Health, Center for Health Data, Health Care Statistics

Rule R428-10

Health Data Authority Hospital Inpatient Reporting Rule

Notice of Proposed Rule

(Amendment)

DAR File No.: 35870
Filed: 02/10/2012 02:17:42 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

Revises the list of data elements reported to meet current industry standards of uniform billing including UB-04, ASC X12N and HIPAA version 5010 transactions. These additions include the national provider identifier (NPI), present on admission, do not resuscitate, additional diagnosis and procedure codes and e-codes. Other improvements include additional physician IDs and specialty information and requiring the patient�s complete address and name. Updates the submittal media accepted by replacing the outdated terms computer diskette and magnetic tape with compact disc and DVD. Also expands the acceptable methods of submittal to include secure electronic uploads or secure emails. Also explicitly delineates the full list of hospital types that are required to report.

Summary of the rule or change:

Expansion of hospital inpatient reporting to current uniform billing standards. This will coordinate our reportable data elements to match improvements the hospitals are currently making to their systems to meet the federal HIPAA version 5010 transaction standard and the upcoming transition to ICD-10 in the billing industry. Receiving data submittals through an electronic interchange network such as UHIN or accepting secure uploads or secure email reflects current business practice.

State statutory or constitutional authorization for this rule:

• Title 26, Chapter 33a

Anticipated cost or savings to:

the state budget:

Initial costs to the state would include the revision of technical specifications and rules, and the establishment of adequate processes to edit, test, and verify data quality. This will be absorbed within the existing budget by reallocating staff resources.

local governments:

This rule does not affect local governments and has no fiscal impact on them.

small businesses:

Moving to an electronic transaction will save small hospitals' personnel time and resources on printing and mailing. The data improvements and electronic data submission will reduce UDOH data processing time and improve the timeliness of data release, and benefit data users and the public.

persons other than small businesses, businesses, or local governmental entities:

Moving to an electronic transaction will save hospitals' personnel time and resources on printing and mailing. The data improvements and electronic data submission will reduce UDOH data processing time and improve the timeliness of data release, and benefit data users and the public.

Compliance costs for affected persons:

The initial cost to set up the revised reporting capacity will occur to the individual hospital or hospital systems. Since the reporting requirement is consistent with the industry standard (billing data), the anticipated reporting cost would not add significant burden to a reporting facility. Hospitals in Utah already use electronic data interchange technology for total or partial submission of claims.

Comments by the department head on the fiscal impact the rule may have on businesses:

"Updating this rule to standardize reporting is expected to reduce the regulatory burden on business and reduce cost."

David Patton, PhD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Center for Health Data, Health Care Statistics
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Mike Martin at the above address, by phone at 801-538-9205, by FAX at 801-538-9916, or by Internet E-mail at [email protected]
• Keely Cofrin Allen at the above address, by phone at 801-538-6551, by FAX at 801-538-9916, or by Internet E-mail at [email protected]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

04/02/2012

This rule may become effective on:

04/09/2012

Authorized by:

David Patton, Executive Director

R428. Health, Center for Health Data, Health Care Statistics.

R428-10. Health Data Authority Hospital Inpatient Reporting Rule.

R428-10-1. Legal Authority.

This rule is promulgated under authority granted by Title 26, Chapter 33a, and in accordance with the Health Data Plan.

 

R428-10-2. Purpose.

This rule establishes the reporting standards for inpatient discharge data by licensed hospitals. Inpatient discharge data are needed to develop and maintain a statewide hospital inpatient discharge data base.

 

R428-10-3. Definitions.

These definitions apply to rule R428-10.

(1) "Office" as defined in R428-2-3(A).

(2) "Discharge data" means the consolidation of complete billing, medical, and personal information describing a patient, the services received, and charges billed for a single inpatient hospital stay into a discharge data record.

(3) "Hospital" means a facility that is licensed under R432-100.

(4) "Level 1 data element" means a required reportable data element.

(5) "Level 2 data element" means a data element that is reported when the information is available from the patient's hospital record.

(6) "Patient Social Security number" is the social security number of the patient receiving inpatient care.

(7) "Record linkage number" is an irreversible, unique, encrypted number that will replace patient social security number. The Office assigns the number to serve as a control number for data analysis.

(8) "Uniform billing form" means the uniform billing form recommended for use by the National Uniform Billing Committee.

 

R428-10-4. Source of Inpatient Hospital Discharge Data Reporting.

The reporting source for hospital inpatient discharge data is Utah licensed hospitals.

(1) A hospital facility, either general acute care, critical access, children's, long term, psychiatric or rehabilitation[specialty] hospital, shall report discharge data records for each inpatient discharged from its facility.

(2) A hospital may designate an intermediary, such as the Utah Hospital Association, or may submit discharge data directly to the committee.

(3) Each hospital is responsible for compliance with these rules. Use of a designated intermediary does not relieve the hospital of its reporting responsibility.

(4) Each hospital shall designate a department within the hospital and a person responsible for submitting the discharge data records. This person shall also be responsible for communicating with the Office.

 

R428-10-5. Data Submittal Schedule.

Each hospital shall submit to the Office a single discharge data record for each patient discharged according to the schedule shown in Table 1, Hospital Discharge Data Submittal Schedule, or a schedule mutually agreed upon by the Office and hospital. For a patient with multiple discharges, each hospital shall submit a single discharge data record for each discharge. For a patient with multiple billing claims each hospital shall consolidate the multiple billings into a single discharge data record for submission after the patient's discharge.

 

TABLE 1
HOSPITAL DISCHARGE DATA SUBMITTAL SCHEDULE

PATIENT'S DATE OF DISCHARGE                 DISCHARGE DATA RECORD

IS BETWEEN                                  IS DUE BY

January 1 through March 31                  May 15

April 1 through June 30                     August 15

July 1 through September 30                 November 15

October 1 through December 31               February 15

 

R428-10-6. Data Element Reporting.

Tables 2 and 3 display the reportable data elements by defined level. A hospital shall, as a minimum, report the required level 1 data elements shown in Table 2. Each hospital shall report level 2 data elements shown in Table 3 whenever the information is a part of the hospital's patient record. [Beginning July 1, 1993, each patient social security number shall be reported as a level 2 (as available) data element.] Beginning January 1, 1995, each hospital shall collect patient social security number as a level 1 (required) data element on the hospital discharge record, and report the patient social security number with the complete discharge record according to the submittal schedule. The Department shall adopt an encryption method to mask patient identity and replace patient social security number with a record linkage number as the control number. The Department may not retain the original record containing patient social security number and shall destroy the original record containing patient social security number after the Department assures the validity of the patient record. The Department of Health may conduct on-site audits to verify the accuracy of all submittals.

Each hospital shall submit the reported data elements on compact disc, DVD,[computer diskette, magnetic tape,] or send electronically[as an "electronic copy" of encounter or claim data,] through the Utah Health Information Network or another compatible electronic data interchange network or other secure upload or secure email method. The Office shall accept data that complies with data standards established in R590-164, Uniform Health Billing Rule. The Office shall provide to each hospital, a Hospital Inpatient Discharge Data Submittal Technical Manual which outlines the specifications, format, and types of data to report. The revised Submittal Technical Manual is effective for discharges occurring on or after January 1, 2012[1995].

 

TABLE 2
REQUIRED LEVEL 1
HOSPITAL INPATIENT DISCHARGE DATA ELEMENTS

     CATEGORY            NAME

     Provider

     1.     Provider identifier (hospital name)

Patient

     2.      Patient control number

     3.      Patient's medical record[chart] number

     4.      Patient Social Security Number


     5.      Patient name

     6[5].     Patient's [postal zip code for ]address, city,

state, zip

     7[6].     Patient's date of birth

     8[7].     Patient's gender 

Service

     9[8].         Admission date

     10[9].         Type of admission/visit

     11[0].         Point of origin for admission or visit
[Source of admission]

     12[1].         Patient's discharge status

     13[2].         Statement covers period 

     14.              Condition codes (do not resuscitate, 
homeless, others)

                Charge

     15.        Service line

     16[3].         Revenue codes

     17.             HCPCS Procedure codes including modifiers

     18.             Unit or basis for measurement code

     19[4].          Service [U]units/days[ of service]

     20[15].        Total charges by revenue code

     Payer

     21[6].         Payer's identification

     22[17].        Patient's relationship to insured

     Diagnosis and Treatment

     23.              Diagnosis version qualifier

     24[18].       Principal diagnosis with present on admission

     25[19].       Other diagnosis codes with present on admission

     26.              Admitting diagnosis code

     27.              Patient's reason for visit codes

     28[0].          External cause of injury codes (E-code)with 
present on admission

     29[1].         Principal ICD procedure code

     30[22].        Other ICD procedure codes

     31[23].         Date of principal procedure[Procedure coding 
method, required if coding is not ICD-9]

     Physician

     32[4].         Attending provider primary[ physician] ID

     33.              Operating physician primary ID

     34.              Other operating physician primary ID

     35[25].            Rendering physician primary ID[Other 
physicians' IDs]

     36.       Referring provider primary ID

       Other

     37[26].        Type of bill

 

 

TABLE 3
WHEN DATA ELEMENT IS AVAILABLE FROM THE
HOSPITAL'S PATIENT RECORD
LEVEL 2
HOSPITAL INPATIENT DISCHARGE DATA ELEMENTS

     CATEGORY            NAME

     Patient

     1.               Patient marital status

     2.               Patient race and ethnicity

     [Payer]

     [2.              Insured group name]

     Employer

     [3.              Employment status code] 

     3[4].          Employer name

     [5.              Employer location]

     Charge

     4[6].          Prior payments

     [7.              Patient Race and Ethnicity]

     5[8].          Estimated amount due

     Payer

      6.             Insured names

     7[9].          Certificate/Social Security Number/Health

                      Insurance Claim/Identification Number

     8.              Insured group names

     Physician

     9.                     Attending provider secondary ID

     10.                   Attending provider specialty 
information

     11.                    Operating physician secondary ID

     12.                    Operating physician specialty 
information

     13.                    Other operating physician secondary 
ID

     14.                    Other operating physic. specialty 
information

     15.                    Rendering physician secondary ID

     16.                    Rendering physician specialty 
information

     17.                    Referring provider secondary ID

     18.                    Referring provider specialty 
information

     19[0].                 Resident ID

     20[11].                Resident ID Type

 

R428-10-7. Exemptions, Extensions, and Waivers.

(1) Hospitals may submit requests for exemptions or waivers to the committee within 60 calendar days of the due date as listed in the hospital discharge data submittal schedule in R428-10-5, Table 1. Exemptions or waivers to the requirements of this rule may be granted for a maximum of one calendar year. A hospital wishing an exemption or waiver for more than one year must submit a request annually.

(2) Requests for extensions must be submitted to the Office at least ten working days prior to the due date as listed in the hospital discharge data submittal schedule. Extensions to the submittal schedule may be granted for a maximum of 30 calendar days. The hospital must separately request each additional 30 calendar day extension.

(3) The committee may grant exemptions or waivers when the hospital demonstrates that compliance imposes an unreasonable cost to the hospital. The Office may grant extensions when the hospital documents that technical or unforeseen difficulties prevent compliance. A petitioner requesting an exemption, extension, or waiver shall make the request in writing. A request for exemption, extension, or waiver must contain the following information:

(a) the petitioner's name, mailing address, telephone number, and contact person;

(b) the date the exemption, extension, or waiver is to start and end;

(c) a description of the relief sought, including reference to the specific sections of the rule;

(d) a statement of facts, reasons, or legal authority in support of the request; and

(e) a proposed alternative to the requirement.

(4) A form for exemption, extension, or waiver can be found in the technical manual available from the Office. Exemptions, extensions, or waivers may be granted for the following:

(a) Hospital exemption: All hospitals are subject to the reporting requirements. Reasons justifying an exemption might be a circumstance where the hospital makes no effort to charge any patient for service.

(b) Discharge data consolidation exemption: This exemption allows variation in the data consolidation requirement, such as allowing the hospital to submit multiple records containing the reportable data elements rather than a single consolidated discharge data record.

(c) Reportable data element exemption: Each request for a data element exemption must be made separately.

(d) Submission media exemption: This exemption allows variation in the submission media, such as uploading using secure sftp[a paper copy of the uniform billing form].

(e) Submittal schedule extension: The request must specifically document the technical or unforeseen difficulties that prevent compliance.

(f) Submission format waiver: This waiver allows variation in the submission format. Each request must state an alternative transfer electronic media, its format, and the record layout for the discharge data records. Granting of this waiver is dependent on the Office's ability to process the submittal media and format with available computer resources.

 

R428-10-8. Penalties.

Pursuant to Section 26-23-6, any person that violates any provision of this rule may be assessed an administrative civil money penalty not to exceed $3,000 upon an administrative finding of a first violation and up to $5,000 for a subsequent similar violation within two years. A person may also be subject to penalties imposed by a civil or criminal court, which may not exceed $5,000 or a class B misdemeanor for the first violation and a class A misdemeanor for any subsequent similar violation within two years.

 

KEY: health, hospital policy, health planning

Date of Enactment or Last Substantive Amendment: [February 27, 2004]2012

Notice of Continuation: November 30, 2011

Authorizing, and Implemented or Interpreted Law: 26-33a-104; 26-33a-108