††††† 900 KAR 7:030. Data reporting by health care providers.

 

††††† RELATES TO: KRS Chapter 13B, 216.2920-216.2929

††††† STATUTORY AUTHORITY: KRS 216.2923(3), 216.2925

††††† NECESSITY, FUNCTION, AND CONFORMITY: KRS 216.2925 requires that the Cabinet for Health and Family Services promulgate administrative regulations requiring specified health care providers to provide the cabinet with data on cost, quality, and outcomes of health care services provided in the Commonwealth. KRS 216.2923(3) authorizes the cabinet to promulgate administrative regulations to impose fines for failure to report required data. This administrative regulation establishes the required data elements, forms, and timetables for submission of data to the cabinet and fines for noncompliance.

 

††††† Section 1. Definitions. (1) "Agent" means any entity with which the cabinet may contract to carry out its statutory mandates, and which it may designate to act on behalf of the cabinet to collect, edit, or analyze data from providers.

††††† (2) "Ambulatory facility" is defined by KRS 216.2920(1).

††††† (3) "Cabinet" is defined by KRS 216.2920(2).

††††† (4) "Coding and transmission specifications", "Kentucky Inpatient and Outpatient Data Coordinator's Manual for Hospitals", or "Kentucky Data Coordinator's Manual for Ambulatory Facilities" means the document containing the technical directives the cabinet issues concerning technical matters subject to frequent change, including codes and data for uniform provider entry into particular character positions and fields of the standard billing form and uniform provider formatting of fields and character positions for purposes of electronic data transmissions.

††††† (5) "Hospital" is defined by KRS 216.2920(6).

††††† (6) "Hospitalization" means the inpatient medical episode identified by a patient's admission date, length of stay, and discharge date, that is identified by a provider-assigned patient control number unique to that inpatient episode, except for:

††††† (a) Inpatient services a hospital may provide in swing, nursing facility, skilled, intermediate or personal care beds; or

††††† (b) Hospice care.

††††† (7) "National Provider Identifier" or "NPI" means the unique identifier assigned by the Centers for Medicare and Medicaid Services to an individual or entity that provides health care services and supplies.

††††† (8) "Outpatient services" means services performed on an outpatient basis in a hospital in accordance with Section 3(2) of this administrative regulation or services performed on an outpatient basis by an ambulatory facility in accordance with Section 4 of this administrative regulation.

††††† (9) "Provider" means a hospital, ambulatory facility, clinic, or other entity of any nature providing hospitalizations, mammograms, or outpatient services as defined in the Kentucky Inpatient and Outpatient Data Coordinator's Manual for Hospitals or the Kentucky Data Coordinator's Manual for Ambulatory Facilities.

††††† (10) "Record" means the documentation of a hospitalization or outpatient service in the format prescribed by the Kentucky Inpatient and Outpatient Data Coordinator's Manual for Hospitals or the Kentucky Data Coordinator's Manual for Ambulatory Facilities as approved by the Statewide Data Advisory Committee on a computer readable electronic medium.

††††† (11) "Standard Billing Form" means the uniform health insurance claim form pursuant to KRS 304.14-135, the Professional 837 (ASC X12N 837) format, the Institutional 837 (ASC X12N 837) format, or its successor as adopted by the Centers for Medicare and Medicaid Services, or the HCFA 1500 for use by hospitals and other providers in billing for hospitalizations and outpatient services.

 

††††† Section 2. Medicare Provider-Based Entity. A licensed outpatient facility that is a Medicare provider-based entity of a hospital and reports under the hospital's provider number shall be separately identifiable through a facility-specific NPI.

 

††††† Section 3. Data Collection for Hospitals. (1) Inpatient Hospitalization records. Hospitals shall document every hospitalization they provide on a Standard Billing Form and shall, from every record, copy and provide to the cabinet the data specified in Section 13 of this administrative regulation.

††††† (2) Outpatient services records.

††††† (a) Hospitals shall document on a Standard Billing Form the outpatient services they provide and shall from every record, copy and provide to the cabinet the data specified in Section 13 of this administrative regulation.

††††† (b) Hospitals shall submit records that contain the required outpatient services procedure codes specified in the Kentucky Inpatient and Outpatient Data Coordinator's Manual for Hospitals.

††††† (3) Data collection on patients. Hospitals shall submit required data on every patient as provided in Section 13 of this administrative regulation, regardless of the patientís billing or payment status.

 

††††† Section 4. Data Collection for Ambulatory Facilities. (1) Outpatient Services Records.

††††† (a) Ambulatory facilities shall document on a Standard Billing Form the outpatient services they provide and shall, for every record, copy and provide to the cabinet the data specified in Section 14 of this administrative regulation.

††††† (b) Ambulatory facilities shall submit records that contain the required outpatient services procedure codes specified in the Kentucky Data Coordinator's Manual for Ambulatory Facilities.

††††† (2) Data collection on patients. Ambulatory facilities shall submit required data on every patient as provided in Section 14 of this administrative regulation, regardless of the patientís billing or payment status.

 

††††† Section 5. Data Finalization and Submission by Providers. (1) Submission of final data.

††††† (a) Data shall be final for purposes of submission to the cabinet as soon as a record is sufficiently final that the provider could submit it to a payor for billing purposes, regardless of whether the record has actually been submitted to a payor.

††††† (b) Finalized data shall not be withheld from submission to the cabinet on grounds that it remains subject to adjudication by a payor.

††††† (c) Data on hospitalizations shall not be submitted to the cabinet before a patient is discharged and before the record is sufficiently final that it could be used for billing.

††††† (2) Data submission responsibility.

††††† (a) If a patient is served by a mobile health service, specialized medical technology service, or another situation where one (1) provider provides services under contract or other arrangement with another provider, responsibility for providing the specified data to the cabinet shall reside with the provider that bills for the service or would do so if a service is unbilled.

††††† (b) Charges for physician services provided within a hospital shall be reported to the cabinet.

††††† 1. Responsibility for reporting the physician charge data shall rest with the hospital if the physician is an employee of the hospital.

††††† 2. A physician charge contained within a record generated by a hospital shall be clearly identified in a separate field within the record so that the cabinet may ensure comparability when aggregating data with other hospital records that do not contain physician charges.

††††† (3) Transmission of records.

††††† (a) Records submitted to the cabinet by hospitals shall be uniformly completed and formatted according to coding and transmission specifications set forth by the Kentucky Inpatient and Outpatient Data Coordinator's Manual for Hospitals.

††††† (b) Records submitted to the cabinet by ambulatory facilities shall be uniformly completed and formatted according to coding and transmission specifications set forth by the Kentucky Data Coordinator's Manual for Ambulatory Facilities.

††††† (c) All providers shall submit records on computer-readable electronic media.

††††† (d) Providers shall provide back-up security against accidental erasure or loss of the data until all incomplete or inaccurate records identified by the cabinet have been corrected and resubmitted.

††††† (4) Verification and audit trail for electronic data submissions.

††††† (a) Each provider shall maintain a date log of data submissions and the number of records contained in each submission, and shall make the log available for inspection upon request by the cabinet.

††††† (b) The cabinet shall, within twenty-four (24) hours of submission, verify by electronic message to each provider the receipt of the provider's data transmissions and the number of records in each transmission.

††††† (c) A provider shall immediately notify the cabinet of a discrepancy between the provider's date log and a verification notice.

 

††††† Section 6. Data Submission Timetable for Providers. (1) Quarterly submissions. Providers shall submit data at least once for each calendar quarter. A quarterly submission shall:

††††† (a) Contain data, which during that quarter became final as specified in Section 5(1) of this administrative regulation; and

††††† (b) Be submitted to the cabinet not later than forty-five (45) days after the last day of the quarter.

††††† 1. If the 45th day falls on a weekend or holiday, the submission due date shall be the next working day.

††††† 2. Calendar quarters shall be January 1 through March 31, April 1 through June 30, July 1 through September 30, and October 1 through December 31.

††††† (2) Submissions more frequent than quarterly. Providers may submit data after records become final as specified in Section 5(1) of this administrative regulation and at a reasonable frequency convenient to a provider for accumulating and submitting batch data.

 

††††† Section 7. Data Corrections for Hospitals. (1) Editing. Data received by the cabinet shall, upon receipt, be edited to ensure completeness and validity of the data. Computer editing routines shall identify for correction every record in which the submitted contents of required fields are not consistent with the cabinetís coding and transmission specifications contained in the Kentucky Inpatient and Outpatient Data Coordinator's Manual for Hospitals.

††††† (2) Time permitted for corrections. The cabinet shall allow providers thirty (30) days in which to submit corrected copies of initially submitted data the cabinet identifies as incomplete or invalid as a result of edits.

††††† (a) The thirty (30) days shall begin on the date of the cabinet's notice informing the provider that corrections are required.

††††† (b) Providers shall submit corrected data by electronic transmission or postmarked mailing within thirty (30) days.

††††† (c) Corrected data submitted to the cabinet shall be uniformly completed and formatted according to the cabinet's coding and transmission specifications contained in the Kentucky Inpatient and Outpatient Data Coordinator's Manual for Hospitals.

††††† (3) Percentage error rate.

††††† (a) When editing data upon its initial submission, the cabinet shall identify and return to the provider for correction every record in which one (1) or more of the required data elements fails to pass the edit.

††††† (b) When editing data that a provider has submitted, the cabinet shall check for an error rate per quarter of no more than one (1) percent of records or not more than ten (10) records, whichever is greater.

††††† (c) The cabinet may return for further correction any submission of allegedly corrected data in which the provider fails to achieve a corrected error rate per quarter of no more than one (1) percent of records or not more than ten (10) records, whichever is greater.

††††† (d) For the first data submission, the cabinet shall not count as errors any data for patients admitted prior to thirty (30) days of the effective date of this administrative regulation.

 

††††† Section 8. Data Corrections for Ambulatory Facilities. (1) Editing. Data received by the cabinet shall, upon receipt, be edited to ensure completeness and validity of the data. Computer editing routines shall identify for correction every record in which the submitted contents of required fields are not consistent with the cabinetís coding and transmission specifications contained in the Kentucky Data Coordinator's Manual for Ambulatory Facilities.

††††† (2) Time permitted for corrections. The cabinet shall allow providers thirty (30) days in which to submit corrected copies of initially submitted data the cabinet identifies as incomplete or invalid as a result of edits.

††††† (a) The thirty (30) days shall begin on the date of the cabinet's notice informing the provider that corrections are required.

††††† (b) Providers shall submit corrected data by electronic transmission or postmarked mailing within the thirty (30) days.

††††† (c) Corrected data submitted to the cabinet shall be uniformly completed and formatted according to the cabinet's coding and transmission specifications contained in the Kentucky Data Coordinator's Manual for Ambulatory Facilities.

††††† (d) The cabinet shall grant a provider an extension of time to submit corrections, if the provider has formally informed the cabinet of significant problems in performing the corrections and has formally requested, in writing, an extension of time beyond the thirty (30) day limit.

††††† (3) Percentage error rate.

††††† (a) When editing data upon its initial submission, the cabinet shall identify and return to the provider for correction every record in which one (1) or more of the required data elements fails to pass the edit.

††††† (b) When editing data that a provider has submitted, the cabinet shall verify an error rate per quarter of no more than one (1) percent of records or not more than (10) records, whichever is greater.

††††† (c) The cabinet may return for further correction any submission of allegedly corrected data in which the provider fails to achieve a corrected error rate per quarter of no more than one (1) percent of records or not more than ten (10) records, whichever is more.

 

††††† Section 9. Fines for Noncompliance for Providers. (1) A provider failing to meet quarterly submission guidelines as established in Sections 6, 7, and 8 of this administrative regulation shall be assessed a fine of $500 per violation.

††††† (2) The cabinet shall notify a noncompliant provider by certified mail, return receipt requested, of the documentation of the reporting deficiency and the assessment of the fine.

††††† (3) A provider shall have thirty (30) days from the date of receipt of the notification letter to pay the fine which shall be made payable to the Kentucky State Treasurer and sent by certified mail to the Kentucky Cabinet for Health and Family Services, Office of Health Policy, 275 East Main Street 4 W-E, Frankfort, Kentucky 40621.

††††† (4) Fines during a calendar year shall not exceed $1,500 per provider.

 

††††† Section 10. Extension or Waiver of Data Submission Timelines. (1) Providers experiencing extenuating circumstances or hardships may request from the cabinet, in writing, a data submission extension or waiver.

††††† (a) Providers shall request an extension or waiver from the Office of Health Policy on or before the last day of the data reporting period to receive an extension or waiver for that period.

††††† (b) Extensions and waivers shall not exceed a continuous period of greater than six (6) months.

††††† (2) The cabinet shall consider the following criteria in determining whether to grant an extension or waiver:

††††† (a) Whether the request was made due to an event beyond the provider's control, such as a natural disaster, catastrophic event, or theft of necessary equipment or information;

††††† (b) The severity of the event prompting the request; and

††††† (c) Whether the provider continues to gather and submit the information necessary for billing.

††††† (3) A provider shall not apply for more than three (3) extensions or waivers during a calendar year.

 

††††† Section 11. Appeals for Providers. (1) A provider notified of its noncompliance and assessed a fine pursuant to Section 9(1) of this administrative regulation shall have the right to appeal within thirty (30) days of the date of the notification letter.

††††† (a) If the provider believes the action by the cabinet is unfair, without reason, or unwarranted, and the provider wishes to appeal, it shall appeal in writing to the Secretary of the Cabinet for Health and Family Services, 5th Floor, 275 East Main Street, Frankfort, Kentucky 40621.

††††† (b) Appeals shall be filed in accordance with KRS Chapter 13B.

††††† (2) Upon receipt of the appeal, the secretary or designee shall issue a notice of hearing no later than twenty (20) days before the date of the hearing. The notice of the hearing shall comply with KRS 13B.050. The secretary shall appoint a hearing officer to conduct the hearing in accordance with KRS Chapter 13B.

††††† (3) The hearing officer shall issue a recommendation in accordance with KRS 13B.110. Upon receipt of the recommended order, following consideration of any exceptions filed pursuant to KRS 13B.110(4), the secretary shall enter a final decision pursuant to KRS 13B.120.

 

††††† Section 12. Working Contacts for Providers. (1) By January 1 of each calendar year, a provider shall report by letter to the cabinet the names and telephone numbers of a designated contact person and one (1) back-up person to facilitate technical follow-up in data reporting and submission.

††††† (a) A provider's designated contact and back-up shall not be the chief executive officer unless no other person employed by the provider has the requisite technical expertise.

††††† (b) The designated contact shall be the person responsible for review of the provider's data for accuracy prior to the publication by the cabinet.

††††† (2) If the chief executive officer, designated contact person, or back-up person changes during the year, the name of the replacing person shall be reported immediately to the cabinet.

 

††††† Section 13. Required Data Elements for Hospitals. (1) Hospitals shall ensure that each record submitted to the cabinet contains at least the data elements identified in this section and as provided on the Standard Billing Form.

††††† (2) Asterisks identify elements that shall not be blank and shall contain data or a code as specified in the cabinet's coding and transmission specifications contained in the Kentucky Inpatient and Outpatient Data Coordinator's Manual for Hospitals.

††††† (3) Additional data elements, as specified in the Kentucky Inpatient and Outpatient Data Coordinator's Manual for Hospitals, shall be required by the cabinet to facilitate proper collection and identification of data.

Required

DATA ELEMENT LABEL

Yes

*Provider Assigned Patient Control Number

Yes

*Provider Assigned Medical Record Number

Yes

*Type of Bill (inpatient, outpatient or other)

Yes

*Federal Tax Number or Employer Identification Number (EIN)

Yes

*Facility-specific NPI

Yes

*Statement Covers Period

Yes

*Patient City and Zip Code

Yes

*Patient Birth date

Yes

*Patient Sex

Yes

*Admission/Start of Care Date

Yes

Admission Hour

Yes

*Type of Admission

Yes

*Source of Admission

Yes

*Patient Status (at end of service or discharge)

No

Occurrence Codes & Dates

No

Value Codes and Amounts, including birth weight in grams

Yes

*Revenue Codes/Groups

Yes

*HCPCS/Rates/Hipps Rate Codes

No

Units of Service

Yes

*Total Charges by Revenue Code Category

Yes

*Payor Identification - Payor Name

Yes

*National Provider Identifier

Yes

*Diagnosis Version Qualifier - ICD version 9.0 or 10.0

Yes

*Principal Diagnosis Code

No

Principal Diagnosis Code present on admission identifier for non-Medicare claims

Yes

*Principal Diagnosis Code present on admission identifier for Medicare claims

Yes

*Secondary and Other Diagnosis Codes if present

No

Secondary and Other Diagnosis code present on admission identifier if present for non-Medicare claims

Yes

*Secondary and Other Diagnosis code present on admission identifier if present for Medicare claims

No

Inpatient Admitting Diagnosis or Outpatient reason for visit

Yes

*External Cause of Injury Code (E-code) if present

No

External Cause of Injury (E-code) present on admission identifier on non-Medicare claims if present

Yes

*External Cause of Injury (E-code) present on admission identifier on Medicare claims if present

Yes

*Principal Procedure Code & Date if present

Yes

*Secondary and Other Procedure Codes & Date if present

Yes

*Attending Physician NPI/QUAL/ID

No

Operating Clinician ID Number/NPI

No

Other Physician NPI/QUAL/ID

Yes

*Race

Yes

*Ethnicity

Yes

*Procedure Coding Method

 

††††† Section 14. Required Data Elements for Ambulatory Facilities.(1) Ambulatory facilities shall ensure that each record submitted to the cabinet contains at least the data elements identified in this section and as provided on the Standard Billing Form.

††††† (2) Asterisks identify elements that shall not be blank and shall contain data or a code as specified in the cabinet's coding and transmission specifications contained in the Kentucky Data Coordinator's Manual for Ambulatory Facilities.

††††† (3) Additional data elements, as specified in the Kentucky Data Coordinator's Manual for Ambulatory Facilities, shall be required by the cabinet to facilitate proper collection and identification of data.

Required

DATA ELEMENT LABEL

Yes

*Patient Birth date

Yes

*Patient Sex

Yes

*Zip Code

Yes

*1st Individual Payer ID#

Yes

*Admission/Start of Care Date

Yes

*Type of Bill

Yes

*Principal Diagnosis Code

Yes

*Secondary and Other Diagnosis Codes if present

Yes

*Principal Procedure Code & Date

Yes

*Secondary and Other Procedure Codes & Date if present

Yes

*1st Units of Service

Yes

*1st Charge

No

Secondary and Other Units of Service and Charge

Yes

*Total Charges for the Case

Yes

*Attending Clinician NPI

Yes

*Provider Assigned Patient ID#

Yes

*1st Insurer Group #

No

2nd Insurer Group #

Yes

*Operating Clinician NPI

Yes

*Billing Facility-specific NPI

Yes

*Federal Tax Number or Employer Identification Number (EIN)

Yes

*Statement Covers Period

Yes

*Primary Payor Name

No

Secondary Payor Name

Yes

*Race

Yes

*Ethnicity

Yes

*HCPCS/Rates/Hipps Rate Codes

 

††††† Section 15. Incorporation by Reference. (1) The following material is incorporated by reference:

††††† (a) "Kentucky Inpatient and Outpatient Data Coordinator's Manual for Hospitals", revised January 1, 2013; and

††††† (b) "Kentucky Data Coordinator's Manual for Ambulatory Facilities," revised January 1, 2013.

††††† (2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Cabinet for Health and Family Services, 275 East Main Street 4WE, Frankfort, Kentucky 40601, Monday through Friday, 8 a.m. to 4:30 p.m. (35 Ky.R. 2838; Am. 36 Ky.R. 325; eff. 8-12-2009; 36 Ky.R. 325; 1356; eff. 3-5-2010; 37 Ky.R. 1097; eff. 12-15-2010; 37 Ky.R. 2763; 38 Ky.R. 22; eff. 8-5-2011; 38 Ky.R. 1236; eff. 3-21-12; 38 Ky.R. 2102; eff. 8-31-2012; 39 Ky.R. 1785; eff. 5-3-2013.)