No. 38565 (Repeal and Reenact): Rule R428-11. Health Data Authority Ambulatory Surgical Data Reporting Rule

(Repeal and Reenact)

DAR File No.: 38565
Filed: 06/02/2014 09:55:55 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

This filing is in response to a review of Title R428 that identified inconsistencies in the writing of the rule.

Summary of the rule or change:

Items in the repealed rule that are not in the reenacted rule: subsections for definitions, compiling of electronic transactions, data security and integrity, exemptions, extensions, and waivers, and penalties. Items in the reenacted rule not in the old rule: none. Other changes: removes definitions of terms, exemption and extension procedures, and penalties contained in Rule R428-2. Makes technical and conforming amendments. (DAR NOTE: the proposed repeal and reenactment of Rule R428-2 is under DAR No. 38562 in this issue, June 15, 2014, of the Bulletin.)

State statutory or constitutional authorization for this rule:

• Title 26, Chapter 33a

Anticipated cost or savings to:

the state budget:

This amendment makes technical changes that improve consistency and clarity of Rule R428-11. The Utah Department of Health (UDOH) determines that these changes will not create any cost or savings impact to the state budget or UDOH's budget, since the changes will not increase workload and can be carried out with existing budget.

local governments:

This filing does not create any direct cost or savings impact to local governments since they are not directly affected by the rule; nor are local governments indirectly impacted because the rule does not create a situation requiring services from local governments.

small businesses:

None--Small businesses will not be impacted by this rule change--as a result, the rule will have no effect on small business budgets for costs or savings.

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

Minor technical changes in Rule R428-11 will not create any cost or savings to businesses, individuals, local governments or persons that are not small businesses.

Compliance costs for affected persons:

There are no compliance costs for persons affected by these changes to Rule R428-11. Although there are several modifications within this amendment, they will not impact affected persons.

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

No effect on business because it does not materially modify current operations.

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 [e-mail]
• Rex Olsen at the above address, by phone at 801-538-9498, by FAX at 801-536-0940, or by Internet E-mail at [e-mail]
• Norman Thurston at the above address, by phone at 801-538-7052, by FAX at 801-237-0787, or by Internet E-mail at [e-mail]

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:

07/15/2014

This rule may become effective on:

07/22/2014

Authorized by:

David Patton, Executive Director

RULE TEXT

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

R428-11. Health Data Authority Ambulatory Surgical Data Reporting Rule.

[ R428-11-1. Legal Authority.

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

 

R428-11-2. Purpose.

This rule establishes the reporting standards for ambulatory surgery data by licensed hospitals and ambulatory surgical facilities. The data are needed to develop and maintain a statewide ambulatory surgical data base.

 

R428-11-3. Definitions.

These definitions apply to rule R428-11.

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

(2) "Ambulatory surgery data" means the consolidation of complete billing, medical, and personal information describing a patient, the services received, and charges billed for a surgical or diagnostic procedure treatment in an outpatient setting into a data record.

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

(4) "Ambulatory surgical facility" means a facility that is licensed under R26-21-2.

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

(6) "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.

(7) "Electronic media" means a magnetic tape or a diskette.

(8) "Electronic transaction" means to submit data directly via electronic connection from a hospital or ambulatory surgery facility to the Office according to Electronic Data Interchange standards established by the American National Standards Institute's Accredited Standards Committee, known as the Health Care Transaction Set (837) ASC X 12N.

(9) "Committee" means the Utah Health Data Committee created by Title 26, Chapter 33a.

 

R428-11-4. Reporting Source of Ambulatory Surgical Data.

The reporting sources for ambulatory surgery data are Utah licensed general acute care hospitals and ambulatory surgical facilities.

(1) A general acute care hospital shall report discharge data records for each surgical outpatient discharged from its facility.

(2) An ambulatory surgical facility shall report surgical and diagnostic procedure data records for each patient discharged from its facility.

(3) A hospital or ambulatory surgical facility may designate an intermediary or may submit ambulatory surgery data directly to the Office.

(4) Each hospital and ambulatory surgical facility is responsible for compliance with the rule. Use of a designated intermediary does not relieve the hospital or ambulatory surgical facility of its reporting responsibility.

(5) Each hospital and ambulatory surgical facility shall designate a department and a person within the department who is responsible for submitting the discharge data records. This person shall also be responsible for communicating with the Office.

 

R428-11-5. Electronic Media Data Submittal Schedule.

Each hospital and ambulatory surgical facility shall submit to the Office a single outpatient surgical data record for each patient discharged according to the schedule shown in Table 1, Hospital and Ambulatory Surgical Facility Data Submittal Schedule,or a schedule mutually agreed upon by the Office and hospital or ambulatory surgical facility.

 

TABLE 1
HOSPITAL AND AMBULATORY SURGICAL FACILITY
DATA SUBMITTAL SCHEDULE

      IF PATIENT'S DATE OF                    DISCHARGE DATA RECORD   DISCHARGE 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 

 

For a patient with multiple discharges, each hospital or ambulatory surgical facility submitting electronic media shall submit a single data record for each discharge. For a patient with multiple billing claims each hospital or ambulatory surgical facility shall consolidate the multiple billings into a single data record for submission after the patient's discharge.

 

R428-11-6. Electronic Transaction Data Submittal.

Hospitals and ambulatory surgical centers may request data submission by electronic transaction, as submitted to the payer through the Exemptions, Extensions, and Waivers process.

 

R428-11-7. Selection of Records to Submit via Electronic Media.

Each hospital or ambulatory surgical facility licensed in Utah shall report to the Office information relating to any patient surgical or diagnostic procedure falling within the types described in Table 2, as defined by the corresponding CPT codes and ICD-9-CM codes. In case of changes in the CPT and/or ICD-9-CM codes in future versions, the most current list shall override the lists in Table 2.

 

TABLE 2
TYPES OF SURGICAL SERVICE TO BE SUBMITTED
IF PERFORMED IN OPERATING OR PROCEDURE ROOM

      DESCRIPTION              CPT CODES      ICD-9-CM CODES      Mastectomy               19120-19220    850-8599   Musculoskeletal          20000-29909    760-8499   Respiratory              30000-32999    300-3499   Cardiovascular           33010-37799    350-3999   Lymphatic                38100-38999    400-4199   Diaphragm                39501-39599   Digestive System         40490-49999    420-5499   Urinary                  50010-53899    550-5999   Male Genital             54000-55899    600-6499   Laparoscopy              56300-56399   Female Genital           56405-58999    650-7199   Endocrine/Nervous        60000-64999    010-0799   Eye                      65091-68899    080-1699   Ear                      69000-69979    180-2099   Heart Catheterization    93501-93660   3721-3723   Nose, Mouth, Pharynx                    210-2999 

 

R428-11-8. Data Element Reporting via Electronic Media.

Table 3 displays the reportable data elements. Hospitals and ambulatory surgical facilities shall report the required data elements shown in Table 3, beginning December 15, 1997.

The Office shall provide to each hospital and ambulatory surgical facility an Ambulatory Surgery Data Submittal Technical Manual which outlines the specifications, format, and types of data to report. The Ambulatory Surgery Data Submittal Technical Manual is effective on November 15, 1997.

 

TABLE 3
REQUIRED AMBULATORY SURGERY AND MAJOR PROCEDURE
DATA ELEMENTS FOR ELECTRONIC MEDIA REPORTING

      CATEGORY:        NAME:   Provider   1                Medical care provider identifier   Patient   2                Patient control number   3                Patient's medical chart number   4                Patient's Social Security Number   5                Patient's postal zip code for address   6                Patient's date of birth   7                Patient's gender   Service   8                Admission date   9                Source of admission   10               Patient's status   11               Discharge date   Diagnosis and Treatment   12               Diagnosis codes   13               Procedure codes   14               Date of principal procedure   15               Modifiers for procedure codes   16               ICD9 Procedure Codes   17               Related Diagnosis Codes   Charge   18               Statement covers period   19               Total facility charge   20               Primary, secondary, and third sources of payment   Physician   21               Performing physician ID   22               Additional physicians' IDs   23               Type of bill (for hospital, if applicable)

 

R428-11-9. Compiling of Electronic Transactions.

The Office shall retain records and data elements that meet specifications listed in Tables 2 and 3 and discard all other records and data elements received via electronic transaction.

 

R428-11-10. Data Security and Integrity.

The Office 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 Office 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 limited data fields within 18 months of submittal.

 

R428-11-11. Exemptions, Extensions, and Waivers.

(1) Hospitals and ambulatory surgical facilities may submit requests for exemptions or waivers to the Committee at least 60 calendar days prior to the due date as listed in the data submittal schedule in R428-11-5, Table 1. Exemptions or waivers to the requirements of this rule may be granted for a maximum of one calendar year. A hospital or ambulatory surgical facility 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 data submittal schedule. Extensions to the submittal schedule may be granted for a maximum of 30 calendar days. The hospital or ambulatory surgical facility must separately request each additional 30 calendar day extension.

(3) The Committee may grant exemptions or waivers when the hospital or ambulatory surgical facility demonstrates that compliance imposes an unreasonable cost to the hospital. The Office may grant extensions when the hospital or ambulatory surgical facility 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 manuals available from the Office. Exemptions, extensions, or waivers may be granted for the following:

(a) Hospital or ambulatory surgical facility exemption: All hospitals and ambulatory surgical facilities are subject to the reporting requirements. Reasons justifying an exemption might be such as 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 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.

 

R428-11-12. 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.]

R428-11-1. Legal Authority.

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

 

R428-11-2. Purpose.

This rule establishes the reporting standards for ambulatory surgery data by licensed hospitals and ambulatory surgical facilities. The data will be used to develop and maintain a statewide ambulatory surgical data base.

 

R428-11-3. Source of Ambulatory Surgical Data.

The reporting sources for ambulatory surgery data are Utah licensed general acute care hospitals and ambulatory surgical facilities.

(1) A general acute care hospital shall report discharge data records for each surgical outpatient discharged from its facility.

(2) An ambulatory surgical facility shall report surgical and diagnostic procedure data records for each patient discharged from its facility.

(3) For a patient with multiple discharges, each hospital or ambulatory surgical facility submitting electronic media shall submit a single data record for each discharge. For a patient with multiple billing claims each hospital or ambulatory surgical facility shall consolidate the multiple billings into a single data record for submission after the patient's discharge.

(4) A hospital or ambulatory surgical facility may designate an intermediary or may submit ambulatory surgery data directly to the Office.

(5) Each hospital and ambulatory surgical facility is responsible for compliance with the rule. Use of a designated intermediary does not relieve the hospital or ambulatory surgical facility of its reporting responsibility.

(6) Each hospital and ambulatory surgical facility shall designate a department or other appropriate entity and a person who is responsible for submitting the discharge data records. This person shall also be responsible for communicating with the Office.

(7) The Department of Health may conduct on-site audits to verify the accuracy of all submittals.

 

R428-11-4. Data Submittal Schedule.

Each hospital and ambulatory surgical facility shall submit to the Office outpatient surgical data according to the schedule shown in Table 1. The Director of the Office may approve an alternate schedule as long as it meets the needs of the committee.

 

TABLE

   (1) DATA SUBMITTAL SCHEDULE      IF PATIENT'S DATE OF                    DISCHARGE DATA RECORD   DISCHARGE 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 

 

R428-11-5. Data Element Reporting.

(1) Each data supplier shall submit to the Office information relating to any patient surgical or diagnostic procedure falling within the types described in Table 2, as defined by the corresponding CPT codes and ICD-9-CM codes. In case of changes in the CPT and/or ICD-9-CM codes in future versions, the most current list shall override the lists in Table 2.

(2) Table 3 lists the required data elements. Each data supplier shall collect and submit all data elements shown in Table 3 based on the specifications in the Submittal Manual for Ambulatory Surgery Data.

(3) Each data supplier shall collect patient social security number as a required data element and report the patient social security number with the complete discharge record according to the submittal schedule.

(4) The Office shall adopt an encryption method for the patient social security number by creating a record linkage number as the control number.

(5) Each data supplier shall submit the reported data elements on encrypted electronic media acceptable to the Office or send them electronically through the Utah Health Information Network or another compatible electronic data interchange network or other secure upload or secure email method.

 

TABLE

      (2) SURGICAL SERVICES TO BE SUBMITTED      DESCRIPTION              CPT CODES      ICD-9-CM CODES   Mastectomy               19120-19396    850-8599   Musculoskeletal          20000-29909    760-8499   Respiratory              30000-32999    300-3499   Cardiovascular           33010-37799    350-3999   Lymphatic                38100-38999    400-4199   Diaphragm                39501-39599   Digestive System         40490-49999    420-5499   Urinary                  50010-53899    550-5999   Male Genital             54000-55899    600-6499   Laparoscopy              56300-56399   Female Genital           56405-58999    650-7199   Endocrine/Nervous        60000-64999    010-0799   Eye                      65091-68899    080-1699   Ear                      69000-69979    180-2099   Heart Catheterization    93501-93660   3721-3723   Nose, Mouth, Pharynx                    210-2999   NOTE (1):  IF PERFORMED IN OPERATING OR PROCEDURE ROOM 

 

 

TABLE

   (3) REQUIRED DATA ELEMENTS      CATEGORY:        NAME:   Provider   1                Medical care provider identifier   Patient   2                Patient control number   3                Patient's medical chart number   4                Patient's Social Security Number   5                Patient's postal zip code for address   6                Patient's date of birth   7                Patient's gender   Service   8                Admission date   9                Source of admission   10               Patient's status   11               Discharge date   Diagnosis and Treatment   12               Diagnosis codes   13               Procedure codes   14               Date of principal procedure   15               Modifiers for procedure codes   16               ICD9 Procedure Codes   17               Related Diagnosis Codes   Charge   18               Statement covers period   19               Total facility charge   20               Primary, secondary, and third sources of payment   Physician   21               Performing physician ID   22               Additional physicians' IDs   23               Type of bill (for hospital, if applicable) 

 

KEY: health, hospital policy, health planning

Date of Enactment or Last Substantive Amendment: [February 27, 2004]2014

Notice of Continuation: November 14, 2012

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

 

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