Administrative Healthcare Data: A Guide to Its Origin, Content, and Application Using SAS

Description

Explains the source and content of administrative healthcare data, which is the product of financial reimbursement for healthcare services. The book integrates the business knowledge of healthcare data with practical and pertinent case studies as shown in SAS Enterprise Guide. Contents About This Book Purpose Is This Book for You? What’s New in This Edition About the Examples Software Used to Develop the Book's Content Example Code and Data Keep in Touch To Contact the Author through SAS Press SAS Books SAS Book Report About These Authors Acknowledgments Chapter 1 Introduction Data and Programming Used in This Book Terminology Table 1.1: Synonymous Terminology Flow of Administrative Healthcare Data Figure 1.1: Industry Relationships Drive the Movement of Administrative Healthcare Data Key Players Figure 1.2: Industry Payers and Providers Medical Claim Submission Claim Processing Recent Legislative Effects HIPAA Affordable Care Act All Payer Claims Database Continuing Enhancements Conclusion Chapter 2 Introduction Sample Data Table 2.1: Types of Claims Data Figure 2.1: Conceptual Data Model What Is SAS Enterprise Guide? Table 2.2: Selected Capabilities of Tasks Menu in Enterprise Guide SAS Libraries and Data Sets Create a Permanent Library Figure 2.2: Create a Library in SAS Enterprise Guide View a SAS Data Set Figure 2.3: Navigate through SAS Server Libraries Figure 2.4: FacilityHeader Data Set SAS Data Types Figure 2.5: View Properties of a Variable Formats DRG Format Figure 2.6: Create Format from Data Set Figure 2.7: The Formats Catalog Diagnosis Code Format Figure 2.8: The Dx Look up Table Figure 2.9: Diagnosis Code Columns in FacilityHeader Figure 2.10: Query Builder Task Figure 2.11: Create a Computed Column Figure 2.12: Query Builder Task with Computed Column Figure 2.13: Data Set DxNomen Figure 2.14: Diagnosis Format Applying Formats to SAS Variables Formatting an Existing Variable Figure 2.15: Format an Existing Variable Figure 2.16: Use a User-Defined Format Figure 2.17: Formatted DRG Placing Results of a Format into a New Variable Conclusion Chapter 3 Introduction Health Insurance Medicare Table 3.1: Elements of Medicare Medicaid Commercial Insurance Others TRICARE CHAMPVA FECA Black Lung Conclusion Chapter 4 Introduction Types of Providers Figure 4.1: Four categories of healthcare providers Facility Table 4.1: Key data elements on Facility claims Professional Pharmacy Ancillary National Provider Registry Table 4.2: Disclosable data content of the National Provider Registry NPI Taxonomy Table 4.3: Taxonomy code structure Other Provider Identifiers Table 4.4: Other provider IDs Case Study: Standardizing Provider Names from the National Provider Registry Figure 4.2: Sample Registry Records Figure 4.3: Data set WORK.NPI_ProvNameTemp Figure 4.4: Standardized Provider Name from the Registry Case Study: Using Taxonomy Code to Identify Primary Care Physicians Figure 4.5: Select taxonomy codes and associated descriptors Figure 4.6: Basic PCP definition Conclusion Chapter 5 Introduction CMS-1450 Paper Claim Form 837I Electronic Claim Format Data Elements Unique to Facilities Type of Bill Table 5.1: First position of TOB (-xx) Table 5.2: Second position of TOB when first is not 7 or 8 (x-x) Table 5.3: Second position of TOB for clinics (7-x) Table 5.4: Second position of TOB for special facilities (8-x) Table 5.5: Third position of TOB—bill sequence (xx-) Admission and Discharge Dates Patient Discharge Status Revenue Code Table 5.6: Revenue code category examples Diagnosis Codes Table 5.7: CMS-1450/837I diagnosis code (DX) types Present on Admission Table 5.8: Present on Admission code values Surgical Procedure Codes DRG Provider IDs Others Table 5.9: Other codes unique to facility claims Case Study: Calculating C-Section Rates among Hospitals Create Summary Data Set for All Births Figure 5.1: Adding filters in Query Builder Figure 5.2: Summarize data Figure 5.3: All births by ProviderID Create Summary Data Set for C-Section Births Figure 5.4: Modify an existing task Figure 5.5: Modify an existing filter Figure 5.6: Modify query Figure 5.7: C-section task and summary data set Join Summary Data Sets Figure 5.8: Join tables Figure 5.9: C-section rates and CSection AmtPaid as a percentage of total AmtPaid Create Bar Graphs Figure 5.10: Create a bar chart Figure 5.11: Verify data source Figure 5.12: Assign variables Figure 5.13: C Section Rates by Provider Case Study: Top Reasons for ER Utilization Figure 5.14: Top reasons for ER visits query Figure 5.15: Filter Top N Reasons for ER query Figure 5.16: Sort data Figure 5.17: Top N Reasons for ER visits Automating Reports with SAS Enterprise Guide Figure 5.18: C-section case study process flow Creating Documentation in SAS Enterprise Guide Figure 5.19: Documentation in SAS Enterprise Guide Conclusion Chapter 6 Introduction Medical Claim Submission CMS-1500 Claim Form 837P Electronic Claim Format Data Elements Unique to CMS-1500/837P Demographic Information Diagnosis Codes Diagnosis Pointer Provider Identifiers Procedure Codes and Modifiers Place of Service Provider Specialty Payment Methodologies Case Study: Identifying Children Who Miss Their Checkups Figure 6.1: Members table Identify Currently Enrolled Children under Six Years of Age Figure 6.2: Create a basic filter on a computed item Figure 6.3: Build a basic filter Figure 6.4: Adding filters in Query Builder Figure 6.5: CurrentMembersKids table Import Excel Data Figure 6.6: Procedure codes used to identity professional claims of interest Figure 6.7: Import Excel data using Enterprise Guide Figure 6.8: Import Excel data using Enterprise Guide Figure 6.9: Embed data in SAS code Figure 6.10: PX codes in SAS data set Identify Appropriate Professional Claims Figure 6.11: Join relationships in Enterprise Guide Figure 6.12: ProfessionalVisits data set Create Outreach Report Figure 6.13: Modify join order Figure 6.14: Outreach report Create Internal Report Figure 6.15: Select columns for internal report Figure 6.16: KidsVisits table Figure 6.17: Inner join on two columns Figure 6.18: Internal Report Case Study: Automating Reports with Macro Variables Extract Code from Enterprise Guide Tasks Figure 6.19: The program directory in Project Tree Figure 6.20: Code Window Import Data Code Program 6.1: Import Task Code Query Builder Code Program 6.2: Code Downloaded from Query Builder Tasks Automate Code Figure 6.21: Prompt Manager in Query Builder Figure 6.22: Naming a new prompt Figure 6.23: Creating a new prompt Figure 6.24: Prompt EndDOS Figure 6.25: Adding prompts in a filter Figure 6.26: Specifying prompt values Conclusion Chapter 7 Introduction NCPDP Claim Formats Table 7.1: NCPDP documentation Paper Claim Form Electronic Format Table 7.2: Transaction segments on a pharmacy claim Data Elements Unique to Pharmacy Data Provider Identifiers National Drug Code Table 7.3: Example NDCs Generic Product Identifier Table 7.4: Example GPI Therapeutic Class Codes Table 7.5: Four-tier structure of AHFS therapeutic class codes Other Fields of Interest Table 7.6: Other data of interest Case Study: Computing Medication Adherence Figure 7.1: Select columns from the Pharmacy data set PDC Computation Data Expansion Using SAS Data Step Program 7.1: Expanding data with DO loops Figure 7.2: ExpandTest Data Set Create Study Period Data Set Program 7.2: Create the study period Figure 7.3: StudyPeriod data set Figure 7.4: StudyPeriod2 data set Create Days Covered Data Set Program 7.3: Data expansion for covered days Figure 7.5: Pharmacy data set Combine and Summarize Data Program 7.4: Create PDC ratio by Member and Medication Figure 7.6: PDC ratio Graphing PDC Figure 7.7: Create a task filter Figure 7.8: Assign columns to task roles Figure 7.9: PDC graph Automating PDC Graphs Generation Program 7.5: Code extracted from Line Plot Program 7.6: Graphs for members with PDC less than .6 Figure 7.10: PDC Graphs for Members.pdf Figure 7.10: Control output placed in SAS Enterprise Guide project Conclusion Chapter 8 Introduction Table 8.1: Medical claim code sets International Classification of Diseases Diagnosis Codes ICD-9-CM Table 8.2: ICD-9 Diagnosis code architecture—xxx.xx Example 8.1: Example ICD-9 diagnosis code Table 8.3: Major Disease Categories, 2014 ICD-9 codes ICD-10-CM Table 8.4: ICD-10 Diagnosis Code Architecture—xxx.xxxx Example 8.2: Example ICD-10 diagnosis code Table 8.5: Major Disease Categories, 2014 ICD-10-CM codes Surgical Procedure Codes ICD-9-PCS Table 8.6: ICD-9-CM surgical procedure code architecture—xx.xx Example 8.3: Example ICD-9 surgical procedure code ICD-10-PCS Table 8.7: ICD-10-PCS surgical procedure code architecture—xxxxxxx Example 8.4: Example ICD-10 surgical procedure code Table 8.8: ICD-10-PCS sections Table 8.9: ICD-10-PCS sections Current Procedural Terminology (CPT) Category I Table 8.10: CPT Category I code architecture—xxxxx Category II Table 8.11: CPT Category II code architecture—xxxxF Category III Table 8.12: CPT Category III code architecture—xxxxT HCPCS Level I Level II Table 8.13: HCPCS Level II code architecture—xxxxx Level III Modifiers Table 8.14: Procedure modifier code architecture—xx HIPPS Table 8.15: HIPPS code architecture—xxxxx Other PPS Code Sets Table 8.16: Additional PPS Codes NDC LOINC Table 8.17: LOINC code nomenclature structure Table 8.18: LOINC code architecture Case Study: Identifying a Patient with Complex Conditions Code Simplification with SAS Array Processing Program 8.1: Searching for CHF without a SAS array Program 8.2: Using an array to simplify and reduce code Identifying Members with Complex Conditions Program 8.3: Identifying members with complex conditions Figure 8.1: Select variables from MemberConditions data set Parameterizing Program 8.3 with Macro Variables Program 8.4: Diagnosis code searching via macro variables Case Study: Using Formats to Create Data Hygiene Routines Figure 8.2: BOOK.ICD9 Program 8.5: Create DxCntlin data set Figure 8.3: DxCntlin data set Program 8.6: Create and verify DxN format Figure 8.4: Invalid Codes Data set Conclusion Chapter 9 Introduction Member Demographics Table 9.1: De-identification elements Member Enrollment Member Eligibility Membership Issues of Interest Membership Maintenance Electronic Eligibility Inquiry Changing Member ID “Cross-Client” Projects Householding Member Months Continuous Enrollment Rate Setting and Risk Adjustment Setting Rates Table 9.2—Pre-ACA Common Rating Practices Adjusting Risk Case Study: Creating Member Months Data Figure 9.1: BOOK.Members table Creating a Callable Macro Program Program 9.1: A callable macro program Program 9.2: Macro inclusion and invocation Figure 9.2: SYMBOLGEN and macro invocation in the LOG file Member Months Macro Program Program 9.3: Member months macro program Figure 9.3: MM table Building a Member Months Table Program 9.4: MM2 macro Figure 9.4: M0000014940000700 in BOOK.Members Figure 9.5: M0000014940000700 in Temp_MM Figure 9.6: M0000014940000700 in MMTable (selected columns shown) Conclusion Chapter 10 Introduction Case Study: Bucketing Costs Program 10.1: Service categories with Facility data Program 10.2: Service categories with Professional data Figure 10.1: AllClaims data set Figure 10.2: Assigning data in summary statistics task Figure 10.3: Statistics-basic tab Figure 10.4: Sum AmtPaid by Category1 and Category2 Case Study: Calculating PMPM Costs Program 10.3: PMPM costs Figure 10.5: The Metrics data set Case Study: Creating Reports Program 10.4: Creating Basic Reports with PROC TABULATE Figure 10.6: Creating basic tables with PROC TABULATE (partial output) Program 10.5: Creating tables with PROC TABULATE Figure 10.7: Creating tables with PROC TABULATE (partial output) Conclusion Chapter 11 Introduction The Business Case The Technical Challenges Reporting System Components Table 11.1: Major components of a HEDIS measure Colorectal Cancer Screening Definition Eligible Population Exclusions to Eligibility Table 11.2: Exclusion criteria Compliant Population Table 11.3: Numerator compliance criteria Hybrid Specification Case Study: Developing a Rate for Colorectal Cancer Screening Create a Driver Table Figure 11.1: BOOK.ColDriver Clean Up of Membership Data Figure 11.2: Data quality issues in BOOK.Members Program 11.1: Pre-process BOOK.Members Figure 11.3: Members_Clean data set Check Continuous Enrollment Program 11.2: Continuous enrollment macro application and code Identify the Denominator Program 11.3: Determine the denominator Program 11.3 (Part 1) Figure 11.4: BOOK.FacilityHeader (only diagnoses and surgical procedure codes columns shown) Figure 11.5: BOOK.ProfessionalDetail (only diagnoses and procedure code columns shown) Program 11.3 (Part 2) Program 11:3 (Part 3) Determine Compliant Population Program 11.4: Identify the compliant population Compute Rate Program 11.5: Combine results Figure 11.6: Rate calculation results Conclusion Chapter 12 Introduction Impact of the Affordable Care Act Transparency in Pricing ICD-10 Patient Centered Medical Home Accountable Care Organization Pharmacy Benefits Manager Evolving Patient Medical Records Electronic Medical Record Electronic Health Record Personal Health Record Meaningful Use Global Billing All Payer Claims Database Conclusion Chapter 13 Introduction Utility Macros Age-as-of Calculation Program 13.1: Age-as-of macro Figure 13.1: Usage of the age macro Identifying Sparse Variables Program 13.2: Testing the sparseness of a data set Figure 13.2: SparseTest data set Figure 13.3: The NValues and OneWays data sets Arrays of Detail Record Elements on the Header Record Program 13.3: Macro HdrArrayCodes Figure 13.4: HrdArrayCodes macro resolution Figure 13.4: FacilityHeader_Colwise data set (not all RevCode columns shown) Linking to the Diagnosis Pointer Program 13.4: Generating test data Figure 13.4: The Test_Hdr and Test_Dtl data sets Program 13.5: Linking to diagnosis pointer Figure 13.7: Detail data set Conclusion Appendix Glossary of Terms CMS-1450 Claim Form Figure A.1: CMS-1450 claim form CMS-1500 Claim Form Figure A.2: CMS-1500 claim form Universal Claim Form for Prescription Drugs Figure A.3a: Universal Claim Form for prescription drugs Figure A.3b: Universal Claim Form for prescription drugs (reverse) Facility Type Table A.1: Facility Type code values Bill Sequence Table A.2: Bill sequence values Place of Service Table A.3: CMS Place of Service codes Patient Status Code Table A.4: NUBC Patient Status codes Revenue Code Table A.5: NUBC Revenue codes Index A B C D E F G H I J K L M N O P Q R S T U V W