Ambulatory Surgical Treatment Center / Outpatient Diagnostic Center Data System User Manual CMS-1500 and UB-04 Reporting 2020 ASTC/ODC Data System User Manual (January 2020) Ambulatory Surgical Treatment Center / Outpatient Diagnostic Center Data System User MManual Tennessee Department of Health Tennessee Department of Health Office of Healthcare Statistics Office of Healthcare Statisstics Division of Population Health Assessment Division of Population Health Assessment Andrew Johnson Tower, 2nd Floor 710 Andrew Johnson Tower, 2nd Floor James Robertson Parkway 710 JamesNash vRille,oberts TN oon37243 Par kway Nash61v5-741-19ille, TN5 4 37243 615-741-1954 ASTC/ODC Data System User Manual (January 2020) Table of Contents Section I: Introduction 1. Introduction to CMS-1500 and UB-04 Reporting .......................................................... 5 2. Changes in the Manual from 2013 through 2018 ........................................................ 6 Section II: Reporting Information CMS-1500 and UB-04 Reporting 1. General Reporting Requirements .................................................................................. 9 2. Special Reporting Requirements ................................................................................. 11 3. Required Fields for CMS-1500 and UB-04 Data ........................................................... 12 4. Vendor Reporting Instructions ..................................................................................... 13 5. CMS-1500 Data System Summary ............................................................................... 16 6. UB-04 Data System Summary ...................................................................................... 18 7. Schedule of Data Submission ...................................................................................... 21 8. Format for Data Submission ........................................................................................ 22 9. Patient Record Data System Contacts ......................................................................... 23 Section III: Field Information CMS-1500 Reporting 1. Required Data Elements and Codebook Definitions ................................................... 25 2. Data Dictionary ............................................................................................................ 29 3. Data Record Format .................................................................................................. 108 Section IV: Field Information UB-04 Reporting 1. Required Data Elements and Codebook Definitions………………………………………… 115 2. Data Dictionary …………………………………………………………………………………………… 119 3. Data Record Format ……………………………………………………………………………………… 218 Section V: Appendices 1. Enabling Legislation .................................................................................................. 227 2. Rules and Regulations ............................................................................................... 229 3. CMS-1500 Reporting Form ........................................................................................ 238 4. UB-04 Reporting Form .............................................................................................. 239 5. US Standard State Abbreviations .............................................................................. 240 6. English Country Names and Code Elements ISO 3166-1 .......................................... 241 ASTC/ODC Data System User Manual (January 2020) SECTION I ASTC/ODC Data System User Manual (January 2020) Introduction to CMS-1500 and UB-04 Reporting Traditionally surgeries were performed in hospitals as inpatient procedures. But in past years, a new trend arose. Concerns about rising hospital costs have led to an increasing proportion of surgeries being performed on an outpatient basis. With the shift to outpatient surgery a second trend arose. Numerous outpatient surgery facilities were built independent of hospitals. These facilities, called ambulatory surgical treatment centers, specialize in performing outpatient surgeries. They do not offer the full range of services provided by a hospital. An increasing proportion of surgeries are now being performed in these facilities. The Department of Health has been collecting information from UB-04 billing claims on all outpatient surgeries performed in Tennessee hospitals since 1995 and started collecting from Ambulatory Surgical Treatment Centers (ASTC) in 2007. T. C. A. 68-1-119 requires each licensed ambulatory surgical treatment center (ASTC) and each licensed outpatient diagnostic center (ODC) in the state to report its claims data to the Tennessee Department of Health. Administrative rule 1200-7-4 was promulgated by the Department to carry out this legislative mandate. This data is to be reported quarterly in the appropriate format via third party entities approved by the Department. Personal identifiers are to be kept confidential. Penalties are prescribed for failure to report. Patient Record Data Systems (PRDS), part of the Division of Population Health Assessment, has been charged by the Department to carry out this project. Each ASTC will transmit its records to the vendor it has selected. Each vendor will send the records it has received from its ambulatory surgical treatment centers to PRDS. Both CMS-1500 claims data and UB-04 claims data will be collected. Each type of claim data should be reported according to its layout in this manual. Several applications are foreseen for the ASTC/ODC data depending on the needs of the end- user. Measures of resource use are valuable for health planning and certificate of need evaluations. These look at the volume of activity for treating various health conditions and for performing various procedures. Public health users would likewise be interested in these measures of resource use by diagnoses and procedures. Also they would want to look at the data to help gain better assessments of the incidence and prevalence of various diseases and health-related conditions. They also are concerned with charges to help assess the costs of health care, both in total and for specific problems. Business users will be interested in the volume of activity in various locations and in various health care segments. They will also be interested in relative charges in the highly competitive health care market. Besides the use of the ASTC data alone, it can be used in conjunction with hospital and ODC data. This can be done either to compare these sources of similar services or to combine them to get a more complete picture of the total usage of health care in Tennessee. ASTC/ODC Data System User Manual (January 2020) 5 Changes in the Manual from 2013 through 2018 Numerous and significant changes have been made to the ASTC/ODC Manual from 2013 through 2018. Some fields have been modified, or codes have been added or omitted for current fields. To match these changes, please review the new reporting instructions needed for claims data reporting. The Following Changes Have Been Made From The 2013 ASTC/ODC Manual: The field First Date Patient Has Had Same or Similar Illness in the CMS-1500 Data Dictionary has been replaced by Other Date. 8 fields have been added to the field Diagnosis or Nature of Illness or Injury Code reflecting the 12 fields in total from the CMS-1500 claims. The field Date Identifier has been added to the CMS-1500 Data Dictionary. The field Patient’s Status (Marital) has been removed from the CMS-1500 Data Dictionary. The field Patient’s Status (Employment) has been removed from the CMS-1500 Data Dictionary. The field Insured’s Employer/School has been removed from the CMS-1500 Data Dictionary. HCPCS/Rates/HIPPS Rates Codes The field Patient Discharge Status has Code “21” (Discharged/Transferred to Court/Law Enforcement) and “81”-“95” added to the UB-04 Data Dictionary. Additional Patient Discharge Codes Several new patient discharge codes have taken effect as of October 1, 2013. See pages 143-144 for the Base Codes and the New Codes. Conversion to ICD-10-CM codes As of October 1, 2015, all patient data changed to the ICD-10-CM coding format. The Tennessee Department of Health (TDH) allowed ASTC/ODC, starting with fourth quarter (October through December 2015) discharge data, the option to submit either ICD-9-CM or ICD-10-CM diagnosis codes. Both will not be allowed in the same file. However, beginning with January 1, 2016, there must be a full conversion over to ICD-10-CM coding. Any data that contains the ICD-9-CM coding after January 1, 2016, will be flagged as a FATAL error. New Payer Codes Starting January 1, 2016 several payer codes have changed and some have been deleted. See pages 88- 91 and 160-165 for all current valid payer codes. New Source of Admission Codes Several codes for the field Source of Admission have changed and some have been deleted. See pages 141-142 for all valid values of this field. ASTC/ODC Data System User Manual (January 2020) 6 Changes in the Manual from 2013 through 2018 (continued) Reporting National Provider Identifier (NPI) The requirement for health providers to change from the Unique Physician Identification (UPIN) to the NPI for Medicare billing took place in May 2007. All health providers and suppliers who provide services and bill Medicare for these services and supplies must have an NPI. The NPI is a national standard under the Health Insurance Portability and Accountability Act (HIPAA). It is a unique identification number for covered healthcare providers and