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

Contents
About This Book
	Purpose
	Is This Book for You?
	What’s New in This Edition
	About the Examples
		Software Used to Develop the Book's Content
		Example Code and Data
	Keep in Touch
		To Contact the Author through SAS Press
		SAS Books
		SAS Book Report
About These Authors
Acknowledgments
Chapter 1
	Introduction
	Data and Programming Used in This Book
	Terminology
		Table 1.1: Synonymous Terminology
	Flow of Administrative Healthcare Data
		Figure 1.1: Industry Relationships Drive the Movement of Administrative Healthcare Data
	Key Players
		Figure 1.2: Industry Payers and Providers
	Medical Claim Submission
	Claim Processing
	Recent Legislative Effects
		HIPAA
		Affordable Care Act
		All Payer Claims Database
		Continuing Enhancements
	Conclusion
Chapter 2
	Introduction
	Sample Data
		Table 2.1: Types of Claims Data
		Figure 2.1: Conceptual Data Model
	What Is SAS Enterprise Guide?
		Table 2.2: Selected Capabilities of Tasks Menu in Enterprise Guide
	SAS Libraries and Data Sets
		Create a Permanent Library
			Figure 2.2: Create a Library in SAS Enterprise Guide
		View a SAS Data Set
			Figure 2.3: Navigate through SAS Server Libraries
			Figure 2.4: FacilityHeader Data Set
		SAS Data Types
			Figure 2.5: View Properties of a Variable
	Formats
		DRG Format
			Figure 2.6: Create Format from Data Set
			Figure 2.7: The Formats Catalog
		Diagnosis Code Format
			Figure 2.8: The Dx Look up Table
			Figure 2.9: Diagnosis Code Columns in FacilityHeader
			Figure 2.10: Query Builder Task
			Figure 2.11: Create a Computed Column
			Figure 2.12: Query Builder Task with Computed Column
			Figure 2.13: Data Set DxNomen
			Figure 2.14: Diagnosis Format
	Applying Formats to SAS Variables
		Formatting an Existing Variable
			Figure 2.15: Format an Existing Variable
			Figure 2.16: Use a User-Defined Format
			Figure 2.17: Formatted DRG
		Placing Results of a Format into a New Variable
	Conclusion
Chapter 3
	Introduction
	Health Insurance
	Medicare
		Table 3.1: Elements of Medicare
	Medicaid
	Commercial Insurance
	Others
		TRICARE
		CHAMPVA
		FECA Black Lung
	Conclusion
Chapter 4
	Introduction
	Types of Providers
		Figure 4.1: Four categories of healthcare providers
		Facility
			Table 4.1: Key data elements on Facility claims
		Professional
		Pharmacy
		Ancillary
	National Provider Registry
		Table 4.2: Disclosable data content of the National Provider Registry
		NPI
		Taxonomy
			Table 4.3: Taxonomy code structure
		Other Provider Identifiers
			Table 4.4: Other provider IDs
	Case Study: Standardizing Provider Names from the National Provider Registry
		Figure 4.2: Sample Registry Records
		Figure 4.3: Data set WORK.NPI_ProvNameTemp
		Figure 4.4: Standardized Provider Name from the Registry
	Case Study: Using Taxonomy Code to Identify Primary Care Physicians
		Figure 4.5: Select taxonomy codes and associated descriptors
		Figure 4.6: Basic PCP definition
	Conclusion
Chapter 5
	Introduction
	CMS-1450 Paper Claim Form
	837I Electronic Claim Format
	Data Elements Unique to Facilities
		Type of Bill
			Table 5.1: First position of TOB (-xx)
			Table 5.2: Second position of TOB when first is not 7 or 8 (x-x)
			Table 5.3: Second position of TOB for clinics (7-x)
			Table 5.4: Second position of TOB for special facilities (8-x)
			Table 5.5: Third position of TOB—bill sequence (xx-)
		Admission and Discharge Dates
		Patient Discharge Status
		Revenue Code
			Table 5.6: Revenue code category examples
		Diagnosis Codes
			Table 5.7: CMS-1450/837I diagnosis code (DX) types
		Present on Admission
			Table 5.8: Present on Admission code values
		Surgical Procedure Codes
		DRG
		Provider IDs
		Others
			Table 5.9: Other codes unique to facility claims
	Case Study: Calculating C-Section Rates among Hospitals
		Create Summary Data Set for All Births
			Figure 5.1: Adding filters in Query Builder
			Figure 5.2: Summarize data
			Figure 5.3: All births by ProviderID
		Create Summary Data Set for C-Section Births
			Figure 5.4: Modify an existing task
			Figure 5.5: Modify an existing filter
			Figure 5.6: Modify query
			Figure 5.7: C-section task and summary data set
		Join Summary Data Sets
			Figure 5.8: Join tables
			Figure 5.9: C-section rates and CSection AmtPaid as a percentage of total AmtPaid
		Create Bar Graphs
			Figure 5.10: Create a bar chart
			Figure 5.11: Verify data source
			Figure 5.12: Assign variables
			Figure 5.13: C Section Rates by Provider
	Case Study: Top Reasons for ER Utilization
		Figure 5.14: Top reasons for ER visits query
		Figure 5.15: Filter Top N Reasons for ER query
		Figure 5.16: Sort data
		Figure 5.17: Top N Reasons for ER visits
	Automating Reports with SAS Enterprise Guide
		Figure 5.18: C-section case study process flow
	Creating Documentation in SAS Enterprise Guide
		Figure 5.19: Documentation in SAS Enterprise Guide
	Conclusion
Chapter 6
	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
		Figure 6.1: Members table
		Identify Currently Enrolled Children under Six Years of Age
			Figure 6.2: Create a basic filter on a computed item
			Figure 6.3: Build a basic filter
			Figure 6.4: Adding filters in Query Builder
			Figure 6.5: CurrentMembersKids table
		Import Excel Data
			Figure 6.6: Procedure codes used to identity professional claims of interest
			Figure 6.7: Import Excel data using Enterprise Guide
			Figure 6.8: Import Excel data using Enterprise Guide
			Figure 6.9: Embed data in SAS code
			Figure 6.10: PX codes in SAS data set
		Identify Appropriate Professional Claims
			Figure 6.11: Join relationships in Enterprise Guide
			Figure 6.12: ProfessionalVisits data set
		Create Outreach Report
			Figure 6.13: Modify join order
			Figure 6.14: Outreach report
		Create Internal Report
			Figure 6.15: Select columns for internal report
			Figure 6.16: KidsVisits table
			Figure 6.17: Inner join on two columns
			Figure 6.18: Internal Report
	Case Study: Automating Reports with Macro Variables
		Extract Code from Enterprise Guide Tasks
			Figure 6.19: The program directory in Project Tree
			Figure 6.20: Code Window
		Import Data Code
			Program 6.1: Import Task Code
		Query Builder Code
			Program 6.2: Code Downloaded from Query Builder Tasks
		Automate Code
			Figure 6.21: Prompt Manager in Query Builder
			Figure 6.22: Naming a new prompt
			Figure 6.23: Creating a new prompt
			Figure 6.24: Prompt EndDOS
			Figure 6.25: Adding prompts in a filter
			Figure 6.26: Specifying prompt values
	Conclusion
Chapter 7
	Introduction
	NCPDP Claim Formats
		Table 7.1: NCPDP documentation
		Paper Claim Form
		Electronic Format
			Table 7.2: Transaction segments on a pharmacy claim
	Data Elements Unique to Pharmacy Data
		Provider Identifiers
		National Drug Code
			Table 7.3: Example NDCs
		Generic Product Identifier
			Table 7.4: Example GPI
		Therapeutic Class Codes
			Table 7.5: Four-tier structure of AHFS therapeutic class codes
		Other Fields of Interest
			Table 7.6: Other data of interest
	Case Study: Computing Medication Adherence
		Figure 7.1: Select columns from the Pharmacy data set
		PDC Computation
		Data Expansion Using SAS Data Step
			Program 7.1: Expanding data with DO loops
			Figure 7.2: ExpandTest Data Set
		Create Study Period Data Set
			Program 7.2: Create the study period
			Figure 7.3: StudyPeriod data set
			Figure 7.4: StudyPeriod2 data set
		Create Days Covered Data Set
			Program 7.3: Data expansion for covered days
			Figure 7.5: Pharmacy data set
		Combine and Summarize Data
			Program 7.4: Create PDC ratio by Member and Medication
			Figure 7.6: PDC ratio
		Graphing PDC
			Figure 7.7: Create a task filter
			Figure 7.8: Assign columns to task roles
			Figure 7.9: PDC graph
		Automating PDC Graphs Generation
			Program 7.5: Code extracted from Line Plot
			Program 7.6: Graphs for members with PDC less than .6
			Figure 7.10: PDC Graphs for Members.pdf
			Figure 7.10: Control output placed in SAS Enterprise Guide project
	Conclusion
Chapter 8
	Introduction
		Table 8.1: Medical claim code sets
	International Classification of Diseases
	Diagnosis Codes
		ICD-9-CM
			Table 8.2: ICD-9 Diagnosis code architecture—xxx.xx
			Example 8.1: Example ICD-9 diagnosis code
			Table 8.3: Major Disease Categories, 2014 ICD-9 codes
		ICD-10-CM
			Table 8.4: ICD-10 Diagnosis Code Architecture—xxx.xxxx
			Example 8.2: Example ICD-10 diagnosis code
			Table 8.5: Major Disease Categories, 2014 ICD-10-CM codes
	Surgical Procedure Codes
		ICD-9-PCS
			Table 8.6: ICD-9-CM surgical procedure code architecture—xx.xx
			Example 8.3: Example ICD-9 surgical procedure code
		ICD-10-PCS
			Table 8.7: ICD-10-PCS surgical procedure code architecture—xxxxxxx
			Example 8.4: Example ICD-10 surgical procedure code
			Table 8.8: ICD-10-PCS sections
			Table 8.9: ICD-10-PCS sections
	Current Procedural Terminology (CPT)
		Category I
			Table 8.10: CPT Category I code architecture—xxxxx
		Category II
			Table 8.11: CPT Category II code architecture—xxxxF
		Category III
			Table 8.12: CPT Category III code architecture—xxxxT
	HCPCS
		Level I
		Level II
			Table 8.13: HCPCS Level II code architecture—xxxxx
		Level III
	Modifiers
		Table 8.14: Procedure modifier code architecture—xx
	HIPPS
		Table 8.15: HIPPS code architecture—xxxxx
		Other PPS Code Sets
			Table 8.16: Additional PPS Codes
	NDC
	LOINC
		Table 8.17: LOINC code nomenclature structure
		Table 8.18: LOINC code architecture
	Case Study: Identifying a Patient with Complex Conditions
		Code Simplification with SAS Array Processing
			Program 8.1: Searching for CHF without a SAS array
			Program 8.2: Using an array to simplify and reduce code
		Identifying Members with Complex Conditions
			Program 8.3: Identifying members with complex conditions
			Figure 8.1: Select variables from MemberConditions data set
		Parameterizing Program 8.3 with Macro Variables
			Program 8.4: Diagnosis code searching via macro variables
	Case Study: Using Formats to Create Data Hygiene Routines
		Figure 8.2: BOOK.ICD9
		Program 8.5: Create DxCntlin data set
		Figure 8.3: DxCntlin data set
		Program 8.6: Create and verify DxN format
		Figure 8.4: Invalid Codes Data set
	Conclusion
Chapter 9
	Introduction
	Member Demographics
		Table 9.1: De-identification elements
	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
			Table 9.2—Pre-ACA Common Rating Practices
		Adjusting Risk
	Case Study: Creating Member Months Data
		Figure 9.1: BOOK.Members table
		Creating a Callable Macro Program
			Program 9.1: A callable macro program
			Program 9.2: Macro inclusion and invocation
			Figure 9.2: SYMBOLGEN and macro invocation in the LOG file
		Member Months Macro Program
			Program 9.3: Member months macro program
			Figure 9.3: MM table
		Building a Member Months Table
			Program 9.4: MM2 macro
			Figure 9.4: M0000014940000700 in BOOK.Members
			Figure 9.5: M0000014940000700 in Temp_MM
			Figure 9.6: M0000014940000700 in MMTable (selected columns shown)
	Conclusion
Chapter 10
	Introduction
	Case Study: Bucketing Costs
		Program 10.1: Service categories with Facility data
		Program 10.2: Service categories with Professional data
		Figure 10.1: AllClaims data set
		Figure 10.2: Assigning data in summary statistics task
		Figure 10.3: Statistics-basic tab
		Figure 10.4: Sum AmtPaid by Category1 and Category2
	Case Study: Calculating PMPM Costs
		Program 10.3: PMPM costs
		Figure 10.5: The Metrics data set
	Case Study: Creating Reports
		Program 10.4: Creating Basic Reports with PROC TABULATE
		Figure 10.6: Creating basic tables with PROC TABULATE (partial output)
		Program 10.5: Creating tables with PROC TABULATE
		Figure 10.7: Creating tables with PROC TABULATE (partial output)
	Conclusion
Chapter 11
	Introduction
	The Business Case
	The Technical Challenges
	Reporting System Components
		Table 11.1: Major components of a HEDIS measure
	Colorectal Cancer Screening
		Definition
		Eligible Population
		Exclusions to Eligibility
			Table 11.2: Exclusion criteria
		Compliant Population
			Table 11.3: Numerator compliance criteria
		Hybrid Specification
	Case Study: Developing a Rate for Colorectal Cancer Screening
		Create a Driver Table
			Figure 11.1: BOOK.ColDriver
		Clean Up of Membership Data
			Figure 11.2: Data quality issues in BOOK.Members
			Program 11.1: Pre-process BOOK.Members
			Figure 11.3: Members_Clean data set
		Check Continuous Enrollment
			Program 11.2: Continuous enrollment macro application and code
		Identify the Denominator
			Program 11.3: Determine the denominator
			Program 11.3 (Part 1)
			Figure 11.4: BOOK.FacilityHeader (only diagnoses and surgical procedure codes columns shown)
			Figure 11.5: BOOK.ProfessionalDetail (only diagnoses and procedure code columns shown)
			Program 11.3 (Part 2)
			Program 11:3 (Part 3)
		Determine Compliant Population
			Program 11.4: Identify the compliant population
		Compute Rate
			Program 11.5: Combine results
			Figure 11.6: Rate calculation results
	Conclusion
Chapter 12
	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
	Introduction
	Utility Macros
		Age-as-of Calculation
			Program 13.1: Age-as-of macro
			Figure 13.1: Usage of the age macro
		Identifying Sparse Variables
			Program 13.2: Testing the sparseness of a data set
			Figure 13.2: SparseTest data set
			Figure 13.3: The NValues and OneWays data sets
	Arrays of Detail Record Elements on the Header Record
		Program 13.3: Macro HdrArrayCodes
		Figure 13.4: HrdArrayCodes macro resolution
		Figure 13.4: FacilityHeader_Colwise data set (not all RevCode columns shown)
	Linking to the Diagnosis Pointer
		Program 13.4: Generating test data
		Figure 13.4: The Test_Hdr and Test_Dtl data sets
		Program 13.5: Linking to diagnosis pointer
		Figure 13.7: Detail data set
	Conclusion
Appendix
	Glossary of Terms
	CMS-1450 Claim Form
		Figure A.1: CMS-1450 claim form
	CMS-1500 Claim Form
		Figure A.2: CMS-1500 claim form
	Universal Claim Form for Prescription Drugs
		Figure A.3a: Universal Claim Form for prescription drugs
		Figure A.3b: Universal Claim Form for prescription drugs (reverse)
	Facility Type
		Table A.1: Facility Type code values
	Bill Sequence
		Table A.2: Bill sequence values
	Place of Service
		Table A.3: CMS Place of Service codes
	Patient Status Code
		Table A.4: NUBC Patient Status codes
	Revenue Code
		Table A.5: NUBC Revenue codes
Index
	A
	B
	C
	D
	E
	F
	G
	H
	I
	J
	K
	L
	M
	N
	O
	P
	Q
	R
	S
	T
	U
	V
	W