Administrative Healthcare Data

Craig Dickstein, Renu Gehring

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.

Sujets

• Health insurance

Informations

• Publié par: SAS Institute
• Date de parution: 01 octobre 2014
• Nombre de lectures: 0
• EAN13: 9781629593814
• Langue: English
• Poids de l'ouvrage: 22 Mo

Extrait

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