WSHA Maternal Data Center (WSHA-MDC) Data Submission Guidelines and Specifications Required Files (Core Files) January 1, 2017

Transcription

1 WSHA Maternal Data Center (WSHA-MDC) Data Submission Guidelines and Specifications equired Files (Ce Files) January 1, 2017 To generate perinatal perfmance metrics f the Washington State Hospital Association (WSHA) Safe Deliveries program, hospitals may submit data to the WSHA Maternal Data Center (WSHA-MDC), an online data aggregation and quality improvement tool developed by the Califnia Maternal Quality Care Collabative (CMQCC) and housed at Stanfd University School of Medicine. Questions Comments Please contact Anne Castles of CMQCC at safedeliveries@cmqcc.g. Summary Guidelines and Timelines Participating hospitals will submit administrative and clinical data files in CSV file fmat to the MDC on a monthly basis. Submissions should be based on discharge date f all files and are to be made on a calendar month basis, representing inpatient discharges from the first day of the month through the last day of the month f the given repting period. You may submit multiple months in a single file, but please ensure the files represent the entire month f each month you are submitting (no partialmonth data). The files should be submitted within 60 days of the close of the repting period. F example, data f March 1-31 is due on May 30. Hospital systems have the option to submit a single patient discharge data file f all hospitals in their system. Please contact CMQCC to learn me. All data submissions will be made via the MDC s secure web-based tool, housed in dedicated server environments maintained by Stanfd University s School of Medicine, Infmation, esources and Technology (Med-IT) Group via the MDC SFTP. Files should be in CSV file fmat using commas to separate values with each case in a single row. A template CSV file fmat is also available at Column headers, as denoted in the specifications below, must be used f all fields you are submitting. If the field is optional and you are choosing not to submit it, please omit the column header/column. Optional fields are highlighted in blue. If a column value is missing, leave no space between the commas(,,) Data Elements The data elements to be submitted fall into three categies, which will be submitted via at least three separate files: Patient Discharge Data (in UB-04 fmat): See Section B. Maternal Clinical Data. See Section C. Newbn Clinical Data. See Section D. ecds to be Submitted Hospitals may choose between submitting all inpatient recds limiting the submission to inpatient delivery-related discharges. If you choose to limit your submission to inpatient delivery-related discharges, please use the codes in Section A below to filter your data. If you submit all inpatient discharge recds, the MDC will apply the filters f you. Some fields are optional; optional fields are highlighted in blue and marked with an O. If you choose not to submit data f these fields, please omit the column headers.

2 egistering with WSHA-MDC Pri to Submitting Data Your hospital s designated Primary Administrat must first register your hospital; that Administrat will then invite the data submitter to register within the MDC System. You will receive an invitation from SafeDeliveries@cmqcc.g with the subject line Maternal Data Center User Invitation. This e- mail should be addressed specifically to you. (Please do not register through invitations fwarded to you from other staff at your hospital.) To register: Click on the coled box in the invitation addressed to you from SafeDeliveries@cmqcc.g. Enter a login name, personal passwd and phone numbers that you personally answer. The phone numbers are part of the MDC security protocols: each time you access patient level infmation, MDC will transmit a computer-generated pin number through a call text to your registered phone number. F hospitals that use extensions, you may use a cell phone a Google App available f smart phones. Uploading Data Files After the initial registration, you will submit data through the MDC online application at the following UL. In der to submit a data file, you will: Enter your login name and personal passwd. In the upper right cner, click the button Data Entry Status. Go through the 3 steps to upload the three data files. You will receive a prompt f second fact authentication: the tempary pin required when submitting patient level data. Click Call Text to select the phone number at which you wish to receive the pin number. Input the tempary pin provided via the call text and click Submit. Select Choose File to attach the file to be uploaded from your system. Click Upload. The data may process f several minutes depending on the size of your file. Once the file is accepted, the wd Complete will display within the Patient Discharge Data bar. If errs are found, you will receive an err message. Please contact CMQCC if you need assistance in interpreting the message; within the MDC, click Suppt in the top black bar and then click Contact MDC Suppt. Your message will automatically include documentation of the page you were visiting when the Suppt link is selected. Or CMQCC directly at safedeliveries@cmqcc.g. NOTE: You also have the option to upload discharge data files via SFTP. See User Guide in the MDC Suppt Section Automated File Submissions to the MDC. WSHA-MDC Data Specifications: equired Files January 1, 2017 Page 2 of 24

3 OPTIONAL Supplemental Data File Your hospital has the option of submitting additional supplemental CSV data files derived from internal systems (e.g. EM, ce measure vend system). The supplemental files might be used to: eplace data already in the MDC system from the Birth Certificate data your administrative data submission (e.g. Gestational Age). Pre-populate the chart-review data elements (e.g. lab Pri Uterine Surgery) in the MDC system. Include a flag that denotes a recd as part of the hospital s Joint Commission sample (from the ce measure vend system). See Supplemental Data File Specifications f me details. OPTIONAL Discharge Data Addendum Files Ability to Add Cases to Previously-Submitted Discharge Data Files If you discover that a case is missing from a monthly/quarterly Discharge Data file that you had previously submitted to the MDC, you can now add these individual discharge cases via a Discharge Addendum file. To submit these new addendum cases: Create your Discharge Addendum File using the same Discharge Data file specifications/fmat delineated in Section B below. All fields required f the standard Discharge Data file are also required f the Addendum Cases. From the MDC Home Page, click Data Entry Status Select Upload Discharge Addendum File Click Choose File to select the file you created, and click Upload Note: This feature does not enable overwriting/replacement of the iginally-submitted discharge recds; i.e. any cases in the Addendum File that are duplicates of previously-submitted cases in the Discharge Data File will not replace the iginal recd. WSHA-MDC Data Specifications: equired Files January 1, 2017 Page 3 of 24

4 Summary of Changes to WSHA-MDC Data Specifications since June 2014 Changes since 10/31/16 Version Instructions Infmation on two new MDC features: Users may now upload Discharge Addendum Files, which provides the ability to add new cases to previously-submitted monthly discharge files--in the event that individual discharge recds were omitted from the iginal Discharge Data File submission. (see Page 3: OPTIONAL Discharge Data Addendum Files) Users have the option to submit Discharge Data and Supplemental Data Files (but not Ce Clinical Files) via SFTP. See Page 2: Automated File Submissions. Maternal Clinical File Data element definitions used f The Joint Commission Perinatal Care measure set have been updated in alignment with the 2016B TJC Manual (effective with January 1, 2017 discharges). The following data elements were modified: Parity (used in PC-02) There is a new *Optional* supplemental data element. Lab Care Provider can be submitted starting March 1, Hospitals may submit this field if they would like to calculate provider-level metrics f their Lab Care Providers (e.g. nurse-midwives) in addition to the provider-level metrics based on the Delivering Provider. Changes since 12/15/15 Version Throughout Clarification that the PDD file should only include inpatient discharge recds, not ambulaty/outpatient recds. The complete list of OPTIONAL supplemental data elements is no longer included in the Ce File Specifications here. To see the full list of optional fields, see the document Supplemental Data File Specifications in the MDC Suppt Section on the WSHA Safe Deliveries site. Maternal Clinical File Data element definitions used f The Joint Commission Perinatal Care measure set have been updated in alignment with the 2016A TJC Manual. The following data elements were modified: Parity (used in PC-02) Newbn Clinical File Data element definitions used f The Joint Commission Perinatal Care measure set have been updated in alignment with the 2016A TJC Manual. The following data elements were modified: The definition f NICU Admission has changed slightly to accommodate both Joint Commission and Leapfrog Group measures that require this data element. Specifically, the CMQCC definition no longer requires that the NICU Admission occur at this hospital. If there is documentation that the newbn was transferred directly from the birth hospital to a NICU at another hospital, you may still respond yes to NICU Admission WSHA-MDC Data Specifications: equired Files January 1, 2017 Page 4 of 24

5 Changes since 7/23/15 Version Section C: Maternal Clinical File Optional data element added: Induced Y/N given ICD-10 codes do not have a code that clearly identifies an induction procedure. Changes since 7/15/15 Version Section A2: ecds to Include in MDC Data Submission efinements were made to the ICD-10 codes to be used to identify cases f inclusion in the Maternal Data Center submissions. Changes since 2/9/15 Version Section A: ecds to Include in MDC Data Submission Section A specifies the ICD codes to be used f identifying maternal and newbn recds, and is now delineated in two sections. Section A1 provides the ICD-9 codes to be used f files that represent discharge dates befe October 1, Section A2 provides the ICD-10 codes to be used f files that represent discharge dates on and after October 1, Changes since 10/1/2014 Version Maternal Clinical File: Gestational Age Fields. The iginal data specifications called f gestational age to be broken down into two distinct fields: Gestational Age-Weeks (required) and Gestational Age-Days (optional). However, some hospitals clinical systems capture Gestational Age as a combined field that includes both completed weeks and days (e.g. 37+4). The MDC now has a new optional field called Gestational Age_combined. If your hospital wishes to submit in the combined fmat, please use the column header gestational age_combined. If you submit the combined fm (e.g ) in the gestational age_weeks column, you will receive an err message. See pages Changes since 7/30/14 Version Admission Source Coding: Codes D,E,F available options f coding. See Page 7. Clarified instructions on selecting cases f clinical files are on pages 13 and 22. Infmation on how to submit Supplemental Files on pages 13 and 22. Changes since Test Phase Draft of 6/24/14 Section A (page 4): Hospitals should not use DGs Maj Diagnostic Categies (MDCs) to identify maternal and newbn recds; use of these codes may inadvertently omit delivery-related cases with severe complications Section A (page 4): Typo crected in the last ICD-9 code used f identifying maternal recds (74.99 replaces 749.9). Patient Discharge Data (Pages 7-8): Wding has been clarified around use of Newbn Codes in Source of eferral field. WSHA-MDC Data Specifications: equired Files January 1, 2017 Page 5 of 24

6 Section A1 ecds to Include in MDC Data Submission ICD-9 Codes Please include all of the following inpatient recds in you MDC Submission. Apply these ICD-9 code filters to both the discharge and clinical files. If it is not possible to use ICD-9 codes as filters f the clinical files, then please attempt to include only maternal and newbn delivery hospitalizations in your clinical files (i.e. no antepartum postpartum hospitalizations) The MDC will transition to ICD-10 codes f discharges from October 2015; the ICD-10 filters are listed in Section A2 below. Mother ecds Include inpatient recds with any of the following ICD-9 V-Codes, Diagnosis Codes, Procedure Codes ICD-9 codes V27 (any) Outcome of Delivery , , , , , , , , , , , , , , , , , , ,642.52, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 72.1, 72.21, 72.29, 72.31, 72.39, 72.4, 72.6, 72.51, 72.52, 72.53, 72.54, 72.71, 72.79, 72.8, 72.9, 73.22, 73.59, 73.6, 74.0, 74.1, 74.2, 74.4, Complication Mainly elated to Pregnancy (Joint Commission Table Number 11.01) Nmal Delivery and Other Indications f Care (Joint Commission Table 11.02) Complication Mainly in the Course of Lab and Delivery (Joint Commission Table 11.03) Complication of the Puerperium (Joint Commission Table 11.04) Delivery-related Procedure Codes WSHA-MDC Data Specifications: equired Files January 1, 2017 Page 6 of 24

7 Infant ecds Dates of Admission and Birth Please include all inpatient newbn discharge recds meeting ANY of the following criteria: Admission Date Date of Birth 28 days ICD-9-CM V-Codes: Neonatal observation and evaluation ICD-9-CM V-Codes: Live births (In-hospital and Out-of-Hospital) V29.x V30.xx V31.xx V32.xx V33.xx V34.xx V35.xx V36.xx V37.xx V39.xx Observation f suspected condition Single livebn Twin livebn, mate livebn Twin livebn, mate stillbn Twin livebn, mate unspecified Other multiple, mates all livebn Other multiple, mates all stillbn Other multiple, mates live and stillbn Other multiple, mates unspecified Unspecified livebn WSHA-MDC Data Specifications: equired Files January 1, 2017 Page 7 of 24

8 Section A2 ecds to Include in MDC Data Submission ICD-10 Codes Please include all of the following inpatient recds in you MDC Submission. Apply these ICD-10 code filters to both the discharge and clinical files. If it is not possible to use ICD-10 codes as filters f the clinical files, then please attempt to include only maternal and newbn delivery hospitalizations in your clinical files (i.e. no antepartum post-partum hospitalizations) Include all inpatient discharge recds meeting ANY of the following criteria Mother ecds Infant ecds Outcome of Delivery Z37.0 Single live birth Z37.1 Single stillbirth Z37.2 Twins, both livebn Z37.3 Twins, one livebn and one stillbn Z37.4 Twins, both stillbn Z37.50-Z37.59 Other multiple birth, all livebn Z37.60-Z37.69 Other multiple birth, some livebn Z37.7 Other multiple birth, all stillbn Z37.9 Outcome of delivery, unspecified Delivery (Letter O codes) O80 Encounter f full-term uncomplicated delivery O82 Encounter f cesarean delivery without indication Delivery Procedure Codes (Joint Commission Table Number ) 10D00Z0 Extraction of Products of Conception, Classical, Open Approach 10D00Z1 Extraction of Products of Conception, Low Cervical, Open Approach 10D00Z2 Extraction of Products of Conception, Extraperitoneal, Open Approach 10D07Z3 Extraction of Products of Conception, Low Fceps, Via Natural Artificial Opening 10D07Z4 Extraction of Products of Conception, Mid Fceps, Via Natural Artificial Opening 10D07Z5 Extraction of Products of Conception, High Fceps, Via Natural Artificial Opening 10D07Z6 Extraction of Products of Conception, Vacuum, Via Natural Artificial Opening 10D07Z7 Extraction of Products of Conception, Internal Version, Via Natural Artificial Opening 10D07Z8 Extraction of Products of Conception, Other, Via Natural Artificial Opening 10E0XZZ Delivery of Products of Conception, External Approach Admission Date Criteria Admission Date Date of Birth 2 days Livebn Infants Z Z38.01 Single livebn infant, bn in hospital Z38.1 Single livebn infant, bn outside hospital Z38.2 Single livebn infant, unspecified as to place of birth Z Z38.31 Twin livebn infant, bn in hospital Z38.4 Twin livebn infant, bn outside hospital Z38.5 Twin livebn infant, unspecified as to place of birth Z Z38.69 Other multiple, bn in hospital Z38.7 Other multiple, bn outside hospital Z38.8 Other multiple, unspecified as to place of birth WSHA-MDC Data Specifications: equired Files January 1, 2017 Page 8 of 24

9 Section B: Patient Discharge Data Elements Please note that while the MDC utilizes the same coding and definitions as CHAS, we do not utilize the CHAS File Fmat. Coding definitions can be found in the following manuals: NUBC UB-04 Data Specifications Manual: CHAS Procedure Manual f Submitting Discharge Data and CHAS Companion Guide: sition.aspx#ub04%20837i%205010%20manuals Notes Use the patient s discharge date to filter the recds f each repting period. Each submission will include one me months wth of discharge data and should include the entire set of recds f each month in the submission. F the Medical/Health ecd field, please supply a patient recd number that will enable authized hospital staff to conduct recd look-ups. The number will be encrypted upon receipt by MDC server, but will be re-constituted to true value by authized hospital staff using private key. CSV File Fmat using commas to separate values with each case in a single row. Column headers, as denoted below, must be used f all fields you are submitting. If a column value is missing, leave no space between the commas (,,) You must submit all fields marked as equired with an. Optional fields are denoted by blue highlighting and the letter O. If the field is optional and you are choosing not to submit it, please omit the column header/column. The file may be rejected if it does not include certain required fields (e.g. Principal Diagnosis). Although we encourage completeness, the file will not be rejected if some recds are missing values in the required fields. equired () Data Element Description Column Header ept Value Accding To Facility ID 6-digit Medicare Provider ID facility_id Medicare.gov O Federal Tax Number The number assigned to the hospital by the federal government f tax repting purposes. Also known as the tax identification number (TIN). O Hospital Campus ID Additional ID that distinguishes one hospital campus from another when two me sites rept under the same Medicare Provider ID number. Medical/Health ecd Number Patient s unique (alphanumeric) number assigned by the provider to facilitate retrieval of the individual s medical recds Patient Address Zip Code ept the entire nine digits zip code if known. Use no dashes between zip and zip+4. If the Zip Code is unknown, use If the patient is homeless, use Tax_id campus_id medical_recd_number zip_code Up to 3 digit internal code of hospital choice WSHA-MDC Data Specifications: equired Files January 1, 2017 Page 9 of 24

10 equired () Data Element Description Column Header ept Value Accding To Patient Birth date The date of birth of the patient. If unknown, use June 30 of the estimated year. (MMDDYYYY) date_of_birth CHAS Procedure Manual Patient Sex The sex of the patient as recded at admission start of care. Use M (Male), F (Female) U (Unknown). sex Admission/Start of Care Date The start date f this episode of care. F inpatient services, this is the date of admission. (MMDDYYYY) admitted_on Admission Hour The code referring to the hour during which the patient was admitted f inpatient care. admit_hour Code Time - AM Code Time - PM 00 12:00 12:59 Midnight 12 12:00 12:59 Noon 01 01:00-01: :00 01: :00-02: :00-02: :00-03: :00-03: :00-04: :00-04: :00-05: :00-05: :00-06: :00-06: :00-07: :00-07: :00-08: :00-08: :00-09: :00-09: :00-10: :00-10: :00-11: :00-11:59 Priity (Type) of Visit A code indicating the priity of this admission/visit. Only values are accepted. 1 Emergency: The patient requires immediate medical intervention as a result of severe, life threatening potentially disabling conditions. 2 Urgent: The patient requires immediate attention f the care and treatment of a physical mental disder. 3 Elective The patient s condition permits adequate time to schedule the services. 4 Newbn: Use of this code necessitates the use of Special Source of Admission Code. See Fm Locat 15 below. 5 Trauma: Visit to a trauma center/hospital as licensed designated by the state local government authity authized to do so, as verified by the American College of Surgeons and involving a trauma activation. 9 Infmation: Infmation not available. visit_type Source of eferral f Admission Visit A code indicating the point of igin f this admission visit. 1 Non-Health Care Facility Point of Origin: The patient was admitted to this facility upon the der of a physician. 2 Clinic: The patient was admitted to this facility. 4 Transfer from a Hospital (Different Facility): The patient was admitted to this facility as a hospital transfer from an acute care facility. 5 Transfer from a Skilled Nursing Facility (SNF) Intermediate Care Facility (ICF): The patient was admitted to this facility as a transfer from an SNF ICF. admit_source WSHA-MDC Data Specifications: equired Files January 1, 2017 Page 10 of 24

11 equired () Data Element Description Column Header ept Value Accding To 6 Transfer from another Health Care Facility: The patient was admitted to this facility as a transfer from another type of health care facility not defined elsewhere in this code list. (continued) 8 Court/Law Enfcement: The patient was admitted to this facility upon the direction of a court of law, upon the request of a law enfcement agency representative. 9 Infmation is Not Available: The means by which the patient was admitted to this hospital is not known. D Transfer from One Distinct Unit of the Hospital to Another Distinct Unit of the Same Hospital: The patient was admitted to this facility as a transfer from hospital inpatient within the hospital resulting in a separate claim to the payer. E Transfer from an Ambulaty Surgery Center: The patient was admitted to this facility as a transfer from an ambulaty surgery center. F Transfer from Hospice and under Hospice Plan of Care: The patient was admitted to this facility as a transfer from hospice. Code Structure f Newbn If above field Priity (Type) of Visit = 4, Newbn, use these codes: 5 Bn Inside Hospital: A baby bn inside this hospital. 6 Bn Outside this Hospital: A baby bn outside of this hospital Discharge Date The date patient discharged from the hospital (MMDDYYYY). Special Instructions: Single-digit months and days must include a preceding zero. Discharge Hour Discharge Hour: A code indicating the discharge hour of the patient from care. discharged_on discharge_hour Code Time - AM Code Time - PM 00 12:00 12:59 Midnight 12 12:00 12:59 Noon 01 01:00-01: :00 01: :00-02: :00-02: :00-03: :00-03: :00-04: :00-04: :00-05: :00-05: :00-06: :00-06: :00-07: :00-07: :00-08: :00-08: :00-09: :00-09: :00-10: :00-10: :00-11: :00-11:59 Patient Discharge Status An NUBC code indicating the disposition discharge status of the patient at the end service f the period covered on this bill as repted in FL6, Statement Covers Period. The following values are accepted by CHAS: 1 Discharged to Home Self care (outine Discharges) 2 Discharged/transferred to Sht Term General Hospital f Inpatient Care 3 Discharged/transferred to Skilled Nursing Facility (SNF) with Medicare Certification in Anticipation of Covered Skilled Care. 4 Discharge /transferred to a Facility That Provides Custodial Supptive Care (Includes ICF and Assisted Living Facilities) 5 Discharged/transferred to a Designated Cancer Center Children s Hospital 6 Discharged/transferred to Home under Care of Organized Home Health Service discharge_status CHAS Procedure Manual WSHA-MDC Data Specifications: equired Files January 1, 2017 Page 11 of 24

12 equired () Data Element Description Column Header ept Value Accding To Organization in Anticipation of Covered Skilled Care. 7 Left Against Medical Advice Discontinued Care 9 Admitted as an inpatient to this hospital 20 Expired 21 Discharged/transferred to Court/Law Enfcement 30 Still patient 43 Discharged/transferred to a Federal Health Care Facility 50 Hospice-Home 51 Hospice Medical Facility (Certified) Providing Hospice Level of Care 61 Discharged/transferred to a Hospital Based Medicare Approved Swing Bed 62 Discharged/transferred to an Inpatient ehabilitation Facility( IF) including ehabilitation Distinct Part Units of a Hospital 63 Discharged/transferred to a Medicare-Certified Long Term Care Hospital (LTCH) 64 Discharged/transferred to a Nursing Facility Certified under Medicaid but not certified under Medicare 65 Discharged/transferred to a Psychiatric Hospital Psychiatric Distinct Part Unit of a Hospital 66 Discharged/transferred to a Critical Access Hospital (CAH) 69 Discharges/transferred to Designated Disaster Alternative Care Site 70 Discharged/transferred to another Type of HealthCare Institution Not Defined Elsewhere in this Codes List 81 Discharged to Home Self Care with a Planned Acute Care Hospital Inpatient eadmission 82 Discharged/Transferred to Sht Term General Hosp f Inpatient Care with a Planned Acute Care Hospital Inpatient eadmission 83 Discharged/Transferred to SNF with Medicare Certification with a Planned Acute Care Hospital Inpatient eadmission 84 Discharged/Transferred to a Facility that Provides Custodial Supptive Care with a Planned Acute Care Hospital Inpatient eadmission 85 Discharged/Transferred to a Designated Cancer Center Children's Hospital with a Planned Acute Care Hospital Inpatient eadmission 86 Discharged/Transferred to Home Under Care of Organized Home Health Service Organization with a Planned Acute Care Hospital Inpatient eadmission 87 Discharged/Transferred to Court/Law Enfcement with a Planned Acute Care Hospital Inpatient eadmission 88 Discharged/Transferred to Federal Health Care Facility with a Planned Acute Care Hospital Inpatient eadmission. 89 Discharged/Transferred to a Hospital Based Medicare Approved Swing Bed with a Planned Acute Care Hospital Inpatient eadmission 90 Discharged/Transferred to Inpatient ehabilitation Facility Including ehabilitation Distinct Part Units of a Hospital with a Planned Acute Care Hospital Inpatient eadmission 91 Discharged/Transferred to Medicare Certified Long Term Care Hospital (LTCH) with a Planned Acute Care Hospital Inpatient eadmission. 92 Discharged/Transferred to A Nursing Facility Certified Under Medicaid but not Medicare with a Planned Acute Care Hospital Inpatient eadmission WSHA-MDC Data Specifications: equired Files January 1, 2017 Page 12 of 24

13 equired () Data Element Description Column Header ept Value Accding To 93 Discharged/Transferred to a Psychiatric Hospital Psychiatric Distinct Part Unit of a Hospital with a Planned Acute Care Hospital Inpatient eadmission 94 Discharged/Transferred to a Critical Access Hospital (CAH) with a Planned Acute Care Hospital Inpatient eadmission 95 Discharged/Transferred to Another Type of Health Care Institution not Defined Elsewhere in the Code List with a Planned Acute Care Hospital Inpatient eadmission O Value Codes Code structure to relate amounts values to identify data elements necessary to process this claim (wker s comp, infmation noted below) May include up to 100 value codes evenue Code Codes that identify a specific accommodation, ancillary service unique billing calculation arrangement. Discharges should include accommodation codes and these are identified in the 010x to 021x series. Ancillary codes are identified in the 022x to 099x series. Bill type 131 discharges will include observation revenue codes 0760, 0761, Legitimate outpatient charges on inpatient discharges shall be mapped to the cresponding inpatient revenue codes. F the list of accepted revenue codes see Appendix C in CHAS procedure manual. O HCPCS/ates/HIPPS ate Codes Please include all revenue codes (max of 100 fields) The Healthcare Common Procedure Coding System (HCPCS) codes are applicable to ancillary service and outpatient bills. efer to the most recent AMA Medicare s National Level II Codes HCPCS and AMA CPT Coding Manual. May include up to 100 HCPCS codes Service Units A quantitative measure of services rendered by revenue categy (i.e., revenue code) to the patient to include items such as number of accommodation days, miles, pints of blood, renal dialysis treatments, etc. Please include all service units associated with the revenue codes provided (max of 100 fields) Payer Name Name of the health plan that the provider might expect some payment f the bill. Payer_1=Primary Payer Payer_2=Secondary Payer value_code_1, value_code_2, revenue_code_1, revenue_code_2, revenue_code_3..revenue_c ode_100 HCPCS_1, HCPCS_2,.. service_unit_1, servce_unit_2,. service_unit_100 payer_1, Payer_2 CHAS Procedure Manual Health Plan Identification Number Payer Identification Number identifying each payer group from which the hospital may expect some payment of the bill. ept all payers that are applicable (up to three). Values f CHAS are: payer_type_1, payer_type_2 CHAS Procedure Manual 001 Medicare: Medicare and Medicare Managed Care (Secure Hizons, Advantage) 002 Medicaid: State Federal, Healthy Options, SCHIP, Medicaid Managed Care, Basic Health Plan, etc 004 Health Maintanence Organizaion (HMO): Kaiser, Group Health, etc. 006 Commercial Mutual of Omaha, AAP, Safeco, etc. 008 Wker's Compensation Wkers Compensation (L&I), Crime Victims, self insured WSHA-MDC Data Specifications: equired Files January 1, 2017 Page 13 of 24

14 equired () Data Element Description Column Header ept Value Accding To employers, etc. 009 Self-Pay: Patient family balance not covered under other catagies 610 Health Service Contracts: Premera, Premera/Blue Cross, KPS, etc. 625 Other Government Sponsed Patients: TI-CAE s, CHAMPUS, Indian Health, Crections, County, etc. 630 Charity Care: Charity Care as defined by evised Code of Washington Principal Diagnosis Code The ICD-9-CM/ICD-10-CM code describing the principal diagnosis (i.e., the condition established after study to be chiefly responsible f occasioning the admission of the patient f care.) To ensure codes stay intact within the CSV fmat, include periods after the third digit f all ICD-9 O ICD-10 diagnosis codes. principal_diagnosis Present on Admission Code f Principal Diagnosis The five repting options f all POA repting are as follows: Y: Yes N: No U: No Infmation in the ecd W: Clinically Undetermined Blank: Exempt from POA repting poa Other Diagnoses Codes and Present on Admission Codes All additional ICD-9-CM/ICD-10-CM diagnosis codes. To ensure codes stay intact within the CSV fmat, include periods after the third digit f all ICD-9 O ICD-10 diagnosis codes. other_diagnosis_1, poa_1, other_diagnosis_2, poa_2,.. CHAS Procedure Manual Please include all other diagnosis and associated poa codes (max of 100 fields) Principal Procedure Code The ICD-9-CM/ICD-10CM-PCS code that identifies the inpatient principal procedure perfmed at the claim level during the period covered by this bill principal_procedure To ensure codes stay intact within the CSV fmat, include periods after the second digit f all ICD-9 procedure codes. Principal Procedure Date The cresponding date (MMDDYYYY) of the principal procedure. principal_procedure_date Other Procedure Codes and Dates All ICD-9-CM /ICD-10CM-PCS procedure codes. To ensure codes stay intact within the CSV fmat, include periods after the second digit f all ICD-9 procedure codes. other_procedure_1, other_procedure_1_date, other_procedure_2, other_procedure_2_date, CHAS Procedure Manual Please include all other procedure codes and other procedure dates (max of 100 fields) Attending Provider Identifier The Attending Provider is the individual who has overall responsibility f the patient s medical care and treatment repted in this claim. Provide the National Provider Identifier (NPI). Attending_provider WSHA-MDC Data Specifications: equired Files January 1, 2017 Page 14 of 24

15 equired () Data Element Description Column Header ept Value Accding To Patient ace The code which best describes the race and ethnicity of the patient. The Federal Office of Management and Budget (OMB) Standard titles are used. 1 White 2 Black African-American 3 American Indian Alaska Native 4 Asian (including Asian Indian, Chinese, Filipino, Japanese, Kean, Vietnamese, etc.) 5 Native Hawaiian Pacific Islander (including Chamro, Samoan, etc.) 8 Patient refused 9 Unknown race _omb CHAS Procedure Manual Patient Ethnicity 1 Hispanic Origin (including Spanish, Mexican, Puerto ican, Cuban, etc.) 2 Not Hispanic 8 Patient refused 9 Unknown Ethnicity_omb WSHA-MDC Data Specifications: equired Files January 1, 2017 Page 15 of 24

16 Section C: Maternal Clinical Data File: Ce equired Data Instructions and File Fmat If possible, use ICD-9 O ICD-10 codes in Section A to filter the recds to be submitted to the MDC. If that is not possible f the clinical file, include only recds f inpatient delivery-related hospitalizations in the clinical file (i.e. do not include antepartum postpartum recds). The Ce Maternal Clinical File must include the following required data fields: Maternal ID, Maternal DOB, Maternal Date of Discharge, Gestational Age, Parity as specified below. If any required data fields are missing from the Ce Maternal File, the file will be rejected. (Although we encourage completeness f required data fields, the file will not be rejected if some recds are missing values in the required fields.) In addition to the required Ce Maternal Clinical File you also have the option to submit additional data. Optional data elements may be submitted either as part of the Ce File in separate Supplemental Files. Supplemental files should only be submitted after all Ce / equired Files have been submitted. See me below. CSV File Fmat with each case in a single row. Column headers, as denoted below, must be used f all fields you are submitting. You must submit all fields marked as equired with an. Optional fields are denoted by blue highlighting and the letter O. If the field is optional and you are choosing not to submit it, please omit the column header/column. If a column value is missing, leave no space between the commas (,,) Use the patient s discharge date to filter the recds f each repting period (each submission will include one me months wth of data; please use complete calendar months.) Please submit separate clinical files f Maternal Data Elements and Newbn Data Elements SUPPLEMENTAL Files You may also choose to submit optional fields at later points in time via supplemental files. These optional fields may be derived from internal systems (e.g. EM, ce measure vend system) and might be used to: eplace data already in the MDC system from your Patient Discharge Data file submission Pre-populate the chart-review data elements (e.g. lab, SOM Pri Uterine Surgery) in the MDC system. Include a flag that denotes a recd as part of the hospital s Joint Commission sample (from the ce measure vend system). To see the full list of optional fields, see the document in the WSHA-MDC Suppt Section: Supplemental Data File Specifications WSHA-MDC Data Specifications: equired Files January 1, 2017 Page 16 of 24

17 If you choose NOT to include any of the optional fields, you must omit the column header/column f those fields. Data Element COE Fields Maternal Medical ecd Number Account Number equired () Definition Column Header Description Unique code identifying a particular patient recd within repting facility medical_recd_nu mber O account_number Medical recd number any patient identification number assigned by the facility. Use a number that matches the recd number f the mother provided in the patient discharge data file submission to MDC. The number will be encrypted upon receipt by the MDC server, but will be re-constituted to true value by authized hospital staff (with MDC passwds tied to the hospital s private key). Discharge Date The date patient discharged from the hospital. discharge_date MMDDYYYY Number of Previous Live Births (fmerly known as Parity) The number of live deliveries the patient experienced pri to current hospitalization. parity Allowable Values: 0-50 UTD=Unable to Determine Notes f Abstraction: Parity may be used in the absence of documentation of the number of previous live births. If the number f parity documented in the EH is "one" and includes the delivery f the current hospitalization, abstract zero f previous live births. The delivery operating room recd should be reviewed first f the number of previous live births. If the number of previous live births is not recded in the delivery operating room recd, then continue to review the data sources in the following der: histy and physical, prenatal fms, clinician admission progress note and discharge summary until a positive finding f the number of previous live births is found. In cases where there is conflicting data, the number of previous live births found in the first document accding to the der listed in the Only Acceptable Sources should be used. If gravidity is documented as one, the number of previous live births should be considered zero. The previous delivery of live twins any live multiple gestation is considered one live birth event. Documentation in the acceptable data sources may be written by the following clinicians: physician, certified nurse midwife (CNM), advanced practice nurse/physician assistant (APN/PA) registered nurse (N). It is acceptable to use data derived from vital recds repts received from state local departments of public health, delivery logs clinical infmation systems if they are available and are directly derived from the medical recd with a process in place to confirm their accuracy. If this is the case, these may be used in lieu of the Only Acceptable Sources listed below. If primagravida nulliparous is documented select zero f the number of previous live births. GTPAL documentation may be used in the absence of documentation of the number of previous live births. When GTPAL terminology is documented G= Gravida, T= Term, P= Preterm, A= Abtions and L= Living, all previous term and preterm deliveries pri to this WSHA-MDC Data Specifications: equired Files January 1, 2017 Page 17 of 24

18 Data Element equired () Definition Column Header Description hospitalization should be added together to determine the number of previous live births. If the number of previous live births entered by the clinician in the first document listed is obviously increct (in err) but it is a valid number two different numbers are listed in the first document and the crect number can be suppted with documentation in the other acceptable data sources in the medical recd, the crect number may be entered. Suggested Data Sources: ONLY ACCEPTABLE SOUCES IN ODE OF PEFEENCE: Delivery recd, note summary Operating room recd, note summary Histy and physical Prenatal fms Admission clinician progress notes Discharge summary Guidelines f Abstraction: Inclusion The following descript must precede the number when determining parity: Parity P Examples: parity=2 g3p2a1 Exclusion A string of three me numbers without the alpha designation of "p" preceding the second number can not be used to determine parity. Example: 321 When GTPAL terminology is documented, G= Gravida, T= Term, P= Preterm, A= Abtions, L= Living, P does not equal parity. Gestational Age- Weeks The weeks of gestation completed at the time of delivery. Gestational age is defined as the best obstetrical estimate (OE) of the newbn s gestation in completed weeks based on the birth attendant s final estimate of gestation, irrespective of whether the gestation results in a live birth a fetal death. This estimate of gestation should be determined by all perinatal facts and assessments such as ultrasound, but not the newbn exam. Ultrasound taken early in pregnancy is preferred (source: American College of Obstetricians and Gynecologists gestational_age_we eks Allowable values: 1-50 UTD=Unable to Determine Notes f Abstraction: Gestational age should be rounded off to the nearest completed week, not the following week. F example, an infant bn on the 5th day of the 36th week (35 weeks and 5/7 days) is at a gestational age of 35 weeks, not 36 weeks. The delivery operating room recd should be reviewed first f gestational age. If gestational age is not recded in the delivery operating room recd, then continue to review the data sources in the following der: histy and physical, prenatal fms,clinician admission progress note and discharge summary until a positive finding f gestational age is found. In cases where there is conflicting data, the gestational age found in the first document accding to the der listed above should be used. The phrase "estimated gestational age" is an acceptable descript f gestational age. If the patient has not received prenatal care and no gestational age was documented, select allowable value UTD. When the admission date is different from the delivery date, use documentation of the gestational age completed closest to the delivery date. Gestational age should be documented by the clinician as a numeric value between Gestational age (written with both weeks and days, eg. 39 weeks and 0 days) is calculated WSHA-MDC Data Specifications: equired Files January 1, 2017 Page 18 of 24

19 Data Element equired () Definition Column Header Description revitalize Initiative). using the best obstetrical Estimated Due Date (EDD) based on the following fmula: Gestational Age = (280 - (EDD - eference Date)) / 7 (source: American College of Obstetricians and Gynecologists revitalize Initiative). The clinician, not the abstract, should perfm the calculation to determine gestational age. If the gestational age entered by the clinician in the first document listed above is obviously increct (in err) but it is a valid number two different numbers are listed in the first document and the crect number can be suppted with documentation in the other acceptable data sources in the medical recd, the crect number may be entered. Documentation in the acceptable data sources may be written by the following clinicians: physician, certified nurse midwife (CNM), advanced practice nurse/physician assistant (APN/PA) registered nurse (N). It is acceptable to use data derived from vital recds repts received from state local departments of public health, delivery logs clinical infmation systems if they are available and are directly derived from the medical recd with a process in place to confirm their accuracy. If this is the case, these may be used in lieu of the acceptable data sources listed below. The EH takes precedence over a hand written entry if different gestational ages are documented in equivalent data sources, e.g., delivery recd and delivery summary. Suggested Data Sources: ONLY ACCEPTABLE SOUCES IN ODE OF PEFEENCE: Delivery room recd Operating room recd Histy and physical Prenatal fms Admission clinician progress notes Discharge summary Optional Gestational Age- Days (OPTIONAL) Optional fields can be submitted either as part of the Ce File as a Supplemental File. See the Supplemental File Specifications f the complete list of Optional Data Elements (the list below is a small subset). O The additional number of days of gestation elapsed after the last completed week. gestational_age_day s Allowable values: 0-6 blank if unknown Gestational Age- Combined (OPTIONAL) O Gestational age in weeks plus days, in a combined fmat. gestational_age_co mbined F hospitals with clinical systems that combine the completed weeks of gestational age with the days. Allowable fms include: /7 37w 3d 37 weeks 3 days WSHA-MDC Data Specifications: equired Files January 1, 2017 Page 19 of 24

20 Data Element Delivering Provider ID equired () O Definition Column Header Description The National Provider Identifier (NPI) of the provider delivering the baby prov_delivering Allowable values: 10-digit alphanumeric. The NPI is issued to health care providers by CMS. This field is designed to identify the provider perfming the delivery itself, and is used to generate provider-level metrics f the hospital s use. Lab Care Provider ID O The National Provider Identifier (NPI) of the provider responsible f the majity of the lab management Can be populated after 3/1/17 prov_lab Allowable values: 10-digit alphanumeric. The NPI is issued to health care providers by CMS. This field is designed to identify the provider responsible f the majity of the lab management and is used to generate provider-level metrics f the hospital s use. Induced O Documentation that lab was induced in the patient. Induced Allowable Values: Y (Yes) N (No) WSHA-MDC Data Specifications: equired Files January 1, 2017 Page 20 of 24

21 Section D: Newbn Clinical Data File Ce equired Data Instructions and File Fmat If possible, use the ICD-9 O ICD-10 codes in Section A to filter the newbn recds to submitted to the MDC. If that is not possible f the clinical file, include only recds f inpatient delivery-related hospitalizations in the clinical file (i.e. do not include postpartum admission recds). The Ce Newbn Clinical File must include the following required data elements: Newbn ID, Maternal ID, Newbn DOB, Newbn Date of Discharge, Birthweight, and Apgar Sce as specified below. If any of these data fields are missing, the file will be rejected. (Although we encourage completeness, the file will not be rejected if some recds are missing values in the required fields.) In addition to the required Ce Newbn File you also have the option to submit additional data. Optional data elements may be submitted either as part of the Ce File in separate Supplemental Files. Supplemental files should only be submitted after all Ce / equired Files have been submitted. See me below. The Maternal MN/ID must be included in the newbn file (as long as the newbn recd reflects the birth hospitalization and not a transfer in). CSV File Fmat with each case in a single row. Column headers, as denoted below, must be used f all fields you are submitting. The required data elements are denoted with an in the equired Optional column. If a column value is missing, leave no space between the commas (,,) Use the patient s discharge date to filter the recds f each repting period (each submission will include one me months wth of data; please use complete calendar months.) Please submit separate clinical files f Maternal Data Elements and Newbn Data Elements SUPPLEMENTAL Files You may also choose to submit optional fields at later points in time via supplemental files. These optional fields may be derived from internal systems (e.g. EM, ce measure vend system) and might be used to: eplace data already in the MDC system from your Patient Discharge Data file submission Pre-populate the chart-review data elements (e.g. NICU Admission) in the MDC system. Include a flag that denotes a recd as part of the hospital s Joint Commission sample (from the ce measure vend system). As long as you have already submitted the Ce Newbn File you can submit as many supplemental files with different data elements as you wish. F example, you might submit one supplemental newbn file that includes solely data on bilirubin screening and a second newbn file that includes data on NICU admission. If two supplemental files are submitted that contain the same field f the same repting period, the last submitted will represent the final value. To see the full list of optional fields, see the document Supplemental Data File Specifications WSHA-MDC Data Specifications: equired Files January 1, 2017 Page 21 of 24