Administrative Healthcare Data: A Guide to Its Origin, Content, and Application Using SAS
By Craig Dickstein and Renu Gehring
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About this ebook
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.
Craig Dickstein
Craig Dickstein, an independent Consultant, works with clients and select project teams to implement customized business technology solutions for the healthcare industry. A SAS user since 1978, he has significant experience developing and managing SAS applications and teaching SAS programming for healthcare analysts. With a Master's degree in statistics, Craig served as Director of Statistical Services with Blue Cross Blue Shield of New Hampshire. He has a long history of SAS user group involvement and has been a frequent invited speaker. Craig is a co-author of Administrative Healthcare Data: A Guide to Its Origin, Content, and Application Using SAS for SAS Press and a Business Knowledge Series course author/instructor on the same subject for SAS Education.
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Administrative Healthcare Data - Craig Dickstein
Administrative Healthcare Data
A Guide to Its Origin, Content, and Application Using SAS®
Craig Dickstein and Renu Gehring
support.sas.com/bookstore
The correct bibliographic citation for this manual is as follows: Dickstein, Craig, and Renu Gehring. 2014. Administrative Healthcare Data: A Guide to Its Origin, Content, and Application Using SAS®. Cary, NC: SAS Institute Inc.
Administrative Healthcare Data: A Guide to Its Origin, Content, and Application Using SAS®
Copyright © 2014, SAS Institute Inc., Cary, NC, USA
ISBN 978-1-62959-381-4
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Contents
About This Book
About These Authors
Acknowledgments
Chapter 1: The U.S. Healthcare System
Introduction
Data and Programming Used in This Book
Terminology
Flow of Administrative Healthcare Data
Key Players
Medical Claim Submission
Claim Processing
Recent Legislative Effects
HIPAA
Affordable Care Act
All Payer Claims Database
Continuing Enhancements
Conclusion
Chapter 2: Introduction to SAS Enterprise Guide and Sample Data
Introduction
Sample Data
What Is SAS Enterprise Guide?
SAS Libraries and Data Sets
Create a Permanent Library
View a SAS Data Set
SAS Data Types
Formats
DRG Format
Diagnosis Code Format
Applying Formats to SAS Variables
Formatting an Existing Variable
Placing Results of a Format into a New Variable
Conclusion
Chapter 3: The Payers
Introduction
Health Insurance
Medicare
Medicaid
Commercial Insurance
Others
TRICARE
CHAMPVA
FECA Black Lung
Conclusion
Chapter 4: The Providers
Introduction
Types of Providers
Facility
Professional
Pharmacy
Ancillary
National Provider Registry
NPI
Taxonomy
Other Provider Identifiers
Case Study: Standardizing Provider Names from the National Provider Registry
Case Study: Using Taxonomy Code to Identify Primary Care Physicians
Conclusion
Chapter 5: Facility Claims
Introduction
CMS-1450 Paper Claim Form
837I Electronic Claim Format
Data Elements Unique to Facilities
Type of Bill
Admission and Discharge Dates
Patient Discharge Status
Revenue Code
Diagnosis Codes
Present on Admission
Surgical Procedure Codes
DRG
Provider IDs
Others
Case Study: Calculating C-Section Rates among Hospitals
Create Summary Data Set for All Births
Create Summary Data Set for C-Section Births
Join Summary Data Sets
Create Bar Graphs
Case Study: Top Reasons for ER Utilization
Automating Reports with SAS Enterprise Guide
Creating Documentation in SAS Enterprise Guide
Conclusion
Chapter 6: Professional and Ancillary Claims
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
Identify Currently Enrolled Children under Six Years of Age
Import Excel Data
Identify Appropriate Professional Claims
Create Outreach Report
Create Internal Report
Case Study: Automating Reports with Macro Variables
Extract Code from Enterprise Guide Tasks
Import Data Code
Query Builder Code
Automate Code
Conclusion
Chapter 7: Pharmacy Claims
Introduction
NCPDP Claim Formats
Paper Claim Form
Electronic Format
Data Elements Unique to Pharmacy Data
Provider Identifiers
National Drug Code
Generic Product Identifier
Therapeutic Class Codes
Other Fields of Interest
Case Study: Computing Medication Adherence
PDC Computation
Data Expansion Using SAS Data Step
Create Study Period Data Set
Create Days Covered Data Set
Combine and Summarize Data
Graphing PDC
Automating PDC Graphs Generation
Conclusion
Chapter 8: Healthcare Claim Codes
Introduction
International Classification of Diseases
Diagnosis Codes
ICD-9-CM
ICD-10-CM
Surgical Procedure Codes
ICD-9-PCS
ICD-10-PCS
Current Procedural Terminology (CPT)
Category I
Category II
Category III
HCPCS
Level I
Level II
Level III
Modifiers
HIPPS
Other PPS Code Sets
NDC
LOINC
Case Study: Identifying a Patient with Complex Conditions
Code Simplification with SAS Array Processing
Identifying Members with Complex Conditions
Parameterizing Program 8.3 with Macro Variables
Case Study: Using Formats to Create Data Hygiene Routines
Conclusion
Chapter 9: The Members
Introduction
Member Demographics
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
Adjusting Risk
Case Study: Creating Member Months Data
Creating a Callable Macro Program
Member Months Macro Program
Building a Member Months Table
Conclusion
Chapter 10: Computing and Tracking Financial Metrics
Introduction
Case Study: Bucketing Costs
Case Study: Calculating PMPM Costs
Case Study: Creating Reports
Conclusion
Chapter 11: HEDIS
Introduction
The Business Case
The Technical Challenges
Reporting System Components
Colorectal Cancer Screening
Definition
Eligible Population
Exclusions to Eligibility
Compliant Population
Hybrid Specification
Case Study: Developing a Rate for Colorectal Cancer Screening
Create a Driver Table
Clean Up of Membership Data
Check Continuous Enrollment
Identify the Denominator
Determine Compliant Population
Compute Rate
Conclusion
Chapter 12: Future Healthcare Data Issues
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: Extended Coding Examples
Introduction
Utility Macros
Age-as-of Calculation
Identifying Sparse Variables
Arrays of Detail Record Elements on the Header Record
Linking to the Diagnosis Pointer
Conclusion
Appendix
Glossary of Terms
CMS-1450 Claim Form
CMS-1500 Claim Form
Universal Claim Form for Prescription Drugs
Facility Type
Bill Sequence
Place of Service
Patient Status Code
Revenue Code
Index
About This Book
Purpose
This book explains the source and content of administrative healthcare data—the product of financial reimbursement for healthcare services. It integrates the business knowledge of healthcare data with practical and pertinent case studies as shown in SAS.
Progressing from simple to complex, the book provides an introduction to the key players in the healthcare industry, details the process and content of claims submissions, and showcases applications of the data in healthcare case studies. In the book you will find answers to the following questions and more.
• Who are the key players and how is data sourced, transmitted, and organized? How can this data be best managed in SAS to create actionable information for the health plan?
• What are the standard medical claim code sets and how does knowledge of them aid in their processing?
• How do you identify emergency room (ER) visits and the top reasons for ER utilization?
• How is pharmacy data different from medical claims data and what are the significant elements in each? Using SAS algorithms, how can you identify patients who are not in compliance with their medication regimen?
• What are utilization and financial metrics and how do you calculate them using SAS?
• What is HEDIS? What are the rules that define a performance measure? How do you calculate a HEDIS measure using SAS?
Is This Book for You?
This book is intended for healthcare analysts regardless of their level of proficiency or experience with SAS Enterprise Guide, SAS programming, or the healthcare industry. SAS solutions in the book progress from easy to complex. As a result, both novice and experienced programmers will learn some new and useful techniques. The book provides a concise, yet complete, foundational knowledge of the business of healthcare; it is certainly a must for analysts new to the industry and a great review for experienced healthcare analysts.
What’s New in This Edition
This book is the much awaited update to a similar work by Marge Scerbo, Craig Dickstein, and Alan Wilson, Health Care Data and SAS® (Cary, NC: SAS Institute, 2001). Although this book covers some of the same material, changes in both the healthcare industry and SAS suggest the need for enhancing that important prior body of knowledge.
About the Examples
Software Used to Develop the Book's Content
Case studies and example code in this book were developed using SAS Enterprise Guide 5.1 and Base SAS version 9.4.
Example Code and Data
You can access the example code and data for this book by linking to its author page at http://support.sas.com/publishing/authors. Select the name of the author. Then, look for the cover thumbnail of this book, and select Example Code and Data to display the SAS programs that are included in this book.
For an alphabetical listing of all books for which example code and data is available, see http://support.sas.com/bookcode. Select a title to display the book’s example code.
Keep in Touch
Given the rich and changing landscape of administrative healthcare data, this book cannot hope to have captured all possible business and data management concepts, despite our best efforts. It is with that acknowledgment that the authors encourage the reader to offer any thoughts on additional content that you feel would add to the usefulness of this book. We would gratefully accept any and all constructive input from our valued customers.
To Contact the Author through SAS Press
By e-mail: saspress@sas.com
Via the Web: http://support.sas.com/author_feedback
SAS Books
For a complete list of books available through SAS, visit http://support.sas.com/bookstore.
Phone: 1-800-727-3228
Fax: 1-919-677-8166
E-mail: sasbook@sas.com
SAS Book Report
Receive up-to-date information about all new SAS publications via e-mail by subscribing to the SAS Book Report monthly eNewsletter. Visit http://support.sas.com/sbr.
About These Authors
Craig Dickstein, an independent Consultant, works with clients and select project teams to implement customized business technology solutions for the healthcare industry. A SAS user since 1978, he has significant experience developing and managing SAS applications and teaching SAS programming for healthcare analysts. With a Master's degree in statistics, Craig served as Director of Statistical Services with Blue Cross Blue Shield of New Hampshire. He has a long history of SAS user group involvement and has been a frequent invited speaker. Craig is a co-author of Administrative Healthcare Data: A Guide to Its Origin, Content, and Application Using SAS for SAS Press and a Business Knowledge Series course author/instructor on the same subject for SAS Education.
Renu Gehring is a SAS instructor and consultant. She is also an analyst at the health insurance company CareOregon, Inc. A SAS user since 1993, she holds the following certifications for SAS 9: SAS Certified Base Programmer, SAS Certified Advanced Programmer, SAS BI Content Developer, and SAS Certified Platform Administrator. Renu is passionate about using and teaching SAS technologies to transform business processes. Her expertise is in combining the power of SAS programming, statistical and predictive analytics, and business intelligence to build effective and actionable applications. Renu is the author of SAS Business Intelligence for the Health Care Industry for SAS Press. She has an undergraduate degree in History and Economics from Mount Holyoke College and a graduate degree in Economics from Brown University.
Learn more about these authors by visiting their author pages, where you can download free book excerpts, access example code and data, read the latest reviews, get updates, and more:
http://support.sas.com/publishing/authors/dickstein.html
http://support.sas.com/publishing/authors/gehring.html
Acknowledgments
Many people contributed to the writing of this book. We want to thank SAS Press’s Shelley Sessoms, Acquisitions Editor, and Julie Platt, Editor-in-Chief, for initiating the project. A special thanks to our Developmental Editor, Stacey Hamilton, who was always there to guide us at each step of the process.
We would like to thank Brenna Leath for her meticulous copyediting and Denise T. Jones for production support. Thanks are also due to Robert Harris and Stacy Suggs who converted our pencil sketches into beautiful graphics. Thank you to Cindy Puryear, our marketing specialist, for her marketing insights.
This book benefited greatly from several rounds of technical reviews. We would like to thank Graham Hughes (SAS Institute), Jerry Bearden (Intellicog, Inc.), Jessica Schmor (Amenity Consulting, LLC), and Mark Dalesandro (healthcare data guru and remarkable SAS wizard), whose unsurpassed technical and industry knowledge benefited the book greatly.
Renu: I would like to thank my co-author, Craig, whose industry and technical knowledge continues to amaze me each time we interact. I also want to thank my family, especially my husband, John, without whose love and support this book would not be possible.
Craig: Renu is a pleasure to work with, and, without her patience, I would not have learned as much Enterprise Guide as this old data step programmer
did. Without my wife Donna’s support throughout, this endeavor would not have been possible. The healthcare industry, along with various colleagues, have been a strong influence in my professional life; there is always something to learn.
Chapter 1: The U.S. Healthcare System
Introduction
Data and Programming Used in This Book
Terminology
Flow of Administrative Healthcare Data
Key Players
Medical Claim Submission
Claim Processing
Recent Legislative Effects
HIPAA
Affordable Care Act
All Payer Claims Database
Continuing Enhancements
Conclusion
Introduction
The U.S. healthcare system is massive, multifaceted, and complex. So is the data that it produces. Your annual visit to the doctor generates data. If you are insured, a form of this data makes its way to your health insurance company, which reimburses your doctor for your care. When you pick up a prescription at your local pharmacy, another type of healthcare data is created. If you give birth at a hospital, the hospital produces yet more data. The insurer houses even more data—providers, benefit structures, and membership all contribute data content to the success of the total business operation.
This book focuses on healthcare data as experienced by a health insurance company. The data is the product of financial reimbursement for health care services. Commonly referred to as administrative healthcare data, it is the result of the relationships among providers, recipients, and payers of health care services. From birth to death, you are generating administrate healthcare data through your interactions with the provider community and your insurer. If you have ever been to a doctor’s office, admitted to a hospital, or covered by an employer healthcare plan, then you already have a rudimentary understanding of the material addressed by this book. A comprehensive understanding of this data is a prerequisite for any analytics.
This book explains the source and content of administrative healthcare data and its related management. It illustrates concepts with actual healthcare case studies. Sample data is created in such a way that it closely simulates real healthcare data. All applications are created with SAS Enterprise Guide and Base SAS, which is further described in Chapter 2. They can be lifted straight from the book and put to use immediately.
This book is intended for the programmer/analyst charged with the analysis of administrative healthcare data. You will learn about how the data originates, what it contains, and best practices for programmatically managing this data. This book will give you the solid foundational knowledge to be a successful healthcare data analyst. This book is not intended to teach healthcare data analytics or analytical programming; that would be the next step in the readers’ learning path.
Data and Programming Used in This Book
This book uses a fictitious insurance company, Healthy Living, Inc., to illustrate concepts of administrative healthcare data. The company’s primary business is to pay medical claims to providers for services rendered to the company’s insured members. As a result, Healthy Living, Inc., is the custodian of several large sources of post-adjudication data originating from institutional, professional, and ancillary providers.
Through the use of SAS Enterprise Guide, this book shows you how to build a number of analytical applications of Healthy Living, Inc.’s rich administrative healthcare data. Some key applications include:
• C-section rates across various hospitals
• Top reasons for emergency room (ER) utilization
• Outreach reports identifying children who miss their checkups
• Identifying patients who do not adhere to their medication regimes
• Reporting on key financial metrics
This book is intended for the healthcare analyst regardless of his or her level of proficiency with SAS Enterprise Guide or SAS programming. As a result, SAS code shown throughout the book is deliberately kept at an accessible level. This approach allows the healthcare analyst who is new to SAS to understand the programming techniques shown in the book. The advanced SAS programmer analyst also benefits from the simplified coding approach as they may add complexities and efficiencies to suit their purpose.
Terminology
Language is so important. It is difficult to run a data analysis project if the team members are not speaking a common language, defining terms in the same way, or deriving information with agreed upon algorithms. Terminology and language are of the utmost importance in the discussion and analysis of administrative healthcare data.
Every project should start at the whiteboard and not on a keyboard. Begin by defining common goals, terminology, and methodology. If the goal is to arrive at utilization metrics for office visits per member per year, how are we to define an office visit, a member, a year? You would be surprised at the variety of possible results when everyone is not on the same page.
The importance of getting the terminology on a common plane cannot be underestimated. It is okay to define an office visit by Place of Service or by CPT® code (Common Procedural Terminology). But it is not okay to define it both ways in the same project. Spend the time to get it right among the project team.
Table 1.1 defines some terms that will be used synonymously in this book to describe certain concepts.
Table 1.1: Synonymous Terminology
What is the difference between health care
and healthcare
? In this book, we will use the two-word phrase to describe the actions of the provider—a well-child checkup is health care. The phrase is an adjective modifying the noun. The single word we will use to describe the system as a whole—healthcare data, healthcare policy. It is generally used as an adjective.
Flow of Administrative Healthcare Data
The U.S. healthcare system is rife with stakeholders and unique relationships among them. To understand the flow of administrative healthcare data you need to understand those relationships and the supply chain that results in the data available to healthcare analysts. If this sounds simple, apologies; it is not!
Think about the flow of data from a provider perspective. The provider interacts with a patient (the insured member), initiating the gathering of information that is needed for the accurate and timely reimbursement by the payer for the services rendered. In a fee-for-service (FFS) model, the provider submits a claim to the payer for reimbursement. In a capitation model, a medical claim
is still submitted, but only for the purpose of data collection, not actual payment. The payer then adjudicates the claim based on additional information about the member and the provider, resultant data is moved to an operational data store, and the member is notified of any out-of-pocket expenses for which they are responsible. Figure 1.1 graphically describes these important relationships. Reimbursement models will be discussed in Chapter 3.
Figure 1.1: Industry Relationships Drive the Movement of Administrative Healthcare Data
Key Players
One way to conceptualize the data origin is from a provider orientation. They initiate the data flow and, depending upon the provider type, use different claim submission mechanisms and provide different data elements. As Figure 1.2 illustrates, there are only four provider types—Professionals, Facilities, Pharmacies, and Ancillaries. These will be discussed in detail in Chapter 4.
There are three types of payers—Commercial, Medicare, and Medicaid. More on these in Chapter 3.
Policy makers, legislators, and regulators have a significant impact on the behavior of the above mentioned key players. Their role, while very important, will not be discussed in this book.
Figure 1.2: Industry Payers and Providers
Medical Claim Submission
The mechanism by which providers submit reimbursement information to payers has changed dramatically in the past few decades. Initially it was a paper-based system, with those forms and formats improving over time. Many commercial payers with tech-savvy decision makers then worked with their provider community to implement electronic data interchange (EDI) formats for