As in effect on June 1, 2008
This rule is promulgated under authority granted by Title 26, Chapter 33a, and in accordance with the Health Data Plan.
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.
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.
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.
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.
Hospitals and ambulatory surgical centers may request data submission by electronic transaction, as submitted to the payer through the Exemptions, Extensions, and Waivers process.
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
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)
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.
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.
(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.
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.
health, hospital policy, health planning
February 27, 2004
April 21, 2008
26-33a-104; 26-33a-108
Rule converted into HTML by the Division of Administrative Rules.
For questions regarding the content or application of rules under Title R428, please contact the promulgating agency (Health, Center for Health Data, Health Care Statistics). A list of agencies with links to their homepages is available at http://www.utah.gov/government/agencylist.html.
For questions about the rulemaking process, please contact the Division of Administrative (801-538-3764). Please Note: The Division of Administrative Rules is not able to answer questions about the content or application of these rules.
The HTML version of this rule is a convenience copy. This information is made available on the Internet as a public service. Please see this disclaimer about information available from www.rules.utah.gov.