AGENCY FOR HEALTH CARE ADMINISTRATION
Cost Management and ControlRule No.: RULE TITLE
59B-9.034: Reporting Instructions
59B-9.038: Ambulatory Data Elements, Codes and StandardsNOTICE OF CORRECTION
Notice is hereby given that the following correction has been made to the proposed rule in Vol. 36 No. 35, September 3, 2010 issue of the Florida Administrative Weekly.
The correction is in response to written comments submitted by the staff of the Joint Administrative Procedures Committee on September 10, 2010 to correct subsection numbering.
59B-9.034 Reporting Instructions.
(1) Ambulatory Surgical centers shall report data for:
(a) through (c) No change.
(d) Report one record for each visit, except pre-operation visits may be combined with the record of the associated ambulatory surgery visit. See subsection 59B-9.031(11), F.A.C.
Proposed Effective Date 7-1-2011
Rulemaking Authority 408.15(8) FS. Law Implemented 408.061, 408.062, 408.063, 408.07, 408.08, 408.15(11) FS. History–New 1-1-10, Amended 7-1-11.
Editorial note: see former Rule 59B-9.011.
The correction is in response to written comments submitted by the staff of the Joint Administrative Procedures Committee on September 10, 2010 to properly code.
59B-9.038 Ambulatory Data Elements, Codes and Standards.
(1) No change.
(2) Patient Control Number. An alpha-numeric code containing standard letters or numbers assigned by the facility as a unique identifier for each record submitted in the reporting period to facilitate retrieval of individual’s account of services (accounts receivable) containing the financial billing records and any postings of payment. The ‘Patient Control Number’ is defined as ‘Record id’ in the schema. Up to twenty four (24) characters. A required field. Duplicate patient control numbers are not permitted. The facility must maintain a key list to locate actual records upon request by AHCA. A required field.
(3) through (9) No change.
(10) Patient Country Code. The country code of residence. A two (2) digit upper case alpha code from the Code for Representation of Names of Countries, ISO 3166 or latest release. A required entry for type of service “2”. Use 99 where the country of residence is unknown, or where efforts to obtain the information have been unsuccessful., or if type of service is “1”. A required entry for type of service “2”.
(11) No change.
(12) Source or Point of Origin of Admission. No change.
(a) 01 – Non-health care facility point source of origin – The patient presented to this facility for outpatient services. Includes patients coming from home, physician office or workplace. The patient presents to this facility with an order from a physician for services or seeks scheduled services for which an order is not required. Includes non-emergent self-referrals.
(b) 02 – Clinic or Physician’s Office. The patient presented was referred to this facility for outpatient services from a clinic or physician’s office or referenced diagnostic procedures.
(c) through (e) No change.
(f) 07 – Emergency Room. The patient received unscheduled services in this facility’s emergency department and discharged without an inpatient admission. Includes self-referrals in emergency situations that require immediate medical attention. Excludes patients who came to the emergency room from another health care facility.
(g) through (k) renumbered (f) through (j) No change.
(13) No change.
(14) Principal Diagnosis Code. The code representing the diagnosis chiefly responsible for the services performed during the visit. Must contain a valid ICD-9-CM or ICD-10-CM diagnosis code if type of service is “1” indicating ambulatory surgery. Must contain a valid ICD-9-CM or ICD-10-CM diagnosis code if type of service is “2” indicating an emergency department visit unless patient status is “07” indicating that the patient left against medical advice or discontinued care. A blank field is permitted if type of service is “2” and patient status is “07.” If not space filled, must contain a valid ICD-9-CM diagnosis code or valid ICD-10-CM diagnosis code for the reporting period. A diagnosis code cannot be used more than once as a principal or other diagnosis for each visit reported. The code must be entered with a decimal point that is included in the valid code and without use of a zero or zeros that are not included in the valid code. Alpha characters must be in upper case.
(15) Other Diagnosis Code (1), Other Diagnosis (2), Other Diagnosis (3), Other Diagnosis (4), Other Diagnosis (5), Other Diagnosis (6), Other Diagnosis (7), Other Diagnosis (8), Other Diagnosis (9). A code representing a diagnosis related to the services provided during the visit. If no principal diagnosis code is reported, another diagnosis code must not be reported unless the patient discharge status is “07” indicating that the patient left against medical advice or discontinued care. No more than nine other diagnosis codes may be reported. Less than nine entries is permitted. If not space filled, must contain a valid ICD-9-CM code or valid ICD-10-CM code for the reporting period. A diagnosis code cannot be used more than once as a principal or other diagnosis for each visit reported. The code must be entered with use of a decimal point that is included in the valid code and without use of a zero or zeros that are not included in the valid code. Alpha characters must be in upper case.
(16) Evaluation and Management Code (1), Evaluation and Management Code (2), Evaluation and Management Code (3), Evaluation and Management Code (4), Evaluation and Management Code (5). A code representative of the patient acuity level for the services provided. If type of service is “2”, must contain a valid Evaluation and Management (EM) Code range 99281-99285; 99288; 99291-99292; and G0380-G0384, even if the only service provided to a registered patient is triage or screening. If patient discharge status is “07” meaning the patient left against medical advice or discontinued care, or where a visit occurs resulting in zero charges, enter default code 99999 to indicate that the patient was not evaluated by a physician. No more than five EM codes may be reported. Less than five entries is permitted. Ambulatory surgical centers, type of service “‘1”, should not report Evaluation and Management codes. A required field.
(17) through (39) No change.
(40) Patient Visit Ending Date. The date at the end of the patient’s visit. A ten (10) character field in the format YYYY-MM-DD where MM represents the numbered months of the year from 1 to 12, DD represents numbered days of the month from 1 to 31, and YYYY represents the year in four digits. Patient visit ending date must equal or follow the patient visit beginning date. Patient visit ending date must occur within the calendar quarter included in the data report. A blank field is not permitted unless type of service is “2” indicating an emergency department visit and patient status is “07” indicating the patient left against medical advice or discontinued care.
(41) through (42) No change.
(43) Patient’s Reason for Visit ICD-CM Code (Admitting Diagnosis). The code representing the patient’s chief complaint or stated reason for seeking care in the Emergency Department. Must contain a valid ICD-9-CM code or valid ICD-10-CM code for the reporting period if type of service is “2” indicating an emergency department visit.
If not space filled, must contain a valid ICD-9-CM or ICD-10-CM diagnosis code. The code must be entered with use of a decimal point that is included in the valid code and without use of a zero or zeros that are not included in the valid code. Space fill if type of service is “1” indicating ambulatory surgery. Alpha characters must be in upper case.
(44) Principal ICD-CM Procedure Code. The code representing the procedure or service most related to the principal diagnosis. A blank field is permitted if type of service is “1” indicating ambulatory surgery. A blank or no entry is permitted consistent with the records of the reporting entity if type of service is “2” indicating an emergency department visit. Must contain a valid ICD-9-CM or ICD-10-CM procedure code for the reporting period. The code must be entered with use of a decimal point that is included in the valid code and without use of a zero or zeros that are not included in the valid code. Space fill if type of service is “1” indicating ambulatory surgery. Alpha characters must be in upper case.
(45) Other ICD-CM Procedure Code (1), Other ICD-CM Procedure Code (2), Other ICD-CM Procedure Code (3), Other ICD-CM Procedure Code (4) – A code representing a procedure or service provided during the visit. If no principal ICD-CM procedure is reported, another ICD-CM procedure code must not be reported unless the patient status is “07” indicating the patient left against medical advice or discontinued care. No more than four other ICD-CM procedure codes may be reported. A blank or no entry is permitted if type of service is “1.” Less than four or no entry is permitted if type of service is “2.” Must be a valid ICD-9-CM or ICD-10-CM procedure code for the reporting period. The code must be entered with use of a decimal point that is included in the valid code and without use of a zero or zeros that are not included in the valid code.
(46) External Cause of Injury Code. External Cause of Injury Code (1), External Cause of Injury Code (2) and External Cause of Injury Code (3). A code representing circumstances or conditions as the cause of the injury, poisoning or other adverse effects recorded as a diagnosis. Assign the appropriate E-code for all initial encounters or treatments, but not for subsequent occurrences. A Place of Occurrence E-code (E849.X) should be included to describe where the event occurred if documented in the patient medical history. No more than three (3) external cause of injury codes may be reported. Less than three (3) or no entry is permitted. If not space filled, must be a valid ICD-9-CM or ICD-10-CM cause of injury code for the reporting period. An external cause of injury code cannot be used more than once for each encounter reported. The code must be entered with use of a decimal point that is included in the valid code and without use of a zero or zeros that are not included in the valid code. Alpha characters must be in upper case.
(47) No change.
(48) Patient Status. –
(a) through (h) No change.
(i) 21 – Discharged or transferred to court/law enforcement.
(i) through (p) renumbered (j) through (q) No change.
(49) No change.
Rulemaking Authority 408.15(8) FS. Law Implemented 408.061, 408.062, 408.063 FS. History–New 1-1-10, Amended_________.
Editorial note: see former Rule 59B-9.018.
