Administrative Code

Virginia Administrative Code
12/8/2022

Chapter 218. Rules and Regulations Governing Outpatient Health Data Reporting

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.

"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 fulfill the requirements specified in 12VAC5-218-25.

"Outpatient 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.

Statutory Authority

§§ 32.1-12 and 32.1-276.6 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 19, Issue 26, eff. October 8, 2003; amended, Virginia Register Volume 31, Issue 22, eff. August 29, 2015.

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

Every reporting entity performing outpatient surgical procedures shall submit each patient level data element listed 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 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 shall be those adopted by the 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

Hospital Identifier

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

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 its successor as approved by the board for the physician identified as the operating physician for the principal procedure reported.

Payor Identifier

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

Employer Identifier

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

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.

Patient Sex

Date of Birth

Enter the code in MM/DD/YYYY format.

Street Address

City or County

Zip Code

Employment Status Code

Status at Discharge

Admission Date

Admission/start of care date

Admission Hour

Hour of admission in military time 00-24

Admission Diagnosis

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

Principal Diagnoses

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

Secondary Diagnoses

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

External Cause of Injury

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

Co-morbid Condition Existing but not 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.

Procedure Dates

Revenue Center Codes

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

Revenue Center Units

Revenue Center Charges

Total Charges

Statutory Authority

§§ 32.1-12 and 32.1-276.6 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 19, Issue 26, eff. October 8, 2003; amended, Virginia Register Volume 31, Issue 22, eff. August 29, 2015.

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.

Statutory Authority

§ 32.1-12 and 32.1-276.6 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 31, Issue 22, eff. August 29, 2015.

12VAC5-218-30. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 19, Issue 26, eff. October 8, 2003; repealed, Virginia Register Volume 31, Issue 22, eff. August 29, 2015.

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 shall transmit it to the nonprofit organization along with any fees submitted 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.

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 shall notify the board and the nonprofit organization of its intent to follow this procedure.

3. A reporting entity may submit 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.

Statutory Authority

§§ 32.1-12 and 32.1-276.6 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 19, Issue 26, eff. October 8, 2003; amended, Virginia Register Volume 31, Issue 22, eff. August 29, 2015.

12VAC5-218-50. Contact person.

Each reporting entity shall notify 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 contact person for that reporting entity.

Statutory Authority

§§ 32.1-12 and 32.1-276.6 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 19, Issue 26, eff. October 8, 2003; amended, Virginia Register Volume 31, Issue 22, eff. August 29, 2015.

12VAC5-218-60. Frequency of submission.

A. Reporting entities shall submit the data required by 12VAC5-218-20 at least on a calendar-year quarterly basis.

B. If the data is submitted to the board or to the nonprofit organization for processing and verification, it shall be received at the office of the board or the office of the nonprofit organization within 45 days after the end of each calendar year quarter.

C. If a reporting entity chooses to submit processed, verified data directly to the nonprofit organization, it shall be received at the office of the nonprofit organization within 120 days after the end of each calendar year quarter.

Statutory Authority

§§ 32.1-12 and 32.1-276.6 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 19, Issue 26, eff. October 8, 2003.

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)

Website addresses provided in the Virginia Administrative Code to documents incorporated by reference are for the reader's convenience only, may not necessarily be active or current, and should not be relied upon. To ensure the information incorporated by reference is accurate, the reader is encouraged to use the source document described in the regulation.

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