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

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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.
LanguageEnglish
PublisherSAS Institute
Release dateOct 1, 2014
ISBN9781629593814
Administrative Healthcare Data: A Guide to Its Origin, Content, and Application Using SAS
Author

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

    All rights reserved. Produced in the United States of America.

    For a hard-copy book: No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without the prior written permission of the publisher, SAS Institute Inc.

    For a web download or e-book: Your use of this publication shall be governed by the terms established by the vendor at the time you acquire this publication.

    The scanning, uploading, and distribution of this book via the Internet or any other means without the permission of the publisher is illegal and punishable by law. Please purchase only authorized electronic editions and do not participate in or encourage electronic piracy of copyrighted materials. Your support of others’ rights is appreciated.

    U.S. Government License Rights; Restricted Rights: The Software and its documentation is commercial computer software developed at private expense and is provided with RESTRICTED RIGHTS to the United States Government. Use, duplication or disclosure of the Software by the United States Government is subject to the license terms of this Agreement pursuant to, as applicable, FAR 12.212, DFAR 227.7202-1(a), DFAR 227.7202-3(a) and DFAR 227.7202-4 and, to the extent required under U.S. federal law, the minimum restricted rights as set out in FAR 52.227-19 (DEC 2007). If FAR 52.227-19 is applicable, this provision serves as notice under clause (c) thereof and no other notice is required to be affixed to the Software or documentation. The Government's rights in Software and documentation shall be only those set forth in this Agreement.

    SAS Institute Inc., SAS Campus Drive, Cary, North Carolina 27513-2414.

    October 2014

    SAS provides a complete selection of books and electronic products to help customers use SAS® software to its fullest potential. For more information about our offerings, visit support.sas.com/bookstore or call 1-800-727-3228.

    SAS® and all other SAS Institute Inc. product or service names are registered trademarks or trademarks of SAS Institute Inc. in the USA and other countries. ® indicates USA registration.

    Other brand and product names are trademarks of their respective companies.

    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

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