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Administrative Healthcare Data

Book Description

Provides a concise yet complete foundational knowledge of the business of healthcare. Administrative Healthcare Data: A Guide to Its Origin, Content, and Application Using SAS 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. The book's blend of SAS programming and industry knowledge is unique. It illustrates concepts of administrative healthcare data with actual healthcare case studies. All applications are created with SAS Enterprise Guide or Base SAS and can be taken straight from the book and put to use immediately. Central topics addressed include key players in the healthcare industry and the roles they play; claim submission mechanisms used by different providers; medical claim content, both pre- and post-adjudication. Written for healthcare analysts regardless of their level of proficiency with SAS Enterprise Guide, SAS programming, or healthcare industry knowledge, Administrative Healthcare Data is a must-read for analysts new to the industry and a great review for experienced healthcare analysts. This book is part of the SAS Press program.

Table of Contents

  1. About This Book
  2. About These Authors
  3. Acknowledgments
  4. Chapter 1: The U.S. Healthcare System
    1. Introduction
    2. Data and Programming Used in This Book
    3. Terminology
    4. Flow of Administrative Healthcare Data
    5. Key Players
    6. Medical Claim Submission
    7. Claim Processing
    8. Recent Legislative Effects
      1. HIPAA
      2. Affordable Care Act
      3. All Payer Claims Database
      4. Continuing Enhancements
    9. Conclusion
  5. Chapter 2: Introduction to SAS Enterprise Guide and Sample Data
    1. Introduction
    2. Sample Data
    3. What Is SAS Enterprise Guide?
    4. SAS Libraries and Data Sets
      1. Create a Permanent Library
      2. View a SAS Data Set
      3. SAS Data Types
    5. Formats
      1. DRG Format
      2. Diagnosis Code Format
    6. Applying Formats to SAS Variables
      1. Formatting an Existing Variable
      2. Placing Results of a Format into a New Variable
    7. Conclusion
  6. Chapter 3: The Payers
    1. Introduction
    2. Health Insurance
    3. Medicare
    4. Medicaid
    5. Commercial Insurance
    6. Others
      1. TRICARE
      2. CHAMPVA
      3. FECA Black Lung
    7. Conclusion
  7. Chapter 4: The Providers
    1. Introduction
    2. Types of Providers
      1. Facility
      2. Professional
      3. Pharmacy
      4. Ancillary
    3. National Provider Registry
      1. NPI
      2. Taxonomy
      3. Other Provider Identifiers
    4. Case Study: Standardizing Provider Names from the National Provider Registry
    5. Case Study: Using Taxonomy Code to Identify Primary Care Physicians
    6. Conclusion
  8. Chapter 5: Facility Claims
    1. Introduction
    2. CMS-1450 Paper Claim Form
    3. 837I Electronic Claim Format
    4. Data Elements Unique to Facilities
      1. Type of Bill
      2. Admission and Discharge Dates
      3. Patient Discharge Status
      4. Revenue Code
      5. Diagnosis Codes
      6. Present on Admission
      7. Surgical Procedure Codes
      8. DRG
      9. Provider IDs
      10. Others
    5. Case Study: Calculating C-Section Rates among Hospitals
      1. Create Summary Data Set for All Births
      2. Create Summary Data Set for C-Section Births
      3. Join Summary Data Sets
      4. Create Bar Graphs
    6. Case Study: Top Reasons for ER Utilization
    7. Automating Reports with SAS Enterprise Guide
    8. Creating Documentation in SAS Enterprise Guide
    9. Conclusion
  9. Chapter 6: Professional and Ancillary Claims
    1. Introduction
    2. Medical Claim Submission
      1. CMS-1500 Claim Form
      2. 837P Electronic Claim Format
    3. Data Elements Unique to CMS-1500/837P
      1. Demographic Information
      2. Diagnosis Codes
      3. Diagnosis Pointer
      4. Provider Identifiers
      5. Procedure Codes and Modifiers
      6. Place of Service
    4. Provider Specialty
    5. Payment Methodologies
    6. Case Study: Identifying Children Who Miss Their Checkups
      1. Identify Currently Enrolled Children under Six Years of Age
      2. Import Excel Data
      3. Identify Appropriate Professional Claims
      4. Create Outreach Report
      5. Create Internal Report
    7. Case Study: Automating Reports with Macro Variables
      1. Extract Code from Enterprise Guide Tasks
      2. Import Data Code
      3. Query Builder Code
      4. Automate Code
    8. Conclusion
  10. Chapter 7: Pharmacy Claims
    1. Introduction
    2. NCPDP Claim Formats
      1. Paper Claim Form
      2. Electronic Format
    3. Data Elements Unique to Pharmacy Data
      1. Provider Identifiers
      2. National Drug Code
      3. Generic Product Identifier
      4. Therapeutic Class Codes
      5. Other Fields of Interest
    4. Case Study: Computing Medication Adherence
      1. PDC Computation
      2. Data Expansion Using SAS Data Step
      3. Create Study Period Data Set
      4. Create Days Covered Data Set
      5. Combine and Summarize Data
      6. Graphing PDC
      7. Automating PDC Graphs Generation
    5. Conclusion
  11. Chapter 8: Healthcare Claim Codes
    1. Introduction
    2. International Classification of Diseases
    3. Diagnosis Codes
    4. ICD-9-CM
    5. ICD-10-CM
    6. Surgical Procedure Codes
      1. ICD-9-PCS
      2. ICD-10-PCS
    7. Current Procedural Terminology (CPT)
      1. Category I
      2. Category II
      3. Category III
    8. HCPCS
      1. Level I
      2. Level II
      3. Level III
    9. Modifiers
    10. HIPPS
      1. Other PPS Code Sets
    11. NDC
    12. LOINC
    13. Case Study: Identifying a Patient with Complex Conditions
      1. Code Simplification with SAS Array Processing
      2. Identifying Members with Complex Conditions
      3. Parameterizing Program 8.3 with Macro Variables
    14. Case Study: Using Formats to Create Data Hygiene Routines
    15. Conclusion
  12. Chapter 9: The Members
    1. Introduction
    2. Member Demographics
    3. Member Enrollment
    4. Member Eligibility
    5. Membership Issues of Interest
      1. Membership Maintenance
      2. Electronic Eligibility Inquiry
      3. Changing Member ID
      4. “Cross-Client” Projects
      5. Householding
      6. Member Months
      7. Continuous Enrollment
    6. Rate Setting and Risk Adjustment
      1. Setting Rates
      2. Adjusting Risk
    7. Case Study: Creating Member Months Data
      1. Creating a Callable Macro Program
      2. Member Months Macro Program
      3. Building a Member Months Table
    8. Conclusion
  13. Chapter 10: Computing and Tracking Financial Metrics
    1. Introduction
    2. Case Study: Bucketing Costs
    3. Case Study: Calculating PMPM Costs
    4. Case Study: Creating Reports
    5. Conclusion
  14. Chapter 11: HEDIS
    1. Introduction
    2. The Business Case
    3. The Technical Challenges
    4. Reporting System Components
    5. Colorectal Cancer Screening
      1. Definition
      2. Eligible Population
      3. Exclusions to Eligibility
      4. Compliant Population
      5. Hybrid Specification
    6. Case Study: Developing a Rate for Colorectal Cancer Screening
      1. Create a Driver Table
      2. Clean Up of Membership Data
      3. Check Continuous Enrollment
      4. Identify the Denominator
      5. Determine Compliant Population
      6. Compute Rate
    7. Conclusion
  15. Chapter 12: Future Healthcare Data Issues
    1. Introduction
    2. Impact of the Affordable Care Act
    3. Transparency in Pricing
    4. ICD-10
    5. Patient Centered Medical Home
    6. Accountable Care Organization
    7. Pharmacy Benefits Manager
    8. Evolving Patient Medical Records
      1. Electronic Medical Record
      2. Electronic Health Record
      3. Personal Health Record
      4. Meaningful Use
    9. Global Billing
    10. All Payer Claims Database
    11. Conclusion
  16. Chapter 13: Extended Coding Examples
    1. Introduction
    2. Utility Macros
      1. Age-as-of Calculation
      2. Identifying Sparse Variables
    3. Arrays of Detail Record Elements on the Header Record
    4. Linking to the Diagnosis Pointer
    5. Conclusion
  17. Appendix
    1. Glossary of Terms
    2. CMS-1450 Claim Form
    3. CMS-1500 Claim Form
    4. Universal Claim Form for Prescription Drugs
    5. Facility Type
    6. Bill Sequence
    7. Place of Service
    8. Patient Status Code
    9. Revenue Code
  18. Index