20. Discharge Date (inpatient) - Year, month, and day of discharge as currently recommended in the UHDDS and by ANSI ASC X12. Patient's Expected Sources of Payment, 12. In the evolving managed care field, the need to follow individuals through a continuum of care and at multiple sites will become increasingly necessary. Health Care Practitioner Identification (outpatient), 21. The NCVHS recommended this as an optional item in the UACDS but that high priority should be given to conducting additional study as to the feasibility, ease and practical utility of collecting the patient's reason for encounter, in as close to the patient's words as possible. Regenstrief Institute, Dora A. McDonald Procedures (inpatient) - All significant procedures, and dates performed, are to be reported. Health Care Planning and Policy, Edna Kamis-Gould, Ph.D. National Institute of Alcohol, Abuse, and Alcoholism, Benjamin C. Duggar, Sc.D. Center for Health Research and Communications, Inc. Craig Zwerling, M.D., Ph.D. During the NCVHS review of core health data elements, discussion arose regarding the specificity of diagnoses reported The official national outpatient/physician coding and reporting guidelines provide instruction that a suspected or rule out condition not be reported as though it is a confirmed diagnosis. Items shown below with an asterisk (*) indicate that this type of information can be obtained from linking the NPI with the National Provider File and may not need separate collection. Congress of the United States, Emilie Schmeidler, Ph.D. B.Discharged/transferred to another short term general hospital for inpatient care Virtually all saw the need for uniform data items and definitions, and the issue of a unique identifier was a frequent topic. 18. New York State Department of Health, Steven Davis Dave Baldridge The priorities for recording an External Cause-of-Injury code (E-code) are: The collection of this element has been recommended by the UHDDS and the UACDS, and a separate element for its collection is included on the UB 92. Whether an injury is work related or not can be of significant importance both in the area of injury prevention and in medical care payment. In August 1994, the Department asked the Committee to provide information and advice that will help maximize the utility of core person and encounter data for meeting the Department's responsibilities. This element refers to living arrangements only. 15. While reviewing the draft list of data elements, respondents indicated a number of additional data elements that they felt were important core elements. Several states, including California, Oklahoma, and New York presented findings on using a combination of key data items to perform probabilistic matches. Although the UHDDS has been in the field for two decades and its data items are widely used by government and private organizations, issues of quality and comparability remain. Additionally, a consensus must be reached on the unique personal identifier. Of these, approximately 70 percent provided information about their data elements. Both the UHDDS and UACDS have been reviewed and updated by the NCVHS and the Department in recent years. There are data items, such as health status and functional status, that are considered crucial elements, but for which substantial additional evaluation and testing must be undertaken to reach consensus on standardized content and definition. A second study is currently underway, one which will investigate core data elements in common use in data sets on persons with disability and/or persons receiving long term care. The description of the element indicates this present lack of agreement. The complete address of the providers office. The data is collected on inpatient hospital discharges for Medicare and Medicaid programs. American Medical Association, Zili Sloboda, Sc.D. It is a standardized, primary screening and assessment tool for health status that forms the foundation of the comprehensive assessment for all . The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. Patient's Expected Sources of Payment - The following categories are recommended for primary and secondary sources of payment: 40A. Aetna Health Plans, Sheila Horman American Medical Association, Mark Epstein, Sc.D. Some third party payers, however, have ignored the guidelines and required facilities and health care practitioners to report a diagnosis that justifies the performance of services being provided. 41. ABLES Project Opfficer, NIOSH, Steven Rosenberg, Ph.D. National Institutes of Health, David . To measure the current state of the use of various data sets, the Committee contracted with the Center for Health Policy Studies (CHPS) in Columbia, MD to begin identifying major data sets already in existence, especially in the private field. Significant medical procedures performed. Capture of the full four-digit year of birth is recommended 03. A. Therefore, billed charges should be collected, at a minimum. The Committee recognizes the ongoing discussion of discrepancies between 'expected' and 'actual' sources of payment. Half of the ten major employers who were asked to participate declined; only four actually sent in a data set. Which of the following data elements is unique to UACDS A. Where can I watch the entire Dragon Ball series for free. 1 vote.UACDS - Uniform Ambulatory Care Data Set - All Acronyms. It is hoped that the system will improve the coordination of benefits, as well as providing access to information about health insurance and making it easier to track third party liability situations. This element is currently collected on the HCFA 1500 form. and provide a thorough description of what you have chosen. Residence - Full address and ZIP code (nine digit ZIP code, if available) of the individual's usual residence.. 4. It is of vital importance to participate in and/or be members of the numerous data standards groups. Years of Schooling - Highest grade of schooling completed by the enrollee/patient. Alexis A. Wilson Whichever method is used should be designated. 30. Provide stable resources to the project to establish an interdepartmental work group, with DHHS taking the lead, to work with the key standards-setting organizations in the area of core health data elements. The Committee recognizes that this is an iterative process and has included in these recommendations several elements that have been proposed for standardization, even though no consensus currently exists concerning appropriate or feasible definitions. The UACDS has never been officially promulgated by the Department, but a 1989 revision by the NCVHS and an Interagency Task Force has been widely circulated, as has a further refinement by the NCVHS in 1994. Georgia State University, Maria Redona Couper The American Academy of Family Physicians, Barbara Faigin medical and surgical care provided to patients who depart from the facility on the same day they receive care (outpatient). After review of the data elements collected, the subcommittees decided to study in-depth six data clusters: The preliminary results of this project have been prepared. The Uniform Hospital Discharge Data Set, or UHDDS, is used for reporting inpatient data in acute-care, short-term care, and long-term care hospitals. Include the full name of the provider as well as the National Provider. Collection of years of schooling has been recommended by the NCVHS and others as a proxy for socioeconomic status (SES). Managed Behavioral Health News, Melvin Sabshin, M.D. This listing should be reviewed by the NCVHS and standards organizations and, if found acceptable, recommended for use. The data is collected on inpatient hospital discharges for Medicare and Medicaid programs. and is the best alternative to insure the availability of small area data. The categories in this element were recommended by the UHDDS for primary and secondary sources of payment. Ronald Carlson 26. Refer the core health data elements recommendations to the National Uniform Claim Committee for their consideration as they study the issue of uniform data elements for paper and electronic collection in Fall 1996. American Hospital Association, Dawn Carlson, Ph.D. Together with marital status, this element provides a picture of potential formal/informal resources available to the person. Phillippine Nurses Association of America, Karen Grady Pennsylvania Health Care Cost Containment Council, P. John Seward, M.D. Vermont Health Care Authority, Michael G. Kassis The Assistant Secretary for Planning and Evaluation (ASPE) is the principal advisor to the Secretary of the U.S. Department of Health and Human Services on policy development, and is responsible for major activities in policy coordination, legislation development, strategic planning, policy research, evaluation, and economic analysis. The MEDSTAT Group, Joel Diringer, JD. American Foundation for the Blind, Karen Kmetik What does UACDS stand for? Connecticut Children's Medical Center, Geraldine Oliva In a number of instances, lists of data items were obtained, but without definitions. Providers, Insurers, and universities represented about 7 percent each. Place holders will be set, and, in some cases data items and definitions decided on, before national and local public health agencies and organizations will be able to act. The NCVHS has undertaken parallel efforts to identify elements specific to mental health, substance abuse, disability and long-term care settings. With the assistance of the Center for Mental Health Services, SAMHSA, and a contractor, Webman Associates, a study was undertaken to identify and survey a representative sample of mental health, managed care, substance abuse, disabilities and long term care experts who would be willing to offer recommendations about the content of an ideal minimal data set for a health care record that is inclusive of the relevant information. University of Pennsylvania Medical Center, Steven Kappel Food and Drug Administration, Mary Devereaux Hutton, R.N., M.P.H. Confidentiality of identifiable records is another critical issue. As a result of the process followed in the conduct of this project and based on careful analysis by its members, the Committee has reached the following conclusions: Because they recognize the significance of this project, respondents also recommended a number of additional items that they would like evaluated and possibly included in a core set of standardized data elements. These data items include birth name, date of birth, place of birth, gender, and mother's first name. 1. National Center for Health Statistics, Richard Rubin They do represent those items that are routinely collected in many efforts, such as basic person information, as well as items specific to inpatient or ambulatory care settings, such as provider information, diagnoses, and services. Principal Diagnosis (inpatient) - As recommended by the UHDDS, the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital or nursing home for care. Workgroup for Electronic Data Interchange, Lucy Johns The Committee acknowledges that there are differences in coding guidelines for reporting diagnosis in inpatient and outpatient settings, and this may result in a lack of comparability in data between the two settings. University of California, San Francisco, Jaclyn Packer The UHDDS guidelines state all significant procedures are to be reported and a significant procedure is defined as one that is: Surgical in nature, or. Centers for Disease Control and Prevention. To assure the widest possible distribution, the document was also placed on the DHHS and NCHS Home Pages in an electronic format. Oklahoma Department of MH and SA Services, Don Eugene Detmer, M.D. Current or Most Recent Occupation and Industry, 28. USDA, Food and Consumer Service, Regina McPhillips, Dr.P.H. There is not one agreed-upon coding system for this item; the International Classification of Primary Care, and the Reason For Visit Classification used by the National Ambulatory Medical Care Survey are two such systems. North Carolina Department of Human Resources, Division of Medical Assistance, Robert W. Mayes UACDS. The set includes reasons for the encounter, living arrangements, and marital status. offices, the location of the usual or principal place of practice should be given. Paul Y. Ertel, M.D. At a minimum, the following classification is suggested: The critical distinction here is whether followup is planned or scheduled, as an indicator of continuing health problems and continuity of care. National Institute of Dental Research, NIH, T. J. Mathews Department of veteran's Affairs (191), W. Michael Boyson, M.H.A. Self-Reported Health Status - There was much interest in documenting health status, one element that can precipitate the demand for health care and help determine the prognosis, although there was no consensus on how its definition should be standardized. National Indian Council on Aging, Inc. Jacqueline R. Bennett Functional assessment scales must also be age-appropriate. The ICD-9-CM is the recommended coding convention. In recent years, the focus of health care has been shifting to hospital outpatient and other outpatient care, including clinic, hospice and home care, sites for which standardized data collection had not been developed. Florida Hospital Association Information Services, George J. Stukenborg, Ph.D. Facility Identification - The unique HCFA identifier as described above. American Physical Therapy Association, Anthony J. It appeared that some types of data linkage could be obtained in states with smaller populations, but might not work nationwide. Office of the Assistant Secretary for Planning and Evaluation. This item would be collected at first clinical visit and periodically updated, at least annually. Patient's Relationship to Subscriber/Person Eligible for Entitlement, 12. I need the ICD-10-PCS codes 2. 1. Favorable input has been received from a wide range of experts, and these elements should be compellingly useful both to states and to provider organizations. Future projects may undertake to seek consensus among some of these items. But time is short; decisions are being made by organizations now. Other potential problems include lack of numbers for newborns, legal and illegal non-citizens and persons who wish to hide their identity, as well as a recommendation that a system would need to be established to assign and track dummy numbers. Operating Clinician Identification - The unique national identification number assigned to the clinician who performed the principal procedure, as recommended by the UHDDS. The type of data collected in each different facility's patient health records is established by required standards or regulations. Based on the compendium effort, a working list of 47 data elements frequently collected or proposed for collection regarding eligibility, enrollment, encounters and claims in the United States was prepared (see appendix B). In addition, home address will allow the application of GIS (Geographic Information Systems) technology to the analysis of health issues. Response was significant and positive to the Committee's request to review a set of core data elements that were identified after a series of hearings and other information- gathering efforts were completed. Attending Physician Identification (inpatient) 1/, 22. Center for Mental Health Services, Corinne Kirchner, Ph.D. Dept. Other Diagnoses (inpatient) - As recommended by the UHDDS, all conditions that coexist at the time of admission, or develop subsequently, which affect the treatment received and/or the length of stay. The information, which is already in the public domain, will be accessible by names and ID numbers, and available in several formats. These discussions led to the issue of needing DHHS staff dedicated to participating in the meetings of numerous data standards committees, advising the Department, and producing further iterations of data elements as future agreement is reached. Virginia Health Information, Charles MacKay More emphasis on the confidential use of SSN is essential. A chart showing the distribution of all respondents by type of organization is shown in appendix D. Approximately 30 percent of respondents were from state and local governments, followed by professional associations and the Federal Government with 18 Percent and 17 percent respectively. In addition, there are some disabilities, such as severe mental illness or blindness, where ADLs and IADLs are not sufficient measures. The primary diagnosis is not part of the UHDDS, and in most diagnostic situations, the principal and primary diagnoses will be identical. Provider Location or Address of Encounter (outpatient), 22. For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. 42. The Uniform Ambulatory Care Data Set (UACDS) regulates ambulatory care. ICD-9-CM Vol. Standardized data sets, starting with the UHDDS developed by the NCVHS, have been in use for more than two decades. These comparisons also included consideration of the general availability, reliability, validity, and utility of data elements. Marital status is one element that is sometimes used as a surrogate for the social support system available to an individual and can be important for program design, targeting of services, utilization and outcome studies, or other research and development purposes. It is recommended that the year of birth be reported in four digits to make the data element more reliable for the increasing number of persons of 100 years and older. The UHDDS guidelines are used by hospitals to report inpatient data elements in a standardized manner. Secondary Source - The secondary source, if any, that will be responsible for the next largest percentage of the patient's current bill. Biometrics, Center for Devices and Radiological Health, Food and Drug Adm. Elizabeth Grossman This recommendation is in accord with the 1992 UHDDS and the UACDS, as well as recommendations by the NCVHS Subcommittee on State and Community Health Statistics. Commonwealth of Virginia, Department of Medical Assistance Services, William R. Taylor, M.D., M.P.H. Office of Statewide Health Planning and Development. Operative Report PREOPERATIVE DIAGNOSIS: Recurrent sigmoid volvulus and tumor POSTOPERATIVE DIAGNOSIS: Recurrent sigmoid volvulus and tumor OPERATION: Directions: Discussion Overview: Choose a specific commonly collected data set (UHDDS, CDC, NCDB, UACDS, OASIS, HEDIS, etc.) A listing of the Core Health Data Elements grouped by level of readiness for implementation is provided after the section with the definitions of each data element. Condition should be recorded to the highest documented level of specificity, such as symptoms, signs, abnormal test results, or other reason for visit, if a definitive diagnosis has not been established at the end of the visit/encounter. Center for Health Policy Studies, Carrie Dunkle, RN A. However, AHCPR is in the process of publishing findings indicating definitional discrepancies even within the organizations collecting the UHDDS. Health Care Practitioner Identification (outpatient) - The unique national identification number assigned to the health care practitioner of record for each encounter. In addition to requesting a written response from these experts, they were invited to participate in one of two special meetings organized by the Committee to discuss the project and to seek input. Condition(s) should be recorded to the highest documented level of specificity. Dates of Procedures (inpatient) - Year, month, and day, as recommended in the UHDDS and by ANSI ASC X12, of each significant procedure. Massachusetts General Hospital, Harvard Medical School, Jonathan M. Ellen, M.D. As highlighted earlier, the Committee has identified a number of areas that should be considered for implementation by the HHS Data Council. 01. Describe each data set element, who developed the data set, and compare the similarities and differences of each data set to the others for the following 3 data sets: Hi there, would you like us to [] University of California. The Committee's goal has been to develop a set of data elements with agreed-upon standardized definitions that, when needed in a data collection effort, can be used to collect and produce standardized data. Years of schooling has been found to be highly predictive of health status and health care use. 35. To this end, the Committee recommends that the Data Council: 3. One would be through the use of a state-level or regional-level organization that already has a line of communication with other organizations. The collection of this element allows for the investigation of issues surrounding health and health care by a person's race and ethnic background. Hartford Health Department, Clem McDonald, M.D. Several organizations have volunteered to facilitate dissemination and feedback of the core data elements project. The Committee encourages the Department and its partners to give high priority to conducting evaluation and testing on such elements and also seeks to alert organizations developing standards or data sets to leave place holders for their inclusion. Birth weight of newborn is readily available in the medical record and has singular importance for risk-adjustment outcome studies and health policy development related to maternal and infant health. 33. To retrieve electronic data B. However, for services billed on a batch basis, two dates would be required to encompass the range of dates from the beginning of all treatments included under the batch (global) code to the end, with a check box to indicate that this is a batch-based encounter. C.Discharged/transferred to skilled nursing facility (SNF) D.Other (specify). ANSI HISPP (Health Informatics Standards Planning Panel). 6. The Committee recommends that the HCFA identifier be adopted when completed. What does Lo Debar represent in the Bible? To retrieve electronic data B. Mayo Medical School, F. Lawrence Clare, M.D., M.P.H. We realized that the industry needed a standardized dataset that provides essential elements for EHR documentation. Molly A. Anthony, Ph.D. Work has been undertaken in the past to try to bring some semblance of order to selected areas of health data collection, especially in the areas of hospital inpatients and physician office visits. The Committee is concerned about the possible inclusion of a "multiracial" category, without an additional element requesting specific racial detail and/or primary racial identification, because of its anticipated impact on trend data and loss of specificity. Sufficient penalties for breach of confidentiality either do not exist or are not enforced. Additional evaluation and testing are warranted for this important information. The data sets that are currently standardized are prime examples of satisfying multiple purposes with a single data set. Moreover, in the electronic format, in most instances, payments would not be available at the time that patient and medical data are entered. It remains unclear whether the modest health gains seen in low-income and racial/ethnic minority populations in the last thirty years will continue, considering the changes in the U.S. health care system. The Committee encourages the use of the above definition, while continuing to study and evaluate other residential categories, such as those used by the Bureau of the Census. Illinois Department of Public Health, Michael T. Lundberg, B.S. Don L. Zimmerman, Ph.D. Future projects may undertake to seek consensus among some of these items. Uniform Ambulatory Care Data Set (UACDS). The collection of information on medications is crucial to understanding the health care encounter and the services provided to a patient. The ever-expanding sites of care, combined with the increasing use of electronic data, make it imperative that all health data collection activities, where possible, utilize standardized data elements and definitions. Because the full residential address could serve as a proxy personal identifier, confidentiality of the complete information must be safeguarded in public use of the data. The Alan Guttmacher Institute, Kathleen A. Frawley ASTM (American Society for Testing and Materials ). (9 days ago) What does uacds mean or stand for?UACDS means Uniform Ambulatory Care Data Set. Disposition (outpatient) - The health care practitioner's statement of the next step(s) in the care of the patient. This issue represents more than just what item or set of items the identifier will include; it opens up the whole issue of data linkage, privacy, and data confidentiality with its relevant benefits and risks. Review state-of-the-art of widely used core data sets in the United States and other countries (including coding and formatting features that allow for flexibility); ANSI (American National Standards Institute). Currently, such a staff does not exist. A person currently married. Medicare administrative data or Medicare Fee-for-Service claims (administrative) data, also known as health services utilization data, are collected by the Centers for Medicare and Medicaid Services (CMS) and derived from reimbursement information or the payment of bills. This relationship (i.e., self, spouse or child of subscriber) is often obtained and can be of importance for payment and research purposes. It is recommended that the NPF be the source of all unique provider identifiers, for institutions and individuals. Health Resources and Service Admin. A person who has never been married or whose only marriages have been annulled. This taxonomy builds on previous NCVHS and departmental work and should be reviewed by the NCVHS and standards organizations. Performance monitoring and outcomes research are two areas that are currently hampered by the inability to link data sets from various sources. 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