Part 16. TEXAS HEALTH CARE INFORMATION COUNCIL

Chapter 1301. HEALTH CARE INFORMATION

Subchapter A. COLLECTION AND RELEASE OF HOSPITAL DISCHARGE DATA

25 TAC §§1301.11, 1301.12, 1301.14 - 1301.19

The Texas Health Care Information Council (Council) proposes amendments to §§1301.11, 1301.12, 1301.14, 1301.15, 1301.16, 1301.17, 1301.18, and 1301.19 in part to comply with the change in billing claim format as required by the Public Law 104-191, Health Insurance Portability and Accountability Act of 1996 (HIPAA), and to provide access to more Public Use Data elements regarding external causes of injury, charges, service utilization, and to clarify language.

The proposed amendments to §1301.11 add definitions of "ANSI 837 Institutional Guide," "HCPCS" and "HIPPS," delete the definition of "Batch file," amend the definitions of : "Data Format," "Discharge file," "Discharge claim," "Discharge report," "Facility Type Indicators," "Patient control number," "Public Use Data File," "Required minimum data set" and "Submission." The proposed amendment to Data Format aligns the chapter with amendments in §1301.11(8), §1301.14(c) and §1301.19(a)(3). The proposed amendments to "Discharge File" and "Discharge report" align the terminology used in this chapter with the language used in the American National Standards Institute's Accredited Standards Committee X12N Form 837 Health Care Institutional Claims Guide (ANSI 837 Institutional Guide). The amended definitions of "Discharge file" and "Discharge claim" are made to clarify confusing language within this chapter. The proposed amendment to "Facility Type Indicator" adds "Long Term Acute Care" facilities. The proposed amendment to the term "Required minimum data set" clarifies that the specified data element list only includes the claim level data elements and does not specify the other data elements that are required to submit a compliant electronic discharge claim to the Council. The proposed amendment to the definition of the term "Submission" is intended to clarify that a submission is a transfer of the required data elements to constitute a discharge report.

The Council proposes to amend §1301.12 (a) and (b) and (d), §1301.15(a), §1301.16(a) and (c), §1301.17(a), §1301.18(a) and (e), and §1301.19(e) as a result of proposing to substitute the definition of "Discharge claim" and as a result of amending the definitions of "Patient control number," "Public Use Data File," and "Required minimum data set."

The Council proposes to amend the references sections in §§1301.12(a) and (b)(4) as a result of the renumbering of subsection in §1301.19.

The Council proposes to amend §1301.14(a)(1) and (2) and §1301.14(b) by removing the record length requirement because the ANSI 837 Institutional Guide has no such requirement.

The Council proposes to amend §1301.14(a)(2)(B) to add in the phrase "THCIC 6-digit Identifier" to clarify which facility identifier is required on the magnetic media.

The Council proposes to delete the following sections requirements for submitting on paper in §1301.11(8), §1301.14(c), §1301.15(a)(3) and the option of submitting on paper in §1301.19(a)(3).

The Council proposes to delete §1301.15(a)(4) as the only data-reporting standard would be the ANSI ASC X12N Form 837.

The Council proposes to amend §1301.18(c)(11) as follows: Replace "Source of Payment, Non-Standard Codes" with "Claim Type Indicator Code" as the combination of the Standard and Non-Standard Source of Payment Codes are included in the ANSI 837 Institutional Guide's "Claim Type Indicator Code"; Delete "Source of Payment Code, Standard Codes"; Expand the number of occurrences for "Other Diagnosis Codes," "Other Procedure Codes" and "Other Procedure Dates" to allow up to 24 codes for each; Remove the previous individually identified "Other Diagnosis Codes" (2) through (8), from the list along with the "Other Procedure Codes" (2) through (5) ; Add the following new data elements: "Encounter Identifier," "Service Line Revenue Code," "Service Line Procedure Code," "HCPCS/HIPPS Procedure Code," "HCPCS/HIPPS Procedure Modifiers," "Service Line Charge Amount," "Service Line Unit Code," "Service Line Unit Count," "Service Line Non-Covered Charge Amount," and "Patient Country"; Delete the qualifying phrases "Beginning with 2000 data" for "Uniform Physician Identifier assigned to Attending Physician" and "Uniform Physician Identifier assigned to Operating or Other Physician"; Delete the qualifying phrase "Beginning with third quarter 2000" from previous data elements relating to charges.

The Council proposes to amend §1301.18(e)(2) to only allow late claims from one quarter prior to the quarter being processed for public use distribution by replacing the word "year" with "quarter."

The Council proposes to amend §1301.19 as follows:

Require in subsection (a) that health care facilities submit discharge reports in the ANSI 837 Institutional Guide, in subsection (a)(1) eliminate the option.

In subsection (a)(1) delete the option to submit discharge claim data in the previously acceptable HCFA UB92 Electronic File format.

Delete the first two sentences in subsection (b) because they duplicate language contained in §1301.19(a).

In subsection (c) inserting the phrase "ANSI 837 Institutional Guide" for "Texas UB-92 Manual" and for the phrase "HCFA UB-92 Electronic Format."

In subsection (c)(1) provide the location in ANSI 837 Institutional Guide and acceptable codes for submitting the race code of a patient.

In subsection (c)(2) provide the location in ANSI 837 Institutional Guide and acceptable codes for submitting the ethnicity code of a patient.

Delete Social Security Number in subsection (c)(3) as the data element has a specified location in the ANSI 837 Institutional Guide.

Delete location of the "Standard Source of Payment Code" and the "Non-standard Source of Payment Code" in subsection (c)(4) as the data elements have been replaced by the "Claim Type Indicator Code," which has a specified location in the ANSI 837 Institutional Guide.

Delete location of the "Facility Name," "Facility address" and "Facility city" (respectively) in subsection (c)(5)-(7) as the ANSI 837 Institutional Guide has specified locations for these data elements.

Delete subsection (d) as it is not needed and the ANSI 837 Institutional Guide specifies the characteristics and formatting of each data element.

Reorder and renumber the required data elements list in subsection (d). Also in subsection (d):

"Patient Address Line 1" replaces "Patient Address";

"Patient Account Number" replaces "Patient Control Number";

"Statement Dates" replaces "Statement Covers Period From" date and Statement Covers Period Through" date;

"Other Diagnosis Codes - up to 24 occurrences (all applicable)" replaces "Other Diagnosis Codes (all applicable)";

"External Cause of Injury (E-Codes) - up to 9 occurrences (if applicable)" replaces External cause of injury (E-Code) (if applicable)";

"Other Procedure Codes - up to 24 occurrences (if applicable)" replaces "Other Surgical Procedure Code (if applicable);

"Other Procedure Dates - up to 24 occurrences (if applicable)" replaces "Other Surgical Procedure Dates";

"Attending Physician Last Name," "Attending Physician First Name" and "Attending Physician Middle Initial" replaces "Attending Physician Name";

"Operating Physician or Other Practitioner Last Name," "Operating Physician or Other Practitioner First Name" and "Operating Physician or Other Practitioner Middle Initial" replaces "Operating or Other Physician Name";

"Service Provider Name" replaces "Facility Name";

"Service Provider Address Line 1"and "Service Provider Address Line 2 (if applicable)" replaces "Facility Address";

"Service Provider City" replaces "Facility City";

"Service Provider ZIP" replaces "Facility ZIP";

Add the following data elements to subsection (d):

"Patient Address Line 2 (if applicable)";

"Patient Country";

"Claim Filing Indicator Code";

"Payer Name";

"National Plan Identifier";

"Admission/ Start of Care Hour"; "Patient Discharge Hour";

"Occurrence Span Code - up to 24 occurrences (if applicable)";

"Occurrence Span Code Associated Date - up to 24 occurrences (if applicable)";

"Occurrence Code - up to 24 occurrences (if applicable)";

"Occurrence Code Associated Date - up to 24 occurrences (if applicable)";

"Value Code - up to 24 occurrences (if applicable)";

"Value Code Associated Amount - up to 24 occurrences (if applicable)";

"Condition Code - up to 24 occurrences (if applicable)";

"Total Claim Charges";

Revenue Service Line Details (up to 999 service lines) (all applicable)

"Revenue Code";

"Procedure Code";

"HCPCS/HIPPS Procedure Modifier 1";

"HCPCS/HIPPS Procedure Modifier 2";

"HCPCS/HIPPS Procedure Modifier 3";

"HCPCS/HIPPS Procedure Modifier 4";

"Charge Amount";

"Unit Code";

"Unit Quantity";

"Unit Rate";

"Non-covered Charge Amount";

"Service Provider Primary Identifier - Provider Federal Tax ID (EIN) or National Provider Identifier (when HIPAA rule is implemented)";

"Service Provider State"; "Service Provider Secondary Identifier - THCIC 6-digit Hospital ID assigned to each facility"

Delete the data element "Reason for no Social Security number" in subsection (d) as it is not a data element in the ANSI ASC X12N Form 837 Institutional Guide or Standard.

Replace the HCFA UB92 Record and Field locations in subsection (f)(1-11) with the corresponding ANSI 837 Institutional Guide, loop and segment identifiers.

Delete subsection (g) as it is no longer required.

Jim Loyd, Executive Director, has determined that for the first five-year period that the proposed sections are in effect, there will be anticipated costs to the State of $29,400. The changes to the Council's application software are included as part of the cost of the recently renewed contract with Commonwealth Clinical Systems for auditing/editing and warehousing the health care data collection system for hospital discharge data. The Council anticipates a one-time programming cost to hospitals associated with the requirements in the following paragraphs: §1301.19 (c)(1), (2) and (3). The other specified changes are resultant to ANSI 837 Institutional Guide requirements and the state owned hospitals would be including those changes as result of converting to the HIPAA compliancy requirements. The following hospitals estimate a cost of $4,900 to make the initial changes to their system to accommodate the THCIC 837 submission requirements: The University of Texas, M.D. Anderson Cancer Center, Texas State Hospitals (for 10 hospitals), South Texas Hospital, Texas Center for Infectious Disease, the University of Texas Health Center in Tyler, Harris County Psychiatric Hospital. The University of Texas, Medical Branch Hospital at Galveston estimates no additional costs to make the initial change to its systems. The Council anticipates no additional recurring costs for submitting this information. The costs are based upon an estimated average salary of computer personnel in Texas of $34.40/hr: ($32.76 [average of four major Metropolitan Areas, Austin-San Marcos, Dallas-Fort Worth, Houston-Galveston-Brazoria and San Antonio] with an estimated five percent increase, Bureau of Labor Statistics for Texas, 2002), and based on an estimated maximum of 40 hours programming time for the additional data elements.

Mr. Loyd has also determined that, for the first five-year period the proposed sections are in effect, there will be $4,900 in anticipated costs to affected local governments as a result of enforcing or administering the amended sections. The anticipated costs are for local governments that own hospitals or hospital districts and are required to report data to the Council. The initial cost is dependent upon each hospital's information systems capabilities and their staff resources. The Council anticipates a one-time programming costs associated with the requirements in the following paragraphs: §1301.19 (c)(1), (2) and (3) of $4,900. The Council does not anticipate any recurring costs to the their information systems.

Mr. Loyd also has determined that, for each year the of the first five year period that the rules are in effect, there will be $4,900 additional costs to persons or hospitals who are required to comply with the amended section. The Council anticipates a one-time programming costs associated with the requirements in the following paragraphs: §1301.19 (c)(1), (2) and (3) of $4,900.

Mr. Loyd also has determined that, for each year of the first five-year period the proposed sections are in effect, the anticipated public benefit will be greater ease in identifying individual encounters in the Public Use Data File and viewing individual revenue codes submitted by hospitals, continuation of collection of racial and ethnic data on patients, and increased information on external cause of injuries on inpatients.

Comments on the proposed sections may be submitted to Bruce M. Burns, D.C., Program Specialist, Texas Health Care Information Council, Two Commodore Plaza, 206 East 9th Street, Suite 19.140, Austin, Texas 78701. Comments must arrive no later than 31 calendar days from the date that these proposed sections are published in the Texas Register .

The Council will entertain requests for a public hearing until the 25th day after the date the rules are published in the Texas Register .

The amendments are proposed under the Health and Safety Code, §108.006 and §108.009. The Council interprets §108.006 as authorizing it to adopt rules necessary to carry out Chapter 108, including rules concerning data dissemination requirements. The Council interprets §108.009 as authorizing the Council to adopt rules regarding the collection of data from hospitals in uniform submission formats in order for the incoming data to be substantially valid, consistent, compatible and manageable.

The Health and Safety Code, §§108.002, 108.006, 108.009, 108.010 and 108.011 are affected by these amendments.

§1301.11.Definitions.

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise.

(1) Accurate and Consistent data--Data that has been edited by the Council and subjected to provider validation and certification.

(2) ANSI 837 Institutional Guide--American National Standards Institute, Accredited Standards Committee X12N, 837 Health Care Institutional Claim Implementation Guide.

(3) [ (2) ] Attending Physician--The individual licensed under the Medical Practice Act (Occupations Code, Chapter 151) who would normally be expected to certify and recertify the medical necessity of the services rendered or the licensed health professional primarily responsible for the care of the patient during the hospital episode. For Skilled Nursing Facility (SNF) services, the attending physician is the individual who certifies the SNF plan of care.

[ (3) 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.]

(4) Certification Process--The process by which a provider confirms the accuracy and completeness of the encounter data set required to produce the public use data file as specified in §1301.17 of this title (relating to Certification of Discharge Reports).

(5) Charge--The amount billed by a provider for specific procedures or services provided to a patient before any adjustment for contractual allowances, government mandated fee schedules or write-offs for charity care, bad debt or administrative courtesy. The term does not include co-payments charged to health maintenance organization enrollees by providers paid by capitation or salary in a health maintenance organization.

(6) Comments--The notes or explanations submitted by the hospitals, physicians or other health professionals concerning the provider quality reports or the encounter data for public use as described in the Texas Health and Safety Code, §108.010(c) and (e) and §108.011(g) respectively.

(7) Council--The Texas Health Care Information Council.

(8) Data format--The sequence or location of data elements in an [ on a paper form or ] electronic record according to prescribed specifications.

(9) Discharge--The formal release of a patient by a hospital; that is, the termination of a period of hospitalization by death or by disposition to a residence or another health care provider.

(10) Discharge claim [ 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. "Discharge claim" corresponds to the ANSI 837 Institutional Guide term, "Transaction set."

(11) 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. "Discharge report" corresponds to the ANSI 837 Institutional Guide terms, "Communication Envelope" or "Interchange Envelope."

(12) DRG--Diagnosis Related Group

(13) EDI--Electronic Data Interchange--A method of sending data electronically from one computer to another. EDI helps providers and payers maintain a flow of vital information by enabling the transmission of claims and managed care transactions.

(14) Edit--An electronic standardized process developed and implemented by the Council to identify potential errors and mistakes in data elements by reviewing data fields for the presence or absence of data and the accuracy and appropriateness of data.

(15) Electronic filing--The submission of computer records in machine readable form by modem transfer from one computer to another (EDI) or by recording the records on a nine track magnetic tape, computer diskette or other magnetic media acceptable to the executive director.

(16) Error--Data submitted on a discharge report which are not consistent with the format and data standards contained in this section or with editing criteria established by the executive director, or the failure to submit required data.

(17) Ethnicity--The status of patients relative to Hispanic background. Hospitals shall report this data element according to the following ethnic types: Hispanic or Non-Hispanic.

(18) 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.

(19) Facility Type Indicators--An indicator that provides information to the data user as to the type of facility or the primary health services delivered at that facility (e.g., Teaching, Acute Care, Rehabilitation, Psychiatric, Pediatric, Cancer, Skilled Nursing , Long Term Acute Care or other Long Term Care Facility). A facility may have more than one indicator. Hospitals may request updates to this field.

(20) Geographic identifiers--A set of codes indicating the public health region and county in which the patient resides.

(21) HCPCS--HCFA's Common Procedure Coding System (HCFA-Health Care Finance Administrations (Now called Centers for Medicare and Medicaid Services)).

(22) [ (21) ] Health care facility--A hospital, an ambulatory surgery center licensed under Chapter 243 of the Health and Safety Code, a chemical dependency treatment facility licensed under Chapter 464 of the Health and Safety Code, a renal dialysis center, a birthing center, a rural health clinic or a federally qualified health center as defined by 42 United States Code, §1396(1)(2)(B).

(23) HIPPS--Health Insurance Prospective Payment System.

(24) [ (22) ] 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.

(25) [ (23) ] ICD--International Classification of Disease.

(26) [ (24) ] 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.

(27) [ (25) ] Operating or Other Physician--The "physician" licensed by the Texas State Board of Medical Examiners, or "other health professional" licensed by the State of Texas who performed the principal procedure or performed the surgical procedure most closely related to the principal diagnosis.

(28) [ (26) ] Other exempted provider--A hospital exempt from state franchise, sales, ad valorem, or other state and local taxes that does not seek or receive reimbursement for providing health care services to patients from any source, including the patient or any person legally obligated to support the patient; a third party payer; or Medicaid, Medicare, or any other federal, state or local program for indigent health care.

(29) [ (27) ] Other health professional--A person licensed to provide health care services other than a physician. An individual other than a physician who admits patients to hospitals or who provides diagnostic or therapeutic procedures to inpatients. The term encompasses persons licensed under various Texas practice statutes, such as psychologists, chiropractors, dentists, nurse practitioners, nurse midwives, and podiatrists who are authorized by the hospital to admit or treat patients.

(30) [ (28) ] Patient account [ control ] number--A number assigned to each patient by the hospital, which appears on each computer record in a patient discharge claim [ 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.

(31) [ (29) ] Physician--An individual licensed under the laws of this state to practice medicine under the Medical Practice Act, Occupations Code, Chapter 151.

(32) [ (30) ] Provider--A physician or health care facility.

(33) [ (31) ] Provider quality data--A report or reports authored by the Council on provider quality or outcomes of care, as defined in Chapter 108 of Health and Safety Code, created from data collected by the Council or obtained from other sources.

(34) [ (32) ] Public use data file--A data file composed of discharge claims [ 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.

(35) [ (33) ] Race--A division of patients according to traits that are transmissible by descent and sufficient to characterize them as distinctly human types. Hospitals shall report this data element according to the following racial types: American Indian, Eskimo, or Aleut; Asian or Pacific Islander; Black; White; or Other.

(36) [ (34) ] Required minimum data set--The list of data elements which hospitals are required to submit in a discharge claim [ file ] for each inpatient stay in the hospital. The required minimum data set is specified in §1301.19(d) of this title[ . ] (relating to Discharge Reports --Records, Data Fields and Codes). This list does not include the data elements that are required by the ANSI 837 Institutional Guide to submit an acceptable discharge report. For example: Interchange Control Headers and Trailers, Functional Group Headers and Trailers, Transaction Set Headers and Trailers and Qualifying Codes (which identify which qualify subsequent data elements).

(37) [ (35) ] Research data file--A customized data file, which includes the data elements in the public use file and may include data elements other than the required minimum data set submitted to the Council, except those data elements that could reasonably identify a patient or physician. The data elements maybe released to a requestor when the requirements specified in §1301.18 (l) [ (f) ] of this title (relating to Hospital Discharge Data Release) are completed.

(38) [ (36) ] Risk adjustment--A statistical method to account for a patient's severity of illness at the time of admission and the likelihood of development of a disease or outcome, prior to any medical intervention.

(39) [ (37) ] Rural provider--A health care facility located in a county with a population of not more than 35,000 as of July 1 of the most recent year according to the most recent United States Bureau of the Census estimate; or located in a county with a population of more than 35,000 but with 100 or fewer licensed hospital beds and not located in an area that is delineated as an urbanized area by the United States Bureau of the Census; and is not state owned, or not managed or directly or indirectly owned by an individual, association, partnership, corporation, or other legal entity that owns or manages one or more other hospitals. A health care facility is not a rural provider if an individual or legal entity that manages or owns one or more other hospitals owns or controls more than 50% of the voting rights with respect to the governance of the facility.

(40) [ (38) ] Scientific Review Panel--The Council's appointees or agent who have experience and expertise in ethics, patient confidentiality, and health care data who review and approve or disapprove requests for data or information other than the public use data. Described in §1301.20 of this title (relating to Scientific Review Panel).

(41) [ (39) ] Service Unit Indicator--An indicator derived from submitted data (based on Bill type or Revenue Codes) and represents the type of service unit or units (e.g., Coronary Care Unit, Detoxification Unit, Intensive Care Unit, Hospice Unit, Nursery, Obstetric Unit, Oncology Unit, Pediatric Unit, Psychiatric Unit, Rehabilitation Unit, Sub acute Care Unit or Skilled Nursing Unit) where the patient received treatment.

(42) [ (40) ] Severity adjustment--A method to stratify patient groups by degrees of illness and mortality.

(43) [ (41) ] Submission-- The transfer of a [ 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.

(44) [ (42) ] 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.

(45) [ (43) ] THCIC Identification Number--A string of six characters assigned by the Council to identify health care facilities for reporting and tracking purposes.

(46) [ (44) ] Uniform facility identifier--A unique number assigned by the Council to each health care facility licensed in the state. For hospitals, this will include the hospital's state license number. For hospitals operating multiple facilities under one license number and duplicating services, the Council will assign a distinguishable uniform facility identifier for each separate facility. The relationship between facility identifier and the name and license number of the facility is public information.

(47) [ (45) ] Uniform patient identifier--A unique identifier assigned by the Council to an individual patient and composed of numeric, alpha, or alphanumeric characters, which remains constant across hospitals and inpatient admissions. The relationship of the identifier to the patient-specific data elements used to assign it is confidential.

(48) [ (46) ] Uniform physician identifier--A unique identifier assigned by the Council to a physician or other health professional who is reported as attending or treating a hospital inpatient and which remains constant across hospitals. The relationship of the identifier to the physician-specific data elements used to assign it is confidential. The uniform physician identifier shall consist of alphanumeric characters.

(49) [ (47) ] Validation--The process by which a provider verifies the accuracy and completeness of data and corrects any errors identified before certification.

§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 claims [ files ] as specified in §1301.19 of this title (relating to Discharge Reports--Records, Data Fields and Codes) on all discharged inpatients to the Council. To the extent the admission, treatment, or discharge is made by a health professional, other than a physician, data elements specified in §1301.19 (d)(36)-(41) [ (e)(39)-(42) ] shall be filled accordingly or data elements (38) or (41) [ (39)-(40) ] shall be marked with one of the Council approved temporary "Physician" or "Other health professional" code numbers and data elements (36)(A-C) or (39)(A-C) [ (41)-(42) ] may be left blank. Hospitals owned by the federal government and hospitals exempted as rural providers may submit hospital discharge claim [ files ].

(b) All inpatient discharges shall be reported. Except as noted in paragraphs (1)- (4) [ (5) ] of this subsection, one or more discharge claims [ files ] shall be submitted for each patient for each discharge covering all services and charges from admission through discharge.

(1) Separate discharge claims [ files ] shall be submitted for mothers and newborns.

(2) Hospitals shall either submit separate discharge claims [ files ] corresponding to each interim, revised, or final discharge claims [ files ] or submit a single consolidated final discharge claim [ file ] for each discharged patient.

(3) For all patients for which the hospital prepares one or more bills for inpatient services, the hospital shall submit a discharge claim [ file ] corresponding to each bill containing the [ required ] data elements required by §1301.19 of this title (relating to Discharge Reports - Records, Data Fields and Codes). For all patients for which the hospital does not prepare a bill for inpatient services, the hospital shall submit a discharge claim [ file ] containing the required minimum data set.

(4) For all patients that are covered by 42 USC 290dd-2 and 42 CFR Part 2.1, a hospital shall submit a discharge claim [ file ] containing the required data elements specified by §1301.19 of this title (relating to Discharge Reports - Records, Data Fields and Codes). The hospital shall replace the patient identifying information with the default values specified in §1301.19 (e) [ (f) ] of this title (relating to Discharge Reports - Records, Data Fields and Codes) or submit the patient identifying information if release of patient identifying information is authorized in writing by the patient or patient's guardian.

(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 claims [ 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 calendar 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 calendar days prior to the agent's submission of any discharge report. The hospital shall inform the Council in writing at least 30 calendar 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 or the director's agent, the Texas Department of Health, 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 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 calendar days advance notice, and ensure that confidentiality of patient records is maintained.

§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 of this title (relating to Discharge Reports--Records, Data Fields and Codes) 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; [ Record length = 192 characters, fixed; Blocking = blocked (170 records per block recommended; 40 records per block minimum) ]; Labeling = IBM standard or facsimile.

(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 as listed in subparagraphs (A)-(G) of this paragraph:

(A) hospital name;

(B) facility identifier (THCIC 6 digit identifier) ;

(C) reporting period for discharges;

(D) number of transaction sets [ 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 (A) through (D) 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 directly in writing 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 1 TAC Chapter 201.

(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, unless the hospital has obtained an exemption authorized by §1301.15 of this title (relating to Exemptions from Filing). [ 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 directly in writing 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 as listed in subparagraphs (A)-(E) of this paragraph:]

[ (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 or other exempted 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 or other exempted 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 or changes in hospital ownership or management relationships. Hospitals that cease to be exempted as rural providers or as other exempted providers shall be responsible for submitting discharge claims [ files ] on all discharges that occur 30 days after loss of the exemption. 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 as shown in subparagraphs (A)-(D) of this paragraph 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 had 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. 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 the hospital shows that it does not currently electronically file UB-92 bills with any payer, or has not done so in the last 12 months prior to the request for exemption.]

[ (4) Exemption from electronic filing in standard formats. Exemptions from electronic filing of discharge reports in the standard formats specified in §1301.19 of this title (relating to Discharge Reports - Records, Data Fields and Codes) shall be granted to hospitals that demonstrate that alternative formats are universally accepted by payers and other entities to whom hospitals are required by law or contract to furnish hospital discharge data for complementary purposes. The exemption from electronic filing of discharge reports in the standard formats does not change the data elements 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), or the schedule for submission specified in §1301.14 of this title (relating to Instructions for Filing Discharge Reports).]

(b) Requests for exemptions shall be submitted and processed using the following procedures as shown in paragraphs (1)-(4) of this subsection.

(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) by appealing to the Council if the executive director does not grant the request for reconsideration. 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.

(c) Reporting loss of exemptions. Hospitals shall notify the executive director in writing within 30 days of their loss of an entitlement to an exemption authorized by subsection (a) of this section.

§1301.16.Acceptance of Discharge Reports and Correction of Errors.

(a) To verify the accuracy of all discharge claims [ 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, §108.011.

(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 discharge report in the same submission format and media that is approved for that provider and state the deficiencies in writing within ten calendar days of receipt. The hospital shall resubmit the report within ten calendar days of notification by the executive director. A discharge report does not meet minimum standards for processing under the following circumstances as shown in paragraphs (1)-(3) of this subsection.

(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), unless the hospital has received a letter from the Council authorizing filing in another format.

(c) Correction of Errors.

(1) The executive director shall review all discharge reports accepted for processing and will process all discharge claims [ files ] against the editing criteria established by this section and by the executive director. Within 10 calendar 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 calendar days of receiving initial notice of errors in a discharge report, the hospital shall correct all discharge claims [ files ] containing errors, add any discharge claims [ files ] determined to be missing from the initial discharge report and resubmit the corrected and/or previously missing discharge claims [ files ]. If the hospital disagrees with any identified error, the hospital may indicate that the discharge claim [ file ] is as accurate as it can be or cannot be corrected. Each hospital shall submit such modified and/or additional discharge claims [ files ] as may be required to allow the chief executive officer or the chief executive officer's designated agent to certify the quarterly discharge report as required by §1301.17 of this title (relating to Certification of Discharge Reports). Corrections to a discharge report shall be submitted on approved media and formats as specified in §1301.14 of this title (relating to Instructions for Filing Discharge Reports) and §1301.19 of this title (relating to Discharge Reports-Records, Data Fields and Codes) unless the executive director approves another medium or format.

(3) Within ten calendar 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 calendar days from receipt of this notice to correct the errors noted or indicate why the data should be deemed acceptable and complete. This process may be repeated until the data is substantially accurate and the hospital is able to certify the discharge report as required by §1301.17 of this title (relating to Certification of Discharge Reports) or the deadline for submitting corrections prior to certification is reached. Corrected data is required to be submitted on or before the following dates for the respective quarter's discharges; Quarter 1 - August 1, Quarter 2 - November 1, Quarter 3 - February 1, Quarter 4 - May 1. No individual hospitals will be granted extensions to the dates. The executive director may grant an extension to all hospitals when deemed necessary.

(4) Discharge claims [ files ] that have not been previously submitted shall be submitted prior to the deadline for the following quarter's data. Correction and certification of these previously missing or additional discharge claims [ files ] for the prior calendar quarter shall be made according to the deadlines established for following quarter in which the data that is scheduled to be processed as specified in §1301.13(a)(1) of this title (relating to the Schedule for Filing Discharge Reports), paragraph (3) of this subsection (relating to the Acceptance of Discharge Reports and Correction of Errors) and §1301.17 (b) and (d) of this title (relating to the Certification of Discharge Encounter Data). Corrections to discharge claims [ files ] previously submitted or that have a discharge date prior to calendar quarter immediately before the calendar quarter being processed scheduled will not be processed.

(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 shall make this information available to submitters without charge and to others for the cost of reproduction.

(e) Failure to correct or comment on a discharge report which has been filed but contains errors or omissions, known to the hospital, within the due dates in §1301.13 of this title (relating to Schedule for Filing Discharge Reports) is punishable by a civil penalty pursuant to Health and Safety Code, §108.014.

§1301.17.Certification of Discharge Reports.

(a) Within five months after the end of each reporting quarter , the executive director shall compile one or more electronic data files for each reporting hospital using all discharge claims [ files ] received from each hospital. The file shall have one record for each patient discharged during the reporting quarter and one record for any patient discharged during one prior reporting quarter for whom additional discharge claims [ files ] have been received. This file will include all data submitted by the hospital, which the executive director intends to use in the creation of the public use data file. The data files, including reports and any additional information returned to the hospital, allows the hospital to provide physicians and other health professionals the opportunity to review, request correction of, and comment on records of discharged patients for whom they are shown as "attending" or "operating or other". The executive director shall determine the format and medium in which the quarterly file will be delivered to hospitals.

(b) The chief executive officer or chief executive officer's designated agent of each hospital shall indicate whether the hospital is certifying or not certifying the discharge encounter data specified in subsection (a) of this section, sign and return the form corresponding to the discharge report for each quarter using forms supplied by the Council. The certification form may be signed by a person designated by the chief executive officer and acting as the officer's agent. Designation of an agent does not relieve the chief executive officer of personal responsibility for the certification. If the chief executive officer or chief executive officer's designated agent does not believe the quarterly file is accurate, the officer shall provide the executive director with detailed comments regarding the errors or submit a written request (on a form supplied by the Council) and provide the data necessary to correct any inaccuracy and certify the file subject to those corrections being made prior to the deadlines specified in this subsection. Corrections to certification discharge data shall be submitted on or prior to the following schedule: Quarter 1 - October 15; Quarter 2 - January 15; Quarter 3 - April 15; Quarter 4 - July 15. Chief Executive Officers or designees that elect not to certify shall submit a reasoned justification explaining their decision to not certify their discharge encounter data and attach the justification to the certification form. Election to not certify data does not prevent data from appearing in the public use data file. Data that is not corrected and submitted by the deadline may appear in the public use data file.

(c) The signed certification form shall represent that:

(1) policies and procedures are in place within the hospital's processes to validate and assure the accuracy of the discharge encounter data and any corrections submitted; and

(2) all errors and omissions known to the hospital have been corrected or the hospital has submitted comments describing the errors and the reasons why they could not be corrected; and

(3) to the best of their knowledge and belief, the data submitted accurately represents the hospital's administrative status of discharged inpatients for the reporting quarter; and

(4) the hospital has provided physicians and other health professionals a reasonable opportunity to review and comment on the discharge data of patients for which they were reported in one of the available physician number and name fields provided on the acceptable formats specified in §1301.19 of this title (relating to Discharge Reports --Records, Data Fields and Codes) (for example, "attending physician" or "operating or other physician" as applicable. The physicians or other health professionals may write comments and have errors brought to the attention of the chief executive officer or the chief executive officer's designated agent and the chief executive officer or the chief executive officer's designated agent, shall address any comments by the physicians or other health professionals.

(5) if the chief executive officer or the officer's designee elects not to certify the discharge encounter data for a specific quarter, a written justification of any unresolved data issues concerning the accuracy and completeness of the data at the time of the certification shall be included on the certification form. Discharge data that has been edited, returned to hospital and is not certified may be released and published in the public use data file.

(d) Each hospital shall submit its certification form for each quarter's data to the Council by the first day of the ninth month (Quarter 1 - December 1; Quarter 2 - March 1; Quarter 3 - June 1; Quarter 4 - September 1) following the last day of the reporting quarter as specified in §1301.13 (a) (1)-(4) of this title (relating to Schedule for Filing Discharge Reports). Individual hospital requests for an extension to these deadlines will not be granted. The executive director may extend the deadline for all hospitals when deemed necessary.

(e) Hospitals, physicians or other health professionals may submit concise written comments regarding any data submitted by them or relating to services, they have delivered which may be released as public use data. Comments shall be submitted to the Council on or before the dates specified in subsection (d) of this section, regarding the submission of the certification form. Commenters are responsible for assuring that the comments contain no patient or physician identifying information. Comments shall be submitted electronically using the method described in §1301.14(a) and (b) of this title (relating to Instructions for Filing Discharge Reports).

(f) Failure to submit a signed certification form that is supplied by the Council on or before the dates specified in subsection (d) of this section corresponding to discharge data previously submitted is punishable by a civil penalty pursuant to Health and Safety Code, §108.014.

(g) Failure to either correct a discharge report which has been submitted and contains errors or omissions known to the hospital on or prior to the dates specified in subsection (b) of this section or to address in the comments the errors known to the hospital contained in the data and return the comments on or prior to the dates specified in subsection (d) of this section is punishable by a civil penalty pursuant to Health and Safety Code, §108.014(b).

§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, §108.010 and §108.013. Copies of such records may be obtained upon request and upon payment of user fees established by the Council. The public use data file shall be available for public inspection during normal business hours. Discharge claims [ files ] in the original format as submitted to the Council are not available to the public, are not stored at the Council's office and are exempt from disclosure pursuant to Health and Safety Code, §108.010 and §108.013, and shall not be released. Likewise, patient and physician identifying data collected by the Council through editing of hospital data shall not be released.

(b) Creation of codes and identifiers. The executive director shall develop the following codes and identifiers, as listed in paragraphs (1)-(2) of this subsection, required for creation of the public use data file and for other purposes.

(1) The executive director shall create a process for assigning uniform patient identifiers, uniform physician identifiers and uniform other health professional identifiers using data elements collected. This process is confidential and not subject to public disclosure. Any documents or records produced describing the process or disclosing the person associated with an identifier are confidential and not subject to public disclosure.

(2) The executive director shall create a process for assigning geographic identifiers to each discharge record.

(c) 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 as listed in paragraphs (1)-(11) of this subsection:

(1) delete patient, and insured name, Social Security Number, address and certificate data elements and any patient identifying information, if submitted; delete patient control and medical record numbers.

(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 and assign a alphanumeric uniform physician identifier for the physicians and other health professionals who were reported as "attending" or "operating or other" on discharged patients;

(6) assign codes indicating the primary and secondary sources of payment;

(7) the minimum cell size required by §108.011(i)(2) of the Health and Safety Code shall be five, unless the executive director determines that a higher cell size is required to protect the confidentiality of an individual patient or physician. When determining a higher cell size, the executive director shall consider comments submitted by a hospital and recommendations submitted by the technical advisory committee as identified in the Texas Health and Safety Code §108.003(g)(5);

(8) convert all procedure codes to ICD codes (in the version that is current for the date the data was due to be submitted or the version in effect at the date of service);

(9) add risk and severity adjustment scores utilizing an algorithm approved by the Council;

(10) suppress admission source data at patient level when the admission type code represents "Newborn";

(11) data elements to be included in the public use data file:

(A) Discharge Year and Quarter

(B) Provider Name (Facility Name)

(C) THCIC Identification Number

(D) Facility Type Indicators

(E) Patient Sex/Gender

(F) Type of Admission

(G) Source of Admission

(H) Patient ZIP Code

(I) County Code

(J) Public Health Region Code

(K) Patient State

(L) Patient Status

(M) Patient Race

(N) Patient Ethnicity

(O) Claim Type Indicator Code [ Source of Payment Code, Non-Standard Codes (Primary payer (and Secondary payer (if applicable))) (Beginning with third quarter 2000 data the second payer code information will be published) ]

[ (P) Source of Payment Code, Standard Codes (Primary payer (and Secondary payer (if applicable))) (Beginning with third quarter 2000 data the second payer code information will be published)]

(P) [ (Q) ] Type of Bill

(Q) [ (R) ] Encounter Indicator: This indicates whether more than one claim was used to create the encounter

(R) [ (S) ] Principal Diagnosis Code (Current version of ICD codes at the time data is submitted)

(S) [ (T) ] Other Diagnosis Codes (Up to 24 diagnosis codes can be submitted and reported. [ (1) ] (Current version of ICD codes at the time data is submitted)

[ (U) Other Diagnosis Codes (2) (Current version of ICD codes at the time data is submitted)]

[ (V) Other Diagnosis Codes (3) (Current version of ICD codes at the time data is submitted)]

[ (W) Other Diagnosis Codes (4) (Current version of ICD codes at the time data is submitted)]

[ (X) Other Diagnosis Codes (5) (Current version of ICD codes at the time data is submitted)]

[ (Y) Other Diagnosis Codes (6) (Current version of ICD codes at the time data is submitted)]

[ (Z) Other Diagnosis Codes (7) (Current version of ICD codes at the time data is submitted)]

[ (AA) Other Diagnosis Codes (8) (Current version of ICD codes at the time data is submitted)]

(T) [ (BB) ] Principal Procedure code (if applicable) (Current version of ICD codes at the time data is submitted)

(U) [ (CC) ] Other Procedure codes (Up to 24 procedure codes can be submitted and report [ code (1) ] (Current version of ICD codes at the time data is submitted)

[ (DD) Other Procedure code (2) (Current version of ICD codes at the time data is submitted)]

[ (EE) Other Procedure code (3) (Current version of ICD codes at the time data is submitted)]

[ (FF) Other Procedure code (4) (Current version of ICD codes at the time data is submitted)]

[ (GG) Other Procedure code (5) (Current version of ICD codes at the time data is submitted)]

(V) [ (HH) ] Admitting Diagnosis (Current version of ICD codes at the time data is submitted)

(W) [ (II) ] External Cause of Injury (E-codes), (if applicable) (Current version of ICD codes at the time data is submitted) up to 9 E-codes can be submitted and reported

(X) [ (JJ) ] Day of Week Patient is admitted code (Sun. = 1, Mon. = 2, Tues. = 3, Wed. = 4, Thur. = 5, Fri. = 6, Sat. = 7)

(Y) [ (KK) ] Length of Stay

(Z) [ (LL) ] Age of patient

(AA) [ (MM) ] Day number of Principal Procedure (Calculated : Principal Procedure Date minus Admission/Start of Care Date)

(BB) [ (NN) ] Day number of Procedure (1) (Calculated : Procedure Date (1) minus Admission/Start of Care Date)

(CC) [ (OO) ] Day number of Procedure (2) (Calculated : Procedure Date (2) minus Admission/Start of Care Date)

(DD) [ (PP) ] Day number of Procedure (3) (Calculated : Procedure Date (3) minus Admission/Start of Care Date)

(EE) [ (QQ) ] Day number of Procedure (4) (Calculated : Procedure Date (4) minus Admission/Start of Care Date)

(FF) [ (RR) ] Day number of Procedure (5) (Calculated : Procedure Date (5) minus Admission/Start of Care Date)

(GG) [ (SS) ] Major Diagnostic Category (MDC)

(HH) [ (TT) ] HCFA-DRG Code (Obtained from the 3M HCFA-DRG Grouper)

(II) [ (UU) ] APR-DRG Code (Obtained from 3M APR-DRG Grouper)

(JJ) [ (VV) ] Risk of Mortality Score (Obtained from 3M APR-DRG Grouper)

(KK) [ (WW) ] Severity of Illness Score (Obtained from 3M APR-DRG Grouper)

(LL) [ (XX) ] Uniform Physician Identifier assigned to Attending Physician [ (Beginning with 2000 data) ]

(MM) [ (YY) ] Uniform Physician Identifier assigned to Operating or Other Physician [ (Beginning with 2000 data) ]

(NN) [ (ZZ) ] Service unit indicator from which the patient received services

(OO) [ (AAA) ] Accommodations Private Room Charges [ (Beginning with third quarter 2000 data) ]

(PP) [ (BBB) ] Accommodations Semi-Private Charges [ (Beginning with third quarter 2000 data) ]

(QQ) [ (CCC) ] Accommodations Ward Charges [ (Beginning with third quarter 2000 data) ]

(RR) [ (DDD) ] Accommodations Intensive Care Charges [ (Beginning with third quarter 2000 data) ]

(SS) [ (EEE) ] Accommodations Coronary Care Charges [ (Beginning with third quarter 2000 data) ]

(TT) [ (FFF) ] Ancillary Service--Other Charges [ (Beginning with third quarter 2000 data) ]

(UU) [ (GGG) ] Ancillary Service--Pharmacy Charges [ (Beginning with third quarter 2000 data) ]

(VV) [ (HHH) ] Ancillary Service--Medical/Surgical Supply Charges [ (Beginning with third quarter 2000 data) ]

(WW) [ (III) ] Ancillary Service--Durable Medical Equipment Charges [ (Beginning with third quarter 2000 data) ]

(XX) [ (JJJ) ] Ancillary Service--Used Durable Medical Equipment Charges [ (Beginning with third quarter 2000 data) ]

(YY) [ (KKK) ] Ancillary Service--Physical Therapy Charges [ (Beginning with third quarter 2000 data) ]

(ZZ) [ (LLL) ] Ancillary Service--Occupational Therapy Charges [ (Beginning with third quarter 2000 data) ]

(AAA) [ (MMM) ] Ancillary Service--Speech Pathology Charges [ (Beginning with third quarter 2000 data) ]

(BBB) [ (NNN) ] Ancillary Service--Inhalation Therapy Charges [ (Beginning with third quarter 2000 data) ]

(CCC) [ (OOO) ] Ancillary Service--Blood Charges [ (Beginning with third quarter 2000 data) ]

(DDD) [ (PPP) ] Ancillary Service--Blood Administration Charges [ (Beginning with third quarter 2000 data) ]

(EEE) [ (QQQ) ] Ancillary Service--Operating Room Charges [ (Beginning with third quarter 2000 data) ]

(FFF) [ (RRR) ] Ancillary Service--Lithotripsy Charges [ (Beginning with third quarter 2000 data) ]

(GGG) [ (SSS) ] Ancillary Service--Cardiology Charges [ (Beginning with third quarter 2000 data) ]

(HHH) [ (TTT) ] Ancillary Service--Anesthesia Charges [ (Beginning with third quarter 2000 data) ]

(III) [ (UUU) ] Ancillary Service--Laboratory Charges [ (Beginning with third quarter 2000 data) ]

(JJJ) [ (VVV) ] Ancillary Service--Radiology Charges [ (Beginning with third quarter 2000 data) ]

(KKK) [ (WWW) ] Ancillary Service--MRI Charges [ (Beginning with third quarter 2000 data) ]

(LLL) [ (XXX) ] Ancillary Service--Outpatient Services Charges [ (Beginning with third quarter 2000 data) ]

(MMM) [ (YYY) ] Ancillary Service--Emergency Service Charges [ (Beginning with third quarter 2000 data) ]

(NNN) [ (ZZZ) ] Ancillary Service--Ambulance Charges [ (Beginning with third quarter 2000 data) ]

(OOO) [ (AAAA) ] Ancillary Service--Professional Fees Charges [ (Beginning with third quarter 2000 data) ]

(PPP) [ (BBBB) ] Ancillary Service--Organ Acquisition Charges [ (Beginning with third quarter 2000 data) ]

(QQQ) [ (CCCC) ] Ancillary Service--ESRD Revenue Setting Charges [ (Beginning with third quarter 2000 data) ]

(RRR) [ (DDDD) ] Ancillary Service--Clinic Visit Charges [ (Beginning with third quarter 2000 data) ]

(SSS) [ (EEEE) ] Total Charges--Accommodations[ , for the Claim (Beginning with third quarter 2000 data) ]

(TTT) [ (FFFF) ] Total Charges--Ancillary[ , for the Claim (Beginning with third quarter 2000 data) ]

(UUU) [ (GGGG) ] Total Non-Covered Accommodation Charges[ , for the Claim (Beginning with third quarter 2000 data) ]

(VVV) [ (HHHH) ] Total Non-Covered Ancillary Charges[ , for the Claim (Beginning with third quarter 2000 data) ]

(WWW) [ (IIII) ] Total Charges[ , for the Claim (Beginning with third quarter 2000 data) ]

(XXX) [ (JJJJ) ] Total Non-Covered Charges[ , for the Claim (Beginning with third quarter 2000 data); ]

(YYY) Encounter Identifier - a unique number for each encounter for the quarter

(ZZZ) Service Line Revenue Code

(AAAA) Service Line Procedure Code

(BBBB) HCPCS/HIPPS Procedure Code

(CCCC) HCPCS/HIPPS Procedure Modifiers (Up to 4 may be submitted and reported)

(DDDD) Service Line Charge Amount

(EEEE) Service Line Unit Code

(FFFF) Service Line Unit Count

(GGGG) Service Line Non-Covered Charge Amount

(HHHH) Patient Country (when address is not in United States of America and confidentiality can be maintained)

(d) Release of public use data files. The Council shall release in an aggregate form, without uniform patient, physician or other health professional identifiers, public use data relating to hospitals described by the Health and Safety Code, §108.0025(1) that are not rural providers because they do not meet the requirements of §108.0025(2).

(e) The executive director will make available a public use data file on electronic, magnetic or optical media for each quarter:

(1) The executive director shall release public use data 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 by the dates specified in §1301.17(d) of this title, or elects to not certify the discharge encounter data shall not prevent the executive director from releasing the hospital's data if the director believes the data submitted is reasonably accurate and complete. The executive director, with the recommendation of the Hospital Discharge Data Committee, may suppress for any quarter's data one or more data elements if deemed necessary to comply with provisions of the statutes. If an element is ordered suppressed by a judicial authority, the executive director may suppress the element without the recommendation of the Hospital Discharge Data Committee.

(2) If additional discharge claims [ files ] (not previously submitted as specified in §1301.16(c)(4) of this title (relating to Acceptance of Discharge Reports and Correction of Errors), excluding replacement, adjustments and void/cancel discharge claims [ files ] become available after the initial release of the public use data file for any quarter, the executive director will add the discharge claims [ files ], that are received on or prior to the date specified in §1301.13(a)(1) of this title (relating to Schedule for Filing Discharge Reports) of the following quarter [ year ], to the public use data file and make the additional records available to the public.

(3) The other sections of these rules notwithstanding, the executive director shall not create a public use data file from the discharge reports covering discharges occurring in 1998. 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.

(4) The first public use data file available for release will cover discharges for the first and second quarter of 1999. 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.

(f) Texas State agencies that request data solely for internal use in accordance with Health and Safety Code, §108.012(b) shall abide by the data users agreement.

(g) 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, §108.013(c).

(h) 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, §108.010.

(i) A public use data file which is specified by the requestor shall not be considered a "report issued by the Council" as referenced in Health and Safety Code, §108.011(f).

(j) Requests for data files including data on one or more providers 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 shall make available on the Council's Internet site and publish in the Council's numbered letter for hospitals a summary of all requests received for public use data.

(k) With any public use data file prepared by the Council, the executive director shall attach all comments submitted by providers, which relate to any data included in the file. The Council shall also make these comments available at the Council's offices and on the Council's Internet site.

(l) A research data file may be released provided the following criteria are met:

(1) the Texas Health Care Information Council Research Data Request Form is completed and submitted to the Council's executive director; and

(2) the requestor has made payment according to the Council's fee schedule. The Council's fee includes a non-refundable "Review of Request Fee"; and

(3) the Scientific Review Panel reviews the research request and has determined the proposed research outcome can be achieved with the requested data; and

(4) the Council's Scientific Review Panel grants authorization to the request or restricts access to specified data elements determined to be inappropriate for the research proposal in accordance with this subsection of this title (relating to Scientific Review Panel); and

(5) the requestor agrees to dispose of the research data using authorized methods by the established end date stated on the written data release agreement, and

(6) the requestor has signed a written data release agreement.

§1301.19.Discharge Reports--Records, Data Fields and Codes.

(a) Hospitals that have not obtained an exemption letter authorized by §1301.15 of this title (relating to Exemptions from Filing) shall submit discharge reports , [ in one of the following formats as listed in paragraphs (1)-(3) of this subsection: ]

[ (1) electronically 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 UB-92 Electronic Format. HCFA updates this format from time to time by issuing new versions. The Council will accept discharge reports in the latest version or versions accepted by HCFA at the service end date specified in the discharge file or at the time of submission of the data to THCIC. ]

[ (2) ] electronically in the file format for inpatient hospital bills defined by the American National Standards Institute (ANSI), commonly known as the ANSI ASC X12N form 837 Health Care Claims (ANSI 837 Institutional Guide) transaction for institutional claims and/or encounters . ANSI updates this format from time to time by issuing new versions. [ The Council will accept discharge reports in the latest version or in a version approved by HCFA at the service end date specified in the discharge file. ]

[ (3) for paper filing, the UB-92 paper form currently approved by the Health Care Finance Administration, also known as the HCFA 1450 paper version.]

(b) [ Except as otherwise provided in this section, discharge reports shall be submitted using the data element specifications as required by HCFA. Hospitals shall submit discharge reports using the data element specifications in effect as of the date of the discharge or as of the date submitted. ] The Council will make detailed specifications for these data elements available to submitters and to the public.

(c) In addition to the data elements contained in the ANSI 837 Institutional Guide ,[ Texas UB-92 Manual ] the Council has defined the following data elements shown in this subsection and [ has ] as defined the location in the ANSI 837 Institutional Guide [ HCFA UB-92 Electronic Format ] where each element is to be reported. Data element content, format and locations may change as federal and state legislative requirements change in regards to Public Law 104-191, Health Insurance Portability and Accountability Act of 1996 (HIPAA) is implemented.

(1) Patient race - This data element shall be reported at Loop 2010BA or 2010CA in the segment DMG05-3 [ Record Type 22, Field 7, Beginning Position 86; Form Locator 11 (upper line) ] as a numeric value. Acceptable codes are 10025 [ 1 ] = American Indian/Eskimo/Aleut, 20289 [ 2 ] = Asian or , 20768 = Native Hawaiian or Pacific Islander, 20545 [ 3 ] = Black or African American , 21063 [ 4 ] = White and 21311 [ 5 ] = Other Race, includes mixed or interracial patients . In order to obtain this data, the hospital staff retrieves the patient's response from a written form or asks the patient, or the person speaking for the patient to classify the patient. If the patient, or person speaking for the patient, declines to answer, the hospital staff is to use its best judgment to make the correct classification based on available data.

(2) Patient ethnicity - This data element shall be reported at Loop 2300 in the segment NTE02 [ Record Type 22, Field 8, Beginning Position 98; Form Locator 11 (lower line) ] as a numeric value. Acceptable codes are 21352 [ 1 ] = Hispanic or Latino Origin and 21865 [ 2 ] = Not of Hispanic or Latino Origin. In order to obtain this data, the hospital staff retrieves the patient's response from a written form or asks the patient, or the person speaking for the patient to classify the patient. If the patient, or person speaking for the patient, declines to answer, the hospital staff is to use its best judgment to make the correct classification based on available data.

(3) Other E-codes - These additional E-codes (maximum of nine (9)) shall be reported in the following ANSI X12N Form 837 locations: Loop 2300, segments, HI05-2, HI06-2, HI07-2, HI08-2, HI09-2, HI10-2, HI11-2 and HI12-2. (The first E-code is reported in Loop 2300 segment HI04-2). [ Patient Social Security Number - This data element shall be reported at Record Type 22, Field 5, Beginning Position 27; Form Locator 2 (upper line) a numeric value. In the event the patient is a newborn or child of United States citizenship for whom a Social Security Number has not been assigned, the hospital shall leave the field blank or shall insert "999999999" and shall indicate a response code in the Record Type 22, Field 6, Beginning Position 56; Form Locator 2 (lower line) as to the reason no Social Security Number was submitted. Acceptable codes are: F = Foreign national, does not have a Social Security Number; N = Newborn or Infant of United States citizenship for whom a Social Security Number has not been assigned; O = Other; R = Refused to provide a social security number; ]

(4) THCIC Identification Number - This data element shall be submitted in data segment REF02 of Loop 2010AA or Loop 2010AB (in the Pay-to provider reported provided the services), or Loop 2310E (if the Service Facility Provider is submitted). [ Source of payment code - This data element shall be reported at Record 30, Field 04, Beginning Position 25 as an alphanumeric value. Primary and secondary payer source codes shall be submitted when the hospital submits claim data for the patient to more than one payer. ]

[ (A) Acceptable codes are:]

[ (i) A = Self pay;]

[ (ii) B = Workers' Compensation;]

[ (iii) C = Medicare;]

[ (iv) D = Medicaid;]

[ (v) E = Other Federal Programs (includes Veterans Administration);]

[ (vi) F = Commercial;]

[ (vii) G = Blue Cross;]

[ (viii) H = Champus;]

[ (ix) I = Other.]

[ (B) Non-Standard Codes shall be reported at the Alternate Code Site Record 22, Field 9, Position 111:]

[ (i) T = State or Local Government Programs;]

[ (ii) U = Commercial PPO;]

[ (iii) V = Medicare Managed Care;]

[ (iv) X = Medicaid Managed Care;]

[ (v) Y = Commercial HMO;]

[ (vi) Z = Charity.]

[ (5) Facility Name - This data element shall be the name of the hospital where the services were rendered and shall be reported at Record Type 10, Field 12.]

[ (6) Facility Address - This data element shall be the actual physical address of the hospital where the services were rendered and shall be reported at Record Type 10, Field 13.]

[ (7) Facility City - This data element shall be the name of the city where the hospital that rendered the services is located and shall be reported in Record Type 10, Field 14. ]

[ (d) Data may be numeric or alphanumeric. All numeric data shall be right justified and zero-filled. All alphanumeric data shall be left justified. The length of all records is 192 characters. Conditional data fields shall be filled with spaces when other data is not present.]

(d) [ (e) ] Hospitals shall submit the required minimum data set for all patients for which a discharge claim [ file ] is required by this title. The required minimum data set includes the following data elements as listed in [ paragraphs (1)-(46) of ] this subsection:

(1) Patient Name

(A) Patient Last Name

(B) Patient First Name

(C) Patient Middle Initial

(2) Patient Address

(A) Patient Address Line 1

(B) Patient Address Line 2 (if applicable)

(C) Patient City

(D) Patient State

(E) Patient ZIP

(F) Patient Country (if address is not in United States of America, or one of its territories)

(3) Patient Birth Date

(4) Patient Sex

(5) Patient Race

(6) Patient Ethnicity

(7) Patient Social Security Number

(8) Patient Account Number

(9) Patient Medical Record Number

(10) Claim Filing Indicator Code (Payer Source - primary and secondary (if applicable for secondary payer source)

(11) Payer Name - Primary and secondary (if applicable, for both)

(12) National Plan Identifier - for primary and secondary (if applicable) payers (National Health Plan Identification number, if applicable and when assigned by the Federal Government)

(13) Type of Bill

(14) Statement Dates (replaces Statement From and Statement Thru dates)

(15) Admission / Start of Care

(A) Admission / Start of Care Date

(B) Admission / Start of Care Hour

(16) Admission Type

(17) Admission Source

(18) Patient (Discharge) Status

(19) Patient Discharge Hour

(20) Principal Diagnosis

(21) Admitting Diagnosis

(22) Principle External Cause of Injury (E-Code)

(23) Other Diagnosis Codes - up to 24 occurrences (all applicable)

(24) External Cause Of Injury (E-Code) - up to 9 occurrences (if applicable)

(25) Principal Procedure Code (if applicable)

(26) Principal Procedure Date (if applicable)

(27) Other Procedure Codes - up to 24 occurrences (if applicable)

(28) Other Procedure Dates - up to 24 occurrences (if applicable)

(29) Occurrence Span Code - up to 24 occurrences (if applicable)

(30) Occurrence Span Code Associated Date - up to 24 occurrences (if applicable)

(31) Occurrence Code - up to 24 occurrences (if applicable)

(32) Occurrence Code Associated Date - up to 24 occurrences (if applicable)

(33) Value Code - up to 24 occurrences (if applicable)

(34) Value Code Associated Amount - up to 24 occurrences (if applicable)

(35) Condition Code - up to 24 occurrences (if applicable)

(36) Attending Physician or Attending Practitioner Name

(A) Attending Practitioner Last Name

(B) Attending Practitioner First Name

(C) Attending Practitioner Middle Initial

(37) Attending Practitioner Primary Identifier (National Provider Identifier, when HIPAA rule is implemented)

(38) Attending Practitioner Secondary Identifier (Texas state license number or UPIN)

(39) Operating Physician or Other Practitioner Name (if applicable)

(A) Operating Physician or Other Practitioner Last Name

(B) Operating Physician or Other Practitioner First Name

(C) Operating Physician or Other Practitioner Middle Initial

(40) Operating Physician or Other Practitioner Primary Identifier (National Provider Identifier, when HIPAA rule is implemented)

(41) Operating Physician or Other Practitioner Secondary Identifier (Texas state license number or UPIN)

(42) Total Claim Charges

(43) Revenue Service Line Details (up to 999 service lines) (all applicable)

(A) Revenue Code

(B) Procedure Code

(C) HCPCS/HIPPS Procedure Modifier 1

(D) HCPCS/HIPPS Procedure Modifier 2

(E) HCPCS/HIPPS Procedure Modifier 3

(F) HCPCS/HIPPS Procedure Modifier 4

(G) Charge Amount

(H) Unit Code

(I) Unit Quantity

(J) Unit Rate

(K) Non-covered Charge Amount

(44) Service Provider Name

(45) Service Provider Primary Identifier - Provider Federal Tax ID (EIN) or National Provider Identifier (when HIPAA rule is implemented)

(46) Service Provider Address

(A) Service Provider Address Line 1

(B) Service Provider Address Line 2 (if applicable)

(C) Service Provider City

(D) Service Provider State

(E) Service Provider ZIP

(47) Service Provider Secondary Identifier - THCIC 6-digit Hospital ID assigned to each facility

[ (1) Patient race;]

[ (2) Patient ethnicity;]

[ (3) Patient Social Security Number;]

[ (4) Patient control number;]

[ (5) Patient last name;]

[ (6) Patient first name;]

[ (7) Patient middle initial;]

[ (8) Patient sex;]

[ (9) Patient birth date;]

[ (10) Type of admission;]

[ (11) Source of admission;]

[ (12) Source of Payment Code (THCIC's standard codes and non-standard codes for the Primary and Secondary payers);]

[ (13) Patient address;]

[ (14) Patient city;]

[ (15) Patient state;]

[ (16) Patient zip;]

[ (17) Admission/start of care date;]

[ (18) Statement covers period from;]

[ (19) Statement covers period through;]

[ (20) Patient status;]

[ (21) Medical record number;]

[ (22) Type of bill;]

[ (23) Accommodations revenue codes (all applicable);]

[ (24) Accommodations rates (all applicable);]

[ (25) Accommodation days (all applicable);]

[ (26) Accommodation total charges (all applicable);]

[ (27) Inpatient ancillary revenue code (all applicable);]

[ (28) Units of service (all applicable);]

[ (29) Ancillary charges total (all applicable);]

[ (30) Principal diagnosis code;]

[ (31) Other diagnosis codes (all applicable);]

[ (32) Principal surgical procedure code (if applicable);]

[ (33) Principal surgical procedure date (if applicable);]

[ (34) Other surgical procedure codes (all applicable);]

[ (35) Other surgical procedure dates (all applicable);]

[ (36) Admitting diagnosis;]

[ (37) External cause of injury (if applicable);]

[ (38) Procedure coding method used;]

[ (39) Attending physician number;]

[ (40) Operating or other physician number (if applicable);]

[ (41) Attending physician name;]

[ (42) Operating or other physician name (if applicable);]

[ (43) Facility Name;]

[ (44) Facility Address;]

[ (45) Facility City;]

[ (46) Reason for no Social Security number.]

(e) [ (f) ] For patients which are covered by 42 USC 290dd-2 and 42 CFR Part 2.1, the hospital shall submit the following patient identifying information or default values in the specified Record and Field locations as required by subsection (a) of this section or the Form Locator for authorized hospitals as required by §1301.14(c) of this title (relating to Instructions for Filing Discharge Reports, Paper Forms):

(1) Patient Account [ Control ] Number - This alphanumeric patient control number shall be reported in Loop 2300, segment CLM01 [ Record 20 Field 03, or Form Locator 3 ]. This number is unique to the institution and episode of care and will be used by the hospital to review and certify data.

(2) Last Name - The patient's last name shall be removed and replaced with "Doe" in Loop 2010BA (Subscriber) or 2010CA (Patient), segment NM103 [ Record 20 Field 04, Form Locator 12 ].

(3) First Name - The patient's first name shall be removed and replaced with "Jane" if female, or "John" if male, and can include a sequential number (e.g., John1, John2, John3... etc.) in Loop 2010BA (Subscriber) or 2010CA (Patient), segment NM104 [ Record 20 Field 05, Form Locator 12 ].

(4) Middle Initial - The patient's middle initial shall be removed and left blank (space filled) in Loop 2010BA (Subscriber) or 2010CA (Patient), segment NM105 [ Record 20 Field 06, Form Locator 12 ].

(5) Date of Birth - The patient's date of birth shall be placed in Loop 2010BA (Subscriber) or 2010CA (Patient), segment DMG02 [ Record 20 Field 08, Form Locator 14 ].

(6) Address - The patient's residence address shall be removed and replaced with the hospital's street address in Loop 2010AA (Billing Provider) or 2010AB (Pay-to Provider) loops or 2310E (Service Facility Name), segment NM103 [ Record 20 Field 12, Form Locator 13 ].

(7) City - The patient's city of residence shall be reported in 2010BA (Subscriber) or 2010CA (Patient), segment N401 [ Record 20 Field 14, Form Locator 13 ].

(8) State - The patient's state of residence shall be reported in 2010BA (Subscriber) or 2010CA (Patient), segment N402 [ Record 20 Field 15, Form Locator 13 ].

(9) ZIP Code - The patient's ZIP code of residence shall be reported in 2010BA (Subscriber) or 2010CA (Patient), segment N403 [ Record 20 Field 16, Form Locator 13 ].

(10) Medical Record Number - The patient's medical record number shall be removed and replace with "99999" and reported in Loop 2300, segment REF02 [ Record 20 Field 25, Form Locator 23 ].

(11) Social Security Number - The patient's Social Security Number shall be removed and replaced with "999999999" in 2010BA (Subscriber) or 2010CA (Patient), Segment REF02. [ Record 22 Field 05, Form Locator 2 (Upper Line) Also, place the letter "O" in Record 22 Field 06, Form Locator 2 (Lower Line) as specified in subsection (c)(3) of this section. ]

[ (g) A submission will consist of a set of the following types of records from the HCFA UB-92 Electronic Format specification as shown in paragraphs (1)-(13) of this subsection.]

[ (1) Processor Label Data (Record 01). Files will be formatted so that this is a data record, not a conventional label. From a system standpoint, this will be a "labelless" file. This record will be the first record in the file.]

[ (2) Provider Data (Record 10). The provider's batch record describes the types of claims submitted for a specific provider. Field 02 of this record identifies the specific type of claim. A provider may be authorized to submit more than one claim type. In that case, more than one batch will be required to identify each claim type. Each claim in the batch will be edited for claim type. Record 40, Field 04 identifies claim type and will be matched to the batch record for claim type. Each batch record must be followed by claim records and then Provider Batch Control Record (Record 95). This record is required at the beginning of each batch.]

[ (3) Patient Data (Record 20). The patient record is the first record of a claim. It is required for all claim types as it contains the patient's demographic data.]

[ (4) Third Party Payer Data (Record 30). The third party payer record identifies the primary insurance payer information and the secondary insurance payer for each patient. If the patient has no third party payer and is paying with personal finances, the hospital shall submit one Record 30 01 (or first Record 30) with Field 04 = A and Record 22 01 Field 09 shall be left "blank". If a non-standard source of payment code is selected, the hospital shall submit a Record 30 with Field 04 = I (Other) or "the most appropriate corresponding standard source of payment code" and the selected non-standard source of payment code shall appear in Record 22, Field 09. For example: If the patient has no third party payer and is treated as a charity patient, where no reimbursement is expected. The hospital shall submit one Record 30 01 with Field 04 = I and a Record 22 01 with Field 09 = Z, if the patient has a commercial PPO plan as the primary payer and Medicare Managed Care Plan for a secondary source of payment, the hospital shall submit two Record 30s'; Record 30 01 Field 04 = F (Commercial) and Record 22 01 Field 09 = U (Commercial PPO), Record 30 02 Field 04 = C (Medicare) and Record 22 Field 09 = V (Medicare Managed Care). Records must be in the correct payer priority sequence. The '01' (First Record 30 and Record 22) Record determines which source of payment code will be considered as primary.]

[ (5) Claim Data (Record 40). The claim data record identifies miscellaneous data needed to process a claim.]

[ (6) Claim Data Conditions and Values (Record 41). This record is used to report condition and value codes. If none are needed, this record is not necessary.]

[ (7) Inpatient Accommodations (Record 50). This record identifies the room charges (revenue codes 100-219) for an inpatient claim.]

[ (8) Inpatient Ancillary Services (Record 60). This record identifies the inpatient ancillary services (revenue codes 220-999). Revenue code "001" (total) is required for all lines of business. It must be the last revenue code listed and must contain the correct totals.]

[ (9) Medical Data (Record 70). This record identifies the diagnosis and surgical procedure code requirements.]

[ (10) Physician Data (Record 80). This record is for the Texas physician license number as assigned by the state licensing boards and name or Unique Physician Identification Number (UPIN) assigned by HCFA and name.]

[ (11) Discharge Totals (Record 90). This record is the final record for each discharge and is required for all discharge types. The record count and charges associated with the discharges will be edited to this record. The discharge will be rejected when the counts or totals do not agree to those accumulated while processing the individual records of each discharge. If a record is not submitted for a discharge, enter "0" for that record count.]

[ (12) Provider Batch Control (Record 95). The provider's batch control record contains information for all the claims of a specific claim type. The system will accumulate totals as it processes each claim. The totals are then edited to the batch totals record. When the totals are out of balance, the batch will be rejected.]

[ (13) File Control Totals (Record 99). The processor's file control record contains control information for all the claims in the file.]

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State on March 10, 2003.

TRD-200301640

Jim Loyd

Executive Director

Texas Health Care Information Council

Earliest possible date of adoption: April 20, 2003

For further information, please call: (512) 482-3320