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12VAC5-218-10

12VAC5-218-10. Definitions.

The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

"Board" means the State Board of Health.

"Inpatient hospital" means a hospital providing inpatient care and licensed pursuant to Article 1 (§ 32.1-123 et seq.) of Chapter 5 of Title 32.1 of the Code of Virginia, a hospital licensed pursuant to Chapter 8 (§ 37.1-179 et seq.) of Title 37.1 of the Code of Virginia, a hospital operated by the Department of Mental Health, Mental Retardation and Substance Abuse Services for the care and treatment of the mentally ill, or a hospital operated by the University of Virginia or Virginia Commonwealth University Health System Authority.

"Nonprofit organization" means a nonprofit, tax-exempt health data organization with the characteristics, expertise and capacity to execute the powers and duties set forth for such entity in Chapter 7.2 (§ 32.1-276.2 et seq.) of Title 32.1 of the Code of Virginia and with which the Commissioner of Health has entered into a contract as required by the Code of Virginia.

"Outpatient processed, verified data" means data on outpatient records that have been subjected to edits fulfill the requirements specified in 12VAC5-218-25. These edits shall be applied to data elements that are on the UB-92 Billing Form, HCFA 1500 Billing Form or a nationally adopted successor billing form used by reporting entities. The edits shall have been agreed to by the board and the nonprofit organization. Outpatient records containing invalid UB-92 codes, HCFA 1500 codes, another nationally adopted billing form codes or all blank fields for any of the data elements subjected to edits shall be designated as error records. To be considered processed and verified, a complete filing of outpatient surgical procedures specified by the board submitted by a reporting entity in aggregate per calendar year quarter and that are subjected to these edits must be free of error at a prescribed rate. The overall error rate shall not exceed 5.0%. A separate error rate shall be calculated for patient identifier, and it shall not exceed 5.0%. The error rate shall be calculated on only those fields approved by the board through the process specified in 12VAC5-218-20.

"Outpatient surgery" surgical procedures" means all surgical procedures performed on an outpatient basis in a general hospital, ordinary hospital, outpatient surgical hospital or other facility licensed or certified pursuant to Article 1 (§ 32.1-123 et seq.) of Chapter 5 of Title 32.1 of the Code of Virginia or in a physician's office or oral and maxillofacial surgeon's office as defined by § 32.1-276.3 of the Code of Virginia. Outpatient surgery refers only to those surgical procedure groups on which data are collected by the nonprofit organization as a part of a pilot study.

"Physician" means a person licensed to practice medicine or osteopathy in the Commonwealth pursuant to Chapter 29 (§ 54.1-2900 et seq.) of Title 54.1 of the Code of Virginia.

"Physician's office" means a place (i) owned or operated by a licensed physician or group of physicians practicing in any legal form whatsoever or by a corporation, partnership, limited liability company or other entity that employs or engages physicians and (ii) designed and equipped solely for the provision of fundamental medical care, whether diagnostic, therapeutic, rehabilitative, preventive or palliative, to ambulatory patients.

"Reporting entity" means every general hospital, ordinary hospital, outpatient surgical hospital or other facility licensed or certified pursuant to Article 1 (§ 32.1-123 et seq.) of Chapter 5 of Title 32.1 of the Code of Virginia and every physician performing surgical procedures in his office or oral and maxillofacial surgeon's office as defined by § 32.1-276.3 of the Code of Virginia.

"Surgical procedure group" means at least five procedure groups, identified by the nonprofit organization designated pursuant to § 32.1-276.4 of the Code of Virginia in compliance with regulations adopted by the board, based on criteria that include, but are not limited to, the frequency with which the procedure is performed, the clinical severity or intensity, and the perception or probability of risk. The nonprofit organization shall form a technical advisory group consisting of members nominated by its board of directors' nominating organizations to assist in selecting surgical procedure groups to recommend to the board for adoption.

"System" means the Virginia Patient Level Data System.

12VAC5-218-20

12VAC5-218-20. Reporting requirements for outpatient data elements.

Every reporting entity performing outpatient surgical procedures shall submit each patient level data element listed below in the table in this section for each patient for which an outpatient surgical procedure is performed and for which the data element is collected on the standard claim form utilized by the reporting entity. Most of these data elements are currently collected from a UB-92 Billing Form or HCFA 1500 Form In the table below, the column for a field description indicates where the data element is located on the UB-92 and HCFA 1500 forms. An asterisk (*) indicates when the required data element is either not on the UB-92 or the HCFA 1500. The instructions provided under that particular data element should then be followed. If a successor billing form to the UB-92/HCFA 1500 form is adopted nationally, information pertaining to the data elements listed below should be derived from that successor billing form Uniform Billing Form (UB-04) located in the latest publication of the Uniform Billing Manual prepared by the National Uniform Billing Committee or from the Centers for Medicare and Medicaid (CMS) Health Insurance Claim Form (CMS 1500). The Uniform Billing Form and the Uniform Billing Manual are located on the National Uniform Billing Committee's website at www.nubc.org. The Centers for Medicare and Medicaid Health Insurance Claim Form is available on the CMS website at www.cms.gov. Every reporting entity performing outpatient surgical procedures shall submit in an electronic data format. The nonprofit organization will develop detailed record layouts for use by reporting entities in reporting outpatient surgical data. This detailed record layout will be based upon the type of base electronic or paper-billing form utilized by the reporting entity. Outpatient surgical procedures reported will shall be those adopted by the Board of Health board as referred by the nonprofit organization. The nonprofit organization may recommend changes to the list of procedures to be reported not more than annually.

Data Element Name

Instructions

UB-92 Form Locator

HCFA 1500 Field Number

Hospital Identifier

Hospitals and ambulatory care centers enter the six-digit Medicare provider number, or when adopted by the Board of Health board, the National Provider Identifier or other number assigned by the board. Physicians, leave blank.

N/A-see instructions

N/A-see instructions

Operating Physician or Oral and Maxillofacial Surgeon Identifier

Enter the nationally assigned physician identification number, either the Uniform Physician Identification Number (UPIN), National Provider Identifier (NPI) or it's its successor as approved by the Board of Health board for the physician identified as the operating physician for the principal procedure reported.

83 A & B

17a but with NPI

Payor Identifier

Enter the Board of Health board approved payor designation which will be the nationally assigned PAYERID, it's its successor, or English description of the payor.

50 A, B, C 50-1 through 50-11 as described in instructions

9d as described in instructions

Employer Identifier

Enter the federally approved EIN, or employer name, whichever is adopted by the Board of Health board.

65 A with name/codes noted in instructions

9c with name/codes noted in instructions

Patient Identifier

Enter the nine-digit social security number of the patient. If a social security number has not been assigned, leave blank. The nine-digit social security number is not required for patients under four years of age.

Not specified as to patient

Not specified as to patient

Patient Sex

15

3

Date of Birth

Enter the code in MM/DD/YYYY format.

14 Must be in format specified in instructions

3 Must be in format specified in instructions

Street Address

City or County

Zip Code

13

5

Patient Relationship to insured

59 A, B, C

6

Employment status code Status Code

64 A, B, C

8

Status at discharge Discharge

22

Use outpatient UB-92 codes

Admission Date

Admission/start of care date

17

24 A

Admission Hour

Hour of admission in military time 00-24

18

See instructions

Admission Diagnosis

Code sets- ICD 9 or CPT 4 or their successors to be specified in detailed record layouts.

76

*

Principal Diagnoses

Code sets- ICD 9 or CPT 4 or their successors to be specified in detailed record layouts.

67

21-1

Secondary Diagnoses

Code sets- ICD 9 or CPT 4 or their successors to be specified in detailed record layouts.

68 to 75t

21-2 to 21-4

External Cause of Injury

(E-code). Record all external cause of injury codes in secondary diagnoses position after recording all treated secondary diagnoses.

77

*

Co-morbid condition existing Condition Existing but not treated Treated

Enter the code for any co-morbid conditions existing but not treated. Code sets- ICD 9 or CPT 4 or their successors to be specified in detailed record layouts.

*

*

Procedures

Code sets- ICD 9 or CPT 4 or their successors to be specified in detailed record layouts.

80

24d:1 to 24d:6

Procedure Dates

81

24a:1 to 24a:6

Revenue Center codes Codes

As specified for UB –92 UB-04 or its successor completion, not available for HCFA 1500 CMS 1500 or its successor

42

N/A

Revenue Center Units

46

24g:1 to 24g:6

Revenue Center charges Charges

47

24f:1 to 24f:6

Total Charges

(R.C. Code 001 is for total charges.)

28

12VAC5-218-25

12VAC5-218-25. Requirements of outpatient processed verified data.

To be considered processed and verified, a complete filing of outpatient surgical procedures specified by the board submitted by a reporting entity in aggregate per calendar year quarter must be free of error at a prescribed rate. The prescribed minimum accuracy rate shall be 95% overall, with patient identifier separately calculated at 95%. The accuracy rate shall be calculated on only those fields designated in 12VAC5-218-20. Outpatient records containing invalid codes or all blank fields for any of the data elements shall be designated as error records.

12VAC5-218-30

12VAC5-218-30. Options for filing format. (Repealed.)

Reporting entities that perform on an annual basis 100 or more of the specified outpatient surgical procedures shall submit patient level data in an electronic data format. Reporting entities performing fewer than 100 of the specified outpatient surgical procedures annually that submit patient level data directly to the board or the nonprofit organization may directly submit it in electronic data format or in hard copy. If hard copy is utilized, the reporting entity shall submit for each outpatient discharged a copy of the UB-92/HCFA 1500 and an addendum sheet for those data elements not collected on the UB-92/HCFA 1500 or nationally adopted billing form. These reporting entities performing specified outpatient surgical procedures must submit all outpatient patient level data in electronic data format by January 1, 2004.

12VAC5-218-40

12VAC5-218-40. Options for submission.

A. Each reporting entity shall submit outpatient level data in one of the following methods:

1. A reporting entity may submit the outpatient patient level data to the board for processing and verification. If data is submitted in this fashion, the board will shall transmit it to the nonprofit organization along with any fees submitted by the reporting entity to the board for the processing and verification of such data. Fees shall not exceed $ .75 per record. Fees shall not be applied to state agencies reporting data.

As an alternative to submitting the outpatient patient level data to the board, a 2. A reporting entity may submit the outpatient patient level data along with any fees to the office of the nonprofit organization for processing and verification. If this alternative is chosen, the reporting entity reporting the outpatient patient level data shall notify the board and the nonprofit organization of its intent to follow this procedure.

In lieu of submitting the patient level data to the board or to the nonprofit organization, a 3. A reporting entity may submit already processed, verified data to the nonprofit organization. In the event that processed, verified data is submitted no fees shall be applied. If a reporting entity chooses this alternative for submission of patient level data, it shall notify the board and the nonprofit organization of its intent to utilize this procedure.

B. If a reporting entity decides to change the option it has chosen, it shall notify the board of its decision 30 days prior to the due date for the next submission of patient level data.

12VAC5-218-50

12VAC5-218-50. Contact person.

Each reporting entity shall notify in writing the board and the nonprofit organization in writing of the name, address, telephone number, email (where available) and fax number (where available) of a contact person. If the contact person changes, the board and the nonprofit organization shall be notified in writing as soon as possible of the name of the new person who shall be the contact person for that reporting entity.

12VAC5-218-9998

FORMS (12VAC5-218)

National Uniform Billing Committee Uniform Billing Form UB-04 (undated)

Centers for Medicare and Medicaid Health Insurance Claim Form, Sample Form, CMS 1500 (approved 2/12)