Current through Reg. 49, No. 38; September 20, 2024
(a) Hospitals that have not obtained an
exemption letter authorized by § 421.81 of this title (relating to Health
Care Facilities Exemptions from Filing Requirements) shall submit discharge
reports, 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.
(b) DSHS 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, DSHS has defined the following
data elements shown in this subsection and as defined the location in the ANSI
837 Institutional Guide 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), as amended, is implemented.
(1) Patient race - This data element shall be
reported at Loop 2300 in the K3 segment as the second numeric value in this
data segment. Acceptable codes are 1 = American Indian/Eskimo/Aleut, 2 = Asian
or, Pacific Islander, 3 = Black, 4 = White and 5 = Other Race. 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 K3 segment as the first numeric value.
Acceptable codes are 1 = Hispanic or Latino Origin and 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).
(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).
(d)
Hospitals shall submit the required minimum data set for all patients for which
a discharge claim is required by this title. The required minimum data set
includes the following data elements as listed in 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 the
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.
(e) A hospital
shall submit the "POA indicator" for all diagnosis codes on inpatient claims
filed, unless exempted by this subsection. Exempted hospitals may, but are not
required to submit POA indicators to DSHS. The following hospital types are
exempted from reporting POA indicators to DSHS for the purposes of this
subsection:
(1) Critical Access Hospitals
(certified by the Secretary of the United States Department of Health and Human
Services as a critical access hospital under Title
42 United States Code,
§1395i-4).
(2) Inpatient Rehabilitation Hospitals (a
majority of the patients are inpatients being rehabilitated).
(3) Inpatient Psychiatric Hospitals (a
majority of the patients are inpatients being treated for psychiatric diseases
or associated conditions).
(4)
Cancer Hospitals (a majority of the patients are inpatients being treated for
cancer or associated cancerous conditions).
(5) Children's or Pediatric Hospitals (a
majority of the patients are under the age of 18 and admitted as
inpatients).
(6) Long Term Care
Hospitals (a majority of the patients are inpatients being treated for chronic
conditions or associated diseases that require extended stays in a
hospital).
(f) For
patients which are covered by
42 USC §
290dd-2 and 42 CFR Part 2, 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:
(1) Patient Account Number - This
alphanumeric patient control number shall be reported. 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."
(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.).
(4) Middle Initial - The patient's middle
initial shall be removed and left blank (space filled).
(5) Date of Birth - "January 1" and the
patient's year of birth shall be reported.
(6) Address - The patient's residence address
shall be removed and replaced with the hospital's street address.
(7) City - The patient's city of residence
shall be removed and replaced with the name of the city where the hospital is
located .
(8) State - The patient's
state of residence shall be reported.
(9) ZIP Code - The patient's ZIP code of
residence shall be removed and replaced with the hospital's ZIP code.
(10) Medical Record Number - The patient's
medical record number shall be reported. This number is unique to the
institution and episode of care and will be used by DSHS to process the claim
data and for the hospital to review and certify the patient's data.
(11) Social Security Number - The patient's
Social Security Number shall be removed and replaced with
"999999999."
(12) Statement Dates -
The month, day, and year of the statement from and statement through dates
shall be reported as required. Only the year of service will be retained with
the record after transfer to the DSHS program administering and completing the
processing of the data for the health care data collection system under Health
and Safety Code, Chapter 108.
