the creation of a statewide hospital discharge data base as eventually
eliminating the need for many organizations to create separate proprietary
data bases at considerable expense and with considerable duplication of effort.
Some of the strongest support for creation of the council came from business
and consumer interests who felt it would be more efficient and beneficial
to create a central state data base. Outside the largest metropolitan areas,
employers do not appear to be able to build their own data systems and thus
lack information to guide their health care purchasing decisions. As the
council's data base becomes available the organizations currently building
data bases will have the opportunity to decide if they need to continue their
separate collection efforts, or if they can rely on the state to collect
the data and devote their resources to analysis of the data.
Severity Adjustments Should Consider Teaching Hospital Status. Several
commenters noted that the statute §108.010(f) requires any severity
adjustment mechanism to consider a hospital's teaching status, and that this
was not addressed in the proposed rule. The proposed rule does not specify
the severity adjustment mechanism, and is not requires to do so. Since teaching
hospital status is hospital-specific and not patient specific, we do not
need to include this as a data element on each discharge. The council has
access to lists of teaching hospitals which can be utilized when making severity
adjustments.
Obligation to provide Consumer Education. Several commenters noted that
the council has the duty to provide consumer education and that this was
a reason not to release a public use data file. The council does have a broad
mission to provide health education information to consumers. This obligation
is not specific to hospital discharge data, but also includes HEDIS data
and other data elements that may become part of a state health care information
system. The council has established a standing committee to develop its consumer
education program. We disagree that there is any inconsistency between the
council's duty to provide consumer education and the proposed release of
public use data files to hospitals, employers, researchers and the general
public.
Legal Liabilities Created for Hospitals by Submitting Patient Data. One
commenter was concerned that an improper release of data by the council which
violated patient confidentiality could create legal liability for the hospital
that originally submitted the data. The same concern is expressed with regard
to any improper release of data from medical records which was obtained during
a data verification effort. We do not believe there is cause for concern
on this issue. We do not see a legal basis for anyone to claim a hospital
has liability for release of data which was made available to the state in
compliance with state and federal statutes and rules. Any liability would
lie against the person or entity responsible for the improper release as
provided in §108.013. The hospitals should be concerned about liability
attaching to them if patient confidentiality was breached as a result of
voluntarily submitting data to a private data collection program.
Cost to Hospitals of Compliance. Many commenters took exception to the
cost estimates contained in the preamble to the proposed rule. One commenter
provided a detailed cost estimate of costs to hospitals which totaled about
$17 million per year. We have considered this estimate and do not believe
it is reasonable. It ignores the use in the proposed rule of the national
standard format and the National Uniform Billing Committee definitions of
UB-92 data elements. It ignores the fact that 40% of hospital discharges
are Medicare patients whose bills are almost all currently submitted electronically
in the national standard format. We have recognized the potential difficulty
in collecting data on race and ethnicity and make no current requirement
for reporting these elements pending legislative guidance. We have also relieved
the hospital of responsibility for assigning a uniform payor identifier or
a uniform facility identifier. The commenter was in error in stating that
a source of payment code is a new data element. It is currently part of the
national standard format. The commenter also asserts that any modification
in any data system must be made separately at each Texas hospital. This is
incorrect. We expect hospitals will make use of their current arrangements
with their corporate parents (e.g. Columbia) and their existing clearinghouse
vendors to remap data elements as necessary. The actual number of entities
submitting data to the council will be far fewer than the number of hospitals
reporting. This substantially reduces the cost of any data system modifications
to utilize the national standard format. We would be interested to learn
of any hospital billing systems which are currently on the market or in use
which are unable to produce an electronic discharge record in the national
standard format utilized by Medicare.
Conflict with the Administrative Simplification Provisions of the Kennedy-Kassebaum
Legislation. One commenter suggested that Texas suspend implementation of
the hospital discharge data system because there might be conflicts with
the recently passed Health Insurance Portability and Accountability Act of
1996 (P.L. 104-191). We disagree with this comment. Subtitle F of the federal
legislation requires the Secretary of Health and Human Services to adopt
standards within 18 months of the effective date of the act. The standards
will include a format and data elements for health claims or equivalent encounter
information which would cover the discharge record defined in the proposed
rule. The Secretary must also adopt standards providing a unique health identifier
for each individual, employer, health plan and health care provider. (Subtitle
F, §1173.)
The council has taken into account the requirements and likely course of
implementation of §1173 in drafting the proposed rule. Since HCFA already
requires use of the national standard format for billing Medicare, it will
be in the interest of the federal government to initially adopt this as the
data format for health claims. We believe there is no real alternative to
the adoption of the National Uniform Billing Committee definitions of the
data elements on the UB-92, and HCFA has had substantial influence on the
development of this standard. As an identifier for individual patients, we
believe it is reasonable to assume the Secretary will use the social security
number, when available, and define an alternative for those without a social
security number. We are not requiring hospitals to adopt uniform facility
or health plan identifiers. Therefore we do not believe there is adequate
reason to postpone carrying out the instructions of the Texas Legislature
to develop a hospital discharge data system. We also note that once the standards
are adopted by the Secretary, there will be two years allowed for implementation.
This will allow ample time for any required revisions to the council's data
system.
Adequate Time for Public Comment. Several commenters stated that because
of when they had received a copy of the proposed rule and because of the
multiple parties within hospitals who needed to review the rule and provide
comments that there had not been adequate opportunity for public comment.
The council notes that it had several meetings with representatives of THA,
(Texas Medical Association) TMA and other interest groups leading up to
the publication of the proposed rule. The council took the initiative to
call a public hearing and worked with the THA and others to promote distribution
of the proposed rules to people who may not regularly read the Texas Register.
Though the time was short between the appearance of the proposed rule in
the Texas Register and the public hearing, we believe that by now, all hospitals
and most other stakeholders are fully aware of this rulemaking process. Because
we are making substantial revisions to the proposed rule, we will republish
it and thus open a new comment period. We believe this should alleviate any
concerns with the opportunities for public input.
Based upon information provided by the Texas Department of Health, Ronald
Luke, chair of the hospital discharge data committee, Texas Health Care Information
Council, has determined that for the first five-year period the sections
are in effect there will be fiscal implications. The costs to state government
may average up to $450,000 per year. A portion of these costs may be recaptured
through revenues generated by user fees for products produced through implementation
of these rules. The revenues to be generated through user fees are expected
to be positive but as yet undetermined. Costs may be less if TDH is able
to contract for data collection services at a lower cost than it could perform
the services internally. There will be no fiscal implications for local governments
except to the extent that local governments operate hospitals that are required
to submit data per these rules.
Dr. Luke has also determined that for each year of the first five years
the sections are in effect, the public benefits anticipated as a result of
enforcing and administering the sections will be public access to hospital
discharge data regarding health care charges, utilization data, provider
quality data, and outcome data to facilitate the promotion and accessibility
of cost-effective, good quality health care; to provide an information and
data source for providers, consumers, purchasers, and policy makers alike;
to promote informed decision making in providing, utilizing, and purchasing
health care and for developing and implementing health care policy throughout
the state; and to provide a means of benchmarking throughout the state to
promote continuous quality improvement by providers to ensure good quality,
accessible health care to the citizens of Texas.
There will be additional, marginal costs to providers. Few, if any, of
the hospitals required to submit data under this rule can be classified as
small businesses. Almost all Texas hospitals currently have the ability to
submit the required data electronically in the required format. Under the
proposed rule, all hospitals shall file discharge reports by electronic filing
(tape, diskette or modem) unless the hospital receives an exemption letter
from the Council. Any costs of submitting data to THCIC may be offset in
part by the reduced need for hospitals to pay to participate in private discharge
data collection efforts.
The Texas Department of Health, Texas Hospital Association, Blue Cross/Blue
Shield, health data organizations in 17 states, and 46 hospitals within the
State of Texas were contacted for information regarding provider costs in
providing data and information required on uniform billing (UB) form 92 (the
format required by these rules). These entities reported a range of costs,
from 2 to 3 cents per discharge up to 75 cents per form submitted. For providers
that have discharge data bases which are similar to that required for completion
of the UB form 92 and which are fully computerized, the cost averages 2 to
3 cents per patient discharged from the hospital; for those that have systems
which are not fully computerized or which do not maintain data bases similar
to that required for completion of the UB form 92, the cost averages 50-55
cents per hospital discharge; and for those that have little or no computer
support and process all claims manually, the cost increases to about 75 cents
per hospital discharge. To the extent that hospitals are not currently collecting
all of the data required by these rules, they may incur additional costs.
Similarly, to the extent that hospitals utilize outside vendors, they may
incur additional costs. As a consequence, the financial impact will be most
significant on small hospitals with little or no automated data processing
capability. For all of the hospitals required to submit data under these
rules within the State of Texas, the total cost is expected to be approximately
$326,000 per year. There is no anticipated effect on local employment.
The new sections are proposed under the Health and Safety Code,
§108.6-108.13, which provide the Texas Health Care Information Council
with the authority to establish rules to implement and administer a state-wide
health data collection system.
These new sections affect Health and Safety Code, Chapter 108.
§1301.11.Definitions.
The following words and terms, when used in this chapter shall have
the following meanings, unless the context clearly indicates otherwise.
Batch file
- A set of computer records as specified in §1301.19
of this title (relating to Discharge Reports - Records, Data Fields and
Codes) which contains one or more discharge files and other required header
and trailer records. A batch contains discharge files for only one hospital.
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-payment charges
to a health maintenance organization enrollees by providers paid by capitation
or salary in a health maintenance organization.
Council
- The Texas Health Care Information Council.
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.
Discharge file
- A set of computer records as specified in
§1301.19 of this title (relating to Discharge Reports - Records, Data
Fields and Codes) relating to a specific patient. Except for some normal
newborn infants there will be one or more discharge files for each inpatient.
Discharge report
- A computer file as defined in § 1301.19
of this title (relating to Discharge Reports - Records, Data Fields and
Codes) periodically submitted on or on behalf of a Hospital in compliance
with the provisions of this chapter.
Electronic filing
-The submission of computer records in machine
readable form by modem transfer from one computer to another or by recording
the records on a nine track magnetic tape, computer diskette or other magnetic
media acceptable to the executive director.
Error
- Data submitted on a discharge report which are not
consistent with the format and data standards contained in this rule or with
editing criteria established by the executive director, or the failure to
submit required data.
Executive director
- The chief administrative officer of the
council, or, in the event the council is without an executive director, the
person designated by the chairperson of the council to perform the functions
and exercise the authority of the executive director.
Facility identifier
- A unique number assigned by the council
to each health care facility in the state. For hospitals this will be the
hospital's state license number. Where a hospital operates multiple facilities
under one license number, the council will assign a suffix for each separate
facility.
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).
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.
Geographic identifier
- A set of codes and accompanying maps
prepared by the Council covering Texas and adjacent states with each code
consisting of two or more zip codes, a set of codes and accompanying maps
prepared by the council covering the rest of the United States consisting
of three digit zip codes, a set of codes and accompanying maps prepared by
the council covering Canada and Mexico consisting of a separate code for
each state or province and a set of codes for each of the other countries.
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.
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 will encompass persons licensed under
various Texas practice statutes, such as psychologists, chiropractors, dentists
and podiatrists who are authorized to admit or treat patients.
Patient control number
- A number assigned to each patient
by the hospital which appears on each computer record in a patient discharge
file. 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. The
council deletes or encrypts this number to protect patient confidentiality
prior to release of data.
Physician
- An individual licensed under the laws of this
state to practice medicine under the Medical Practice Act (Vernon's Texas
Civil Statutes, Article 4495b).
Provider
- A physician, health care facility or health maintenance
organization.
Public use data file
- A data file composed of discharge files
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.
Required minimum data set
- The data elements which hospitals
are required to submit in a discharge file for each inpatient regardless
of whether or not the hospital would have prepared a bill for the inpatient.
The required minimum data set is specified in §1301.19(e) of this title
(relating to Discharge Reports - Records, Data Fields and Codes).
Rural provider
- A provider located in a county with a population
of not more than 35,000 according to the most recent United States Bureau
of the Census estimate, those portions of extended cities that the United
States Bureau of the Census has determined to be rural, or an area that is
not delineated as an urbanized area by the United States Bureau of the Census.
Submission
- A set of computer records as specified in §1301.19
of this title (relating to Discharge Reports - Records, Data Fields and Codes)
that constitutes the discharge report for one or more hospitals.
Submitter
- The person or organization which physically prepares
discharge reports for one or more hospitals and submits them to the council.
A submitter may be a hospital or an agent designated by a hospital or its
owner.
Uniform patient identifier
- A random number assigned to an
individual patient which remains constant across hospitals and inpatient
admissions.
Uniform payor identifier
- A unique number assigned by the
council to every third party payor of UB-92 bills. Where ever possible the
council will use established numbering systems such as that maintained by
the National Association of Insurance Commissioners.
Uniform physician identifier
-A unique number assigned by the
council to any physician or other health professional who is reported as
admitting or treating a hospital inpatient which remains constant across
hospitals.
§1301.12.Collection of Hospital Discharge Data.
(a)
All hospitals in operation for all or any of the reporting
periods described in §1301.13 of this title (relating to Schedule for
Filing Discharge Reports) shall submit discharge files on all inpatients
to the Council. Hospitals owned by the federal government and hospitals exempted
as rural providers may submit hospital discharge files.
(b)
All inpatient discharges shall be reported. Except as noted
as follows, one or more discharge files shall be submitted for each patient
for each discharge covering all services and charges from admission through
discharge.
(1)
Separate discharge files shall normally be submitted for
mothers and newborns. Hospitals are not required to create a separate discharge
file for a normal newborn infant if the delivery is covered by a third party
payor and the third party payor does not require separate bills for the mother
and the infant. For any birth where there is no third party coverage, separate
discharge files are required for the mother and the infant.
(2)
Where a hospital has issued interim and final bills
covering a single patient discharge, the hospital shall submit separate discharge
files corresponding to each bill.
(3)
Where a patient has been served in multiple units
of a hospital (e.g. acute care, skilled nursing care, comprehensive medical
rehabilitation, substance abuse) during a single continuous stay, some third
party payors require that separate bills be prepared for services in acute
and sub-acute units while others do not. Where a patient has third party
coverage, the discharge files submitted by the hospital shall correspond
to the bills submitted to the payor. Where a patient has no third party coverage,
the hospital shall submit a separate discharge file for each unit.
(4)
For all patients for which the hospital prepares one
or more bills for inpatient services, the hospital shall submit a discharge
file corresponding to each bill containing the required minimum data set
and all other data elements included on the bill whether included because
of the requirements of third party payors or because of hospital policy.
For all patients for which the hospital does not prepare a bill for inpatient
services, the hospital shall submit a discharge file containing the required
minimum data set.
(c)
All hospitals shall file discharge reports by electronic
filing unless the hospital receives an exemption letter from the Council.
(d)
All hospitals shall submit discharge files and discharge
reports in the format specified in §1301.19 of this title (relating
to Discharge Reports - Records, Data Fields and Codes).
(e)
Hospitals shall submit discharge reports, data certifications,
exemption requests and other required information to the council or its agents
at physical or telephonic addresses specified by the executive director.
The executive director shall notify all hospitals and submitters in writing
and by publication in the
Texas Register
at least 30 days before any change in the addresses.
(f)
Hospitals may submit discharge reports, or may designate
an agent to submit the reports. If a hospital designates an agent, it shall
inform the council of the designation in writing at least 30 days prior to
the agent's submission of any discharge report. The hospital shall inform
the council in writing at least 30 days prior to changing agents or making
the submissions itself. Designation of an agent does not relieve the hospital
of responsibility for compliance with this chapter or other related law.
(g)
If requested by the council, a hospital shall provide the
executive director and his agents access to, copies of and/or information
from the hospital documents and records underlying and documenting the discharge
reports submitted, as well as other patient related documentation deemed
necessary to conduct audit hospital data to verify its accuracy and reliability.
Each request from the council shall detail the reasons for such request,
provide the hospital with at least 14 days advance notice, and ensure that
confidentiality of patient records is maintained.
§1301.13.Schedule for Filing Discharge Reports.
(a)
For discharges occurring on or after July 1, 1997, hospitals
shall file discharge reports according to the following schedule unless a
hospital has received an exemption letter from the council.
(1)
Each discharge report covering inpatient discharges occurring
between January 1 and March 31, inclusive, shall be submitted no later than
June 1 of the calendar year in which the discharge occurred.
(2)
Each discharge report covering inpatient discharges
occurring between April 1 and June 30, inclusive, shall be submitted no later
than September 1, of the calendar year in which the discharge occurred.
(3)
Each discharge report covering inpatient discharges
occurring between July 1 and September 30, inclusive, shall be submitted
no later than December 1 of the calendar year in which the discharge occurred.
(4)
Each discharge report covering inpatient discharges
occurring between October 1 and December 31, inclusive, shall be submitted
no later than March 1 of the year following the year in which the discharge
occurred.
(b)
On or before May 30, 1997, hospitals shall submit a discharge
report drawn from inpatient discharges occurring between January 1, 1997
and March 31, 1997, inclusive. This discharge report shall be used for test
and certification purposes only. The discharge report may include all discharges
for the quarter, but the hospital is only required to submit discharge files
covering discharges for any consecutive 30 days of the quarter.
(c)
Extensions to processing due dates may be granted by the
executive director for a maximum of ten working days in response to a written
request signed by the hospital's chief executive officer. Requests must be
in writing, must be received at least five working days prior to the due
date and must be accompanied by adequate justification for the delay.
(d)
Failure to file a discharge report on or before the due
date without an extension, is punishable by a civil penalty pursuant to Health
and Safety Code, §108.14.
(e)
The other provisions of this section not withstanding,
no hospital shall be required to file a discharge report sooner than 90 calendar
days after the effective date of this rule.
§1301.14.Instructions for Filing Discharge Reports.
(a)
Magnetic Media - A discharge report may be filed on computer
diskettes, nine track tapes or other magnetic media approved by the executive
director. All discharges shall be reported using the same file and record
formats specified in §1301.19 regardless of medium.
(1)
Media specifications are:
(A)
Diskette: MS-DOS formatted; PC Text file (ASCII); Record
length = 192 characters, fixed; 3.5 inch diskette, 1.4 megabyte, high density.
(B)
Nine track tape: Density = 1600 or 6250 BPI, nine track;
Collating sequence = EBCDIC or ASCII; Record length = 192 characters, fixed;
Blocking = unblocked; Labeling = no label.
(C)
Other magnetic media: Discharge reports may be filed on
other magnetic media only with the prior written approval of the executive
director. The executive director will not normally approve any medium which
the Council is not currently equipped to read.
(2)
Hospitals shall submit no more than one tape
or two diskettes per submission, with the following external identification
affixed:
(A)
Hospital name.
(B)
Facility identifier.
(C)
Reporting period for discharges.
(D)
Number of records by record type.
(E)
Tape density: 1600/6250 BPI (if applicable).
(F)
Collating sequence for tapes (if applicable).
(G)
The description: "DISCHARGE DATA".
(3)
Data for more than one hospital may be submitted
on a single tape if the submitter provides external identification items
in paragraph (2)(A)-(D) of this section for each hospital.
(4)
In addition to the provisions of this section, the
council shall document instructions for filing discharge reports on magnetic
media and shall make this documentation available to hospitals at no charge
and to the public for the cost of reproduction. The council shall notify
hospitals or their designated agents at least 90 days in advance of any change
in instructions for filing discharge reports on magnetic media. The council's
instructions shall follow Department of Information Resources standards for
magnetic media established under Chapter 201 of this Title.
(b)
Electronic Data Interchange: Discharge reports may be filed
by modem using electronic data interchange (EDI). All discharges shall be
reported using the same file and record formats specified in §1301.19
of this title (relating to Discharge Reports - Records, Data Fields and Codes)
regardless of the medium of transmission. Record length is 192 characters
for all records. The council shall document instructions for filing discharge
reports by EDI and shall make this documentation available to hospitals at
no charge and to the public for the cost of reproduction. The council shall
notify hospitals and their designated agents at least 90 days in advance
of any change in instructions for filing discharge reports by EDI. The council's
instructions shall follow Department of Information Resources standards for
EDI.
(c)
Paper Forms: Only hospitals granted an exemption from electronic
filing of discharge reports may file discharge reports using paper UB-92
billing forms. Hospitals using paper forms are required to provide all data
elements specified in §1301.19 of this title (relating to Discharge
Reports - Records, Data Fields and Codes).
(1)
All UB-92 forms filed shall be on the form currently approved
by the federal Health Care Finance Administration. Photocopies are not acceptable.
(2)
Hospitals shall submit no more than one batch of paper
forms per submission, with the following external identification affixed:
(A)
Hospital name;
(B)
Facility identifier;
(C)
Reporting period for discharges;
(D)
Number of forms; and
(E)
The description: "DISCHARGE DATA".
(3)
In addition to the provisions of this section,
the Council shall document instructions for filing paper UB-92 forms and
shall make this documentation available to hospitals at no charge and to
the public for the cost of reproduction. The council shall notify hospitals
or their designated agents at least 90 days in advance of any change in instructions
for filing paper forms.
§1301.15.Exemptions from Filing Requirements.
(a)
Types of Exemptions
(1)
Exemption as a Rural Provider - All hospitals except those
owned by the federal government shall submit discharge reports to the council
unless the council determines that the hospital is a rural provider. The
executive director shall make a determination of which hospitals are entitled
to this exemption at least annually and shall notify qualifying hospitals
by publication in the Texas Register and by regular United States mail. Hospitals
which are not initially given an exemption may apply for an exemption. This
exemption, if granted, may be revoked by the council should the hospital
cease to meet the criteria for exemption based upon the most current data
issued by the United States Bureau of the Census. Hospitals that cease to
be exempted as rural providers shall be responsible for submitting discharge
files on all discharges that occur 30 days after notice is given. The initial
discharge report shall not be due until 90 days after notice is given. Subsequent
discharge reports are due as specified in §1301.13(a) of this title
(relating to Schedule for Filing Discharge Reports).
(2)
Exemptions from Quarterly Filing of Discharge Reports
- Hospitals that wish to submit discharge reports to the council more often
than quarterly may do so by requesting an exemption to the standard submission
schedule. The council may also issue general exemptions based on the processing
arrangements for data collection. Exemption requests meeting the following
criteria will normally be approved.
(A)
The exemption request includes the specific schedule on
which the hospital will make its discharge reports which will usually be
daily, weekly or monthly.
(B)
The exemption request states the medium in which submissions
will be made.
(C)
The exemption request will not result in data on any discharge
being submitted to the council at a later date than it would have been if
the standard schedule been followed.
(D)
The hospital agrees to adhere to the schedule specified
in the exemption request until the hospital notifies the executive director
in writing that it wishes to end the exemption and report according to the
standard schedule, or until a new exemption letter is issued.
(3)
Exemption from Electronic Filing of Discharge
Reports - The council will grant exemptions from electronic filing of discharge
reports only when a hospital can demonstrate that it lacks electronic data
processing capacity and that electronic filing of discharge reports imposes
an unreasonable financial burden upon the hospital. If granted, the exemption
is valid for one year and must be renewed annually by the hospital. The exemption
from electronic filing of discharge reports does not change the data the
hospital is required to file on each discharge as specified in §1301.19
of this title (relating to Discharge Reports - Records, Data Fields and Codes),
nor the schedule for submission specified in §1301.14 of this title
(relating to Instructions for Filing Discharge Reports). Exemptions from
electronic reporting to the council will not normally be granted unless
(A)
the hospital shows that it does not currently electronically
file UB-92 bills with any payor, or has not done so in the last 12 months
prior to the request for exemption; and
(B)
the hospital shows that it could not cost-effectively
submit UB-92 bills electronically to its payors and to the Council utilizing
internal staff or utilizing contractors for this function.
(b)
Requests for exemptions shall be submitted and processed
using the following procedures.
(1)
A hospital requesting an exemption shall submit to the
executive director a letter requesting the exemption and providing all information
necessary to establish the hospital's entitlement to the exemption. The exemption
request shall be signed by the chief executive officer of the hospital who
shall certify that all information contained in the request is true and correct.
(2)
The executive director shall review the request for
exemption. The executive director may request additional information from
the hospital relevant to the exemption request. Within 30 days of receipt
of a request, the executive director shall issue a letter granting or denying
the exemption. If denied, the letter shall state in detail the reasons for
the denial. The executive director shall notify council members of exemptions
requested and the disposition of these requests for information only.
(3)
If the executive director denies an exemption request
the hospital may
(A)
Resubmit the request along with any additional information
or analysis the hospital deems relevant to the executive director. The resubmission
shall be considered in the same manner as an initial submission; or
(B)
Appeal the executive director's decision to the council.
The hospital may make an appeal directly to the council. In making its determination,
the council will consider only those facts and issues which have been previously
presented to the executive director. The council will decide exemption appeals
by majority vote of members present.
(4)
The executive director may revoke any type of
exemption if facts indicate that a hospital no longer meets the criteria
required for an exemption. The executive director shall give the hospital
written notice of the revocation at least 30 days prior to the effective
date of the revocation. The notice shall include a detailed statement of
the facts on which the revocation is based. A hospital may challenge the
revocation of its exemption by:
(A)
Requesting the executive director to reconsider the revocation
by submitting any information or analysis the hospital deems relevant to
the executive director in writing at least ten days prior to the effective
date of the revocation; and
(B)
If the executive director does not agree that the exemption
should continue, by appealing the executive director's decision to the council.
In making its determination, the council will consider only those facts and
issues which have been previously presented to the executive director. The
council will decide exemption appeals by majority vote of members present.
§1301.16.Acceptance of Discharge Reports and Correction of Errors.
(a)
To verify the accuracy of all discharge files prior to
public release, the executive director shall establish procedures for the
review of all discharge reports to determine whether the report is acceptable,
as required by Health and Safety Code, §108.11.
(b)
Upon receipt of a discharge report, the executive director
shall determine if it satisfies minimum criteria for processing. If it does
not, the executive director shall return the report and state the deficiencies
in writing within ten days of receipt. The hospital shall resubmit the report
within ten days of notification by the executive director. A discharge report
does not meet minimum standards for processing under the following circumstances.
(1)
The physical media and labeling do not conform to the specifications
in §1301.14 of this title (relating to Instructions for Filing Discharge
Reports).
(2)
The physical media are unreadable due to physical
damage.
(3)
The file structure does not conform to the specifications
in §1301.19 of this title (relating to Discharge Reports - Records,
Data Fields and Codes).
(c)
Correction of Errors
(1)
The executive director shall review all discharge reports
accepted for processing and will process all discharge files against the
editing criteria established by the this rule and by the executive director.
Within 30 days of receipt of an accepted discharge report the executive director
shall notify the hospital in detail of all errors detected in the discharge
report.
(2)
Within 30 days of receiving initial notice of errors
in a discharge report, the hospital shall correct all discharge files containing
errors, add any discharge files determined to be missing from the initial
discharge report and resubmit the discharge files. If the hospital disagrees
with any identified error, the hospital shall submit written justification
of the correctness or completeness of its data. Each hospital shall submit
such modified and/or additional discharge files as may be required to allow
the chief executive officer or chief financial officer to certify the discharge
report as required by §1301.17 of this title (relating to Certification
of Discharge Reports). Corrections to a discharge report shall be submitted
in the same medium and format as the original discharge report unless the
executive director approves another medium.
(3)
Within ten days of receiving corrections to a discharge
report from a hospital, the executive director shall notify the hospital
of any remaining errors. The hospital shall have ten days from receipt of
this notice to correct the errors noted or submit a written explanation of
why the data should be deemed correct and complete. This process shall be
repeated until the executive director is satisfied that the data submitted
by the hospital is substantially accurate and until the hospital is able
to certify the discharge report as required by §1301.17 of this title
(relating to Certification of Discharge Reports).
(d)
The executive director will document and the council will
approve all acceptance and editing criteria utilized in reviewing discharge
reports. If acceptance and editing criteria are incorporated into computer
software, and if the software is the property of the council, the executive
director will make copies of the portions of the software containing the
criteria available on paper or magnetic media. The executive director will
shall make this information available to submitters without charge and to
others for the cost of reproduction.
(e)
Failure to correct a discharge report which has been filed
but contains errors or omissions within the due dates in §1031.13 of
this title (relating to Schedule for Filing Discharge Reports) is punishable
by a civil penalty pursuant to Health and Safety Code, §108.14.
§1301.17.Certification of Discharge Reports.
(a)
The chief executive officer or the chief financial officer
of each hospital shall certify that the discharge report for each quarter
is accurate using forms supplied by the council.
(b)
The certification shall represent that a complete review
of hospital records was accomplished to assure the accuracy of the discharge
report and any corrections submitted, that all errors and omissions known
to the hospital have been corrected, and that to the best of their knowledge
and belief, the data submitted is accurate and complete. The certification
shall also represent that the hospital has provided physicians and other
health professionals on its medical staff a reasonable opportunity to review
the discharge files for which they were the admitting or treating physician
or other health professional prior to certification, have corrected any errors
brought to the hospital's attention and have included with the discharge
report any comments on the accuracy of the data submitted by physicians or
other health professionals. Written explanation of any unresolved disagreements
with the executive director concerning the accuracy and completeness of the
data at the time of the certification shall be attached to the certification
form.
(c)
Each hospital must file its certification of each quarter's
data with the council within six months following the last day of the reporting
quarter. Extensions to this period will not be granted.
(d)
Failure to timely file a certification of discharge data
previously submitted is punishable by a civil penalty pursuant to Health
and Safety Code, §108.14.
§1301.18.Hospital Discharge Data Release.
(a)
Council records are public records under Government Code,
Chapter 552, except as specifically exempted by Health and Safety Code, §108.10
and §108.13, and are available for public inspection during normal business
hours. Copies of such records may be obtained upon request and upon payment
of user fees established by the council. Discharge files in the original
format they are submitted to the council are exempt from disclosure pursuant
to Health and Safety Code, §108.10 and §108.13, and shall not be
released. Likewise, patient specific data collected by the council through
audits of hospital data shall not be released.
(b)
Creation of public use data file - The executive director
will create a public use data file by creating a single record for each inpatient
discharge and adding, modifying or deleting data elements in the following
manner:
(1)
Delete patient and insured name, address, certificate and
social security data elements. Delete patient control and medical record
numbers. Assign geographic identifier and county code.
(2)
Convert patient birth date to age.
(3)
Convert admission and discharge dates to a length
of stay measured in days and a code for the day of the week of the admission.
(4)
Convert procedure and occurrence dates to day of stay
values.
(5)
Delete physician and other health professional names
and numbers.
(6)
Convert payor names and identification numbers to
uniform payor identifiers.
(7)
Convert employer name and address data to a Standard
Industrial Classification Code.
(8)
Delete provider name address and identification numbers.
Assign facility identifier.
(9)
Convert all procedure codes to ICD-9-CM.
(10)
Add risk and severity adjustment scores.
(c)
Release of files and statistical compilations based on
the public use data file. The council shall promptly provide data to those
requesting it, subject to restrictions imposed by Health and Safety Code,
§108.10 and 108.13 as interpreted by the council's rules.
(1)
The executive director will make available a public use
data file on magnetic media for each quarter not later than seven months
after the end of the quarter.
(A)
The executive director shall release discharge files from
hospitals that have certified the data as required by §1301.17 of this
title (relating to Certification of Discharge Reports). A hospital's failure
to execute the certification form after six months shall not prevent the
executive director from releasing the hospital's data if he believes the
data submitted is reasonably accurate and complete. The executive director
shall not include in the public use data file records derived from hospital
discharge files which contain material errors. The executive director will
include with the public use data file information on the number of discharge
files received from each hospital and the number of discharge files from
each hospital included on the public use data file.
(B)
If additional discharge files become available after the
initial release of the public use data file for any quarter, the executive
director will add these records to the public use data file and make the
additional records available to the public.
(C)
The other sections of this rule not withstanding, the
executive director shall not create a public use data file from the discharge
reports covering discharges occurring in the first or second quarters of
1997. It is the intent of the council to utilize this data only for testing
and calibration of its data processing systems and to allow hospitals the
opportunity to test and calibrate their own data reporting systems.
(D)
The other sections of this rule not withstanding, the
executive director shall not create or release a public use data file from
discharge reports covering discharges for the third quarter of 1997 until
a public use data file covering discharges for the fourth quarter of 1997
is created and released. The council will initially release six months of
data in order to provide a more reliable body of data for analysis and decision-making
and to make available public use data files on a quarterly schedule thereafter.
(2)
The public may request the executive director
to prepare statistical compilations based on public use data files. The executive
director will take the steps necessary to fill these requests by providing
the public with on-line access to public use data files and statistical report
software and by preparing statistical compilations to user specifications.
(3)
The council shall establish standard forms for ordering
public use data files and statistical compilations based on public use data
files. The council shall provide for computer to computer access to allow
persons to make requests using electronic mail and to download public use
data files and statistical compilations based on public use data files. The
council shall also fill requests on magnetic media and on paper as specified
by the requestor. The council's service standard shall be to normally fill
requests within five working days of receipt of the request and payment for
the request. The executive director shall establish procedures to accommodate
standing orders for recurring requests.
(4)
The council shall adopt a fee schedule for filling
requests for public use data files and statistical compilations based on
public use data files, and shall update this fee schedule at least annually.
In adopting a fee schedule the council shall strike a reasonable balance
between the statutory goals of improved public access to health care data
(Health and Safety Code, §108.013(a)), and the goal of providing part
of the costs of operation of the council through user fees (Health and Safety
Code, §108.12(b)). The executive director shall establish procedures
for providing price quotations to requestors and for collecting user fees
prior to filling requests. These procedures may include the establishment
of advance deposit accounts by requestors. This fee schedule may include
restrictions on distribution, republication or reuse of the data in ways
that would diminish user fees to the Council.
(5)
The council shall not charge Texas state agencies
a fee for data requested solely for the internal use of the agency to comply
with Health and Safety Code, §108.12(b). Prior to filling the request
of a state agency without fee, the executive director shall secure an interagency
agreement imposing restrictions on distribution, republication or reuse of
the data in ways that would diminish user fees to the council.
(6)
The executive director shall establish procedures
for screening all requests to assure that filling the request will not violate
the provisions of Health and Safety Code, §108.13(c).
(d)
The data elements specified for discharge reports in §1301.19
of this title (relating to Discharge Reports - Records, Data Fields and
Codes) do not constitute "Provider Quality Data" as discussed in Health and
Safety Code, §108.10. Statistical compilations compiled from public
use data files may be released with or without either discharge-specific
or aggregate provider quality data. Statistical compilations without provider
quality data are not subject to the restrictions imposed on the council by
Health and Safety Code, §108.10. Public use data files and statistical
compilations compiled from public use data files with provider quality data
may only be released subject to the restrictions in Health and Safety Code,
§108.10, and rules adopted by the council to implement this section
of the statute.
(e)
A public use data file or a statistical compilation compiled
from public use data files which is specified by the requestor shall not
be considered a "report issued by the Council" as referenced in Health and
Safety Code, §108.11(f). No opportunity for review or comment by providers
whose discharges may be included in the file or statistical compilation is
required prior to release of the data to the requestor.
(f)
Requests for data files and statistical compilations based
on public use data files including data on one or more provider are matters
of public record and copies of all requests shall be maintained by the council
for two years from the date of receipt. The executive director will transmit
monthly a summary of all requests received to all hospitals submitting discharge
data to comply with Health and Safety Code, §108.11(e).
(g)
With any public use data file or any statistical compilation
prepared by the council, the executive director shall attach all comments
submitted by providers which relate to any data included in the file or compilation.
§1301.19.Discharge Reports - Records, Data Fields and Codes.
(a)
Discharge reports shall be submitted in the national standard
flat file format for inpatient hospital bills defined by the United States
Department of Health and Human Services, Health Care Finance Administration
(HCFA); commonly known as the HCFA 1450. HCFA updates this format from time
to time by issuing new versions. The council will accept discharge reports
in the latest version or in the immediately preceding version. At the effective
date of this rule, the latest version was version 4.1 and the immediately
preceding version was version 4.0. The council will make detailed specifications
for these formats available to submitters and to the public.
(b)
Except as otherwise provided in this section, discharge
reports shall be submitted using the national uniform billing data element
specifications as developed by the National Uniform Billing Committee (NUBC)
as published by the State Uniform Billing Committee (SUBC) with instructions
specific to Texas third party fiscal intermediaries in the Texas UB-92 Manual.
The NUBC revises these data element specifications from time to time and
the SUBC publishes revisions showing the effective date for changes to each
data element. Hospitals shall submit discharge reports using the data element
specifications in effect as of