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National Health Amendment Regulations 2006 (No. 1)

Authoritative Version
  • - F2006L01920
  • No longer in force
SLI 2006 No. 168 Regulations as made
These Regulations amend the National Health Regulations 1954, Hospital Casemix Protocols (HCP).
Administered by: Health
Registered 27 Jun 2006
Tabling HistoryDate
Tabled HR08-Aug-2006
Tabled Senate08-Aug-2006
Date of repeal 19 Mar 2014
Repealed by Health (Spent and Redundant Instruments) Repeal Regulation 2014

National Health Amendment Regulations 2006 (No. 1)1

Select Legislative Instrument 2006 No. 168

I, PHILIP MICHAEL JEFFERY, Governor-General of the Commonwealth of Australia, acting with the advice of the Federal Executive Council, make the following Regulations under the National Health Act 1953.

Dated 22 June 2006

P. M. JEFFERY

Governor-General

By His Excellency’s Command

TONY ABBOTT


1              Name of Regulations

                These Regulations are the National Health Amendment Regulations 2006 (No. 1).

2              Commencement

                These Regulations commence on 1 July 2006.

3              Amendment of National Health Regulations 1954

                Schedule 1 amends the National Health Regulations 1954.


Schedule 1        Amendments

(regulation 3)

  

[1]           Paragraph 49B (1) (i)

omit

Version 5.0.

insert

Version 5.0;

[2]           After paragraph 49B (1) (i)

insert

                (j)    Australian Refined Diagnosis Related Groups Definitions Manual Version 5.1.

[3]           Schedule 7

substitute

Schedule 7        Hospital Casemix Protocol

(regulation 49A)

Part 1          Explanatory notes

1              Object

                The object of the Hospital Casemix Protocol is to specify the financial, clinical and demographic data that a registered health benefits organisation must give to the Department in respect of each episode of hospital treatment for which an amount is charged to the registered health benefits organisation.

2              Definitions

         (1)   In this Schedule:

ADA means the Australian Dental Association.

AN-SNAP means the Australian National Sub-Acute and Non-Acute Patient Classification System.

blank filled, in relation to a data item, means that the data item is filled with blank spaces.

CCU means the coronary care unit of a hospital.

contracted doctor means a medical practitioner that has entered into a medical purchaser-provider agreement.

contracted hospital means a hospital or day hospital facility that has entered into a hospital purchaser-provider agreement.

DRG means the Australian refined diagnosis related group.

episode means the period between admission and separation that a person spends in 1 hospital, and includes leave periods not exceeding 7 days.

Note   This definition of episode differs from the definition set out in the NHDD.

FIM means functional independence measure.

formal admission, in relation to a person, means the administrative process used by a hospital to record the commencement of accommodation, care or treatment of the person.

formal separation, in relation to a person, means the administrative process used by a hospital to record the cessation of accommodation, care or treatment of the person.

fund means a health benefits fund that is conducted by a registered health benefits organisation.

HDU means the high dependency unit of a hospital.

ICD-10-AM means ‘The International Statistical Classification of Diseases and Related Health Problems, 10th revision, Australian Modification’, 5th edition, published by the National Centre for Classification in Health (Australia).

ICU means the intensive care unit of a hospital.

MAA, in relation to a data item, means that the item must be completed with a valid entry.

MBS means the Medicare Benefits Schedule, comprising:

                (a)    the Health Insurance (Diagnostic Imaging Services Table) Regulations 2005; and

               (b)    the Health Insurance (General Medical Services Table) Regulations 2005; and

                (c)    the Health Insurance (Pathology Services Table) Regulations 2005;

as in force from time to time, or any Regulations made in substitution for those Regulations.

NHDD means the ‘National Health Data Dictionary’, version 12, published in 2003.

NICU means the neonatal intensive care unit of a hospital.

OPA, in relation to a data item, means that the data item is optional for all hospitals.

OPH, in relation to a data item, means that the data item:

                (a)    may be completed by a public hospital regardless of whether the hospital is contracted; and

               (b)    must be completed by a private hospital or a private day facility.

overnight-stay patient means a person who is admitted to and separates from a hospital on different dates.

PICU means the paediatric intensive care unit of a hospital.

same day patient means a person who is admitted to and separates from a hospital on the same date.

SCN means the special care nursery of a hospital.

special character means a character that has a visual representation but is not an alphanumeric character, ideogram or blank space.

statistical admission, in relation to a person, means the administrative process used by a hospital to record the commencement of a new episode of care that provides the person with a new care type during a single hospital stay.

statistical separation, in relation to a person, means the administrative process used by a hospital to record the cessation of an episode of care of the person during a single hospital stay.

zero fill, in relation to a data item, means that the data item is filled with zeros.

zero prefix, in relation to a data item, means that leading zeros are to be inserted if necessary to ensure that the number of characters in the entry matches the data item size specified for the item.

         (2)   In column 5 of an item in a table set out in Part 2, 3, 4 or 5 of this Schedule:

A means that the item is a character set that:

                (a)    uses alphabetic characters a to z (in upper or lower case); and

               (b)    does not use numeric characters.

DDMMYYYY means that the item is a character set that consists of numeric characters representing a date, where:

                (a)    DD indicates the day; and

               (b)    MM indicates the month; and

                (c)    YYYY indicates the year.

Example

The date 9 March 2006 is to be entered as 09032006.

hhmm means that the item is a character set that consists of numeric characters representing a time based on a 24-hour clock, where:

                (a)    hh indicates the hour; and

               (b)    mm indicates the number of minutes.

Example

The time 6:35am is to be entered as 0635.

N means that the item is a character set that:

                (a)    uses numeric characters; and

               (b)    does not use alphabetic characters; and

                (c)    subject to column 8 of the item, does not include blank spaces or special characters.

X means that the item is a character set that:

                (a)    uses alphabetic characters, numeric characters, blank spaces or a combination of alphabetic characters, numeric characters and blank spaces; and

               (b)    does not use special characters.

3              Parts of the Protocol

         (1)   A hospital episode record that is supplied to the Department by a fund must comply with Part 2 of this Schedule.

         (2)   A medical record that is supplied to the Department by a fund must comply with Part 3 of this Schedule.

         (3)   If a hospital episode of a patient includes the supply of a prosthesis to the patient, the prosthetic record that is supplied to the Department by a fund for the episode must comply with Part 4 of this Schedule.

         (4)   If a patient is treated in a hospital under an AN-SNAP funding agreement between the hospital and a fund, the AN-SNAP record that is supplied to the Department by the fund must comply with Part 5 of this Schedule.

4              Data items — format specifications

         (1)   Except as specified in subclause (2), a blank filled data item is not a valid entry.

         (2)   A blank filled data item is a valid entry if:

                (a)    the data item is optional; or

               (b)    for an item in Part 2, 3, 4 or 5 of this Schedule — the conditions specified in column 8 of the item allow the item to be blank filled in certain circumstances, and those circumstances are satisfied.

         (3)   If column 8 in a data item in Part 2, 3, 4 or 5 of this Schedule indicates that the amount specified for the item requires rounding, and the amount is not a whole number, the amount:

                (a)    if it does not end in 0.5 — is to be rounded to the nearest whole number; and

               (b)    if it ends in 0.5 and the number preceding the decimal point is odd — is to be rounded up; and

                (c)    if it ends in 0.5 and the number preceding the decimal point is even — is to be rounded down.

         (4)   All data items must reflect the completed discharge data set.

5              Data transfer and acceptance

         (1)   A fund is responsible for sending to the Department the information set out in Parts 2 to 5 of this Schedule.

         (2)   If a fund gives data to the Department, the data must:

                (a)    include all episodes, regardless of whether the episode took place in a contracted hospital; and

               (b)    be supplied in accordance with the specifications set out in Parts 2, 3, 4 and 5 of this Schedule (as the case requires); and

                (c)    be supplied in text file format; and

               (d)    be supplied using disks or other electronic media agreed, in writing, between the Department and the fund.

         (3)   If a hospital gives data to a fund, the hospital must supply, in a form agreed to by the hospital and the fund:

                (a)    the hospital episode record information set out in items 1, 7, 9, 11, 13, 15, 17, 19, 21, 29 to 66, and 68 to 83 in Part 2 of this Schedule in accordance with the specifications set out in that Part; and

               (b)    the AN-SNAP record information (if any) set out in Part 5 of this Schedule in accordance with the specifications set out in that Part.

         (4)   A record will be rejected by the Department if the data item codes do not comply with the requirements of Parts 2, 3, 4 and 5 (as the case requires).

         (5)   If 10% or more of the records sent by a fund to the Department in any transmission batch are rejected:

                (a)    all records in that transmission batch will be returned to the fund by the Department; and

               (b)    after receiving the batch, the fund must:

                          (i)    correct the records in the rejected batch; and

                         (ii)    resubmit all of the records that had been sent to the Department in that transmission within 4 weeks after the fund received the rejected records from the Department.


Part 2          File structure and record content — hospital episode record

 

Item

Data item

Start position

Repetitions

Format of data item

Size of data item

Required

Description of data item

1

Fund identifier

1

1

A

3

MAA

Fund identifier selected from the list set out in Part 6.

2

Link identifier

4

1

X

24

MAA

A unique identifier of the episode that links data items from this Part to Parts 3, 4 and 5.

The fund may encrypt the membership identifier.

3

Provider (hospital) code

28

1

X

8

MAA

The hospital provider number.

The provider number must be 8 characters in length (zero prefix) and in upper case.

OVERSEAS = overseas provider.

4

Product code

36

1

X

8

MAA

The product code for a patient’s insurance cover at admission.

The fund must supply documentation of cover field values.

5

Hospital contract status

44

1

A

1

MAA

Y = a hospital with which a fund has a contract.

N = a hospital with which a fund does not have a contract.

T = a hospital that is paid under second tier benefit arrangement.

B = a hospital that is paid under a ‘bulk payment’ arrangement.

6

Total days paid

45

1

N

4

MAA

The total number of days for which benefits were paid by a fund including days for which benefits were paid for a patient as a nursing-home type patient.

Zero prefix if the number is not a 4 digit number.

Same day cases = 0001.

An entry of ‘0000’ must be reported if no benefit was paid for accommodation by the fund.

7

Accommodation charge

49

1

N

9

MAA

An accommodation charge must reflect the gross amount charged for accommodation (in dollars and cents).

The accommodation charge includes ex-gratia and patient portion accommodation charges.

Accommodation refers to private, shared or high dependency accommodation for any type of accommodation (for example advanced surgical, surgical, medical, rehabilitation, obstetrics, and psychiatry).

All hospital episodes must have a charge component reported under accommodation unless the charge was bundled or the hospital charged a procedure-only fee.

Omit decimal point.

Zero prefix.

All values must be greater than or equal to zero.

An entry of ‘000000000’ means that no accommodation charge was charged.

A blank filled data item is valid if the accommodation charge was not separately identified but was charged under another charge item.

8

Accommodation benefit

58

1

N

9

MAA

An accommodation benefit must reflect the gross benefit paid for accommodation (in dollars and cents).

The accommodation benefit includes ex-gratia accommodation benefits.

Accommodation refers to private, shared or high dependency accommodation for any type of accommodation (for example advanced surgical, surgical, medical, rehabilitation, obstetrics, and psychiatry).

Omit decimal point.

Zero prefix.

All values must be greater than or equal to zero.

An entry of ‘000000000’ means that no accommodation benefit was paid.

A blank filled data item is valid if the accommodation benefit was not separately identified but was paid under another benefit item.

All hospital episodes must have a benefit component relating to accommodation unless the benefit was bundled, the hospital charged a procedure-only fee or no benefit was payable.

9

Theatre charge

67

1

N

9

MAA

A theatre charge must reflect the gross amount charged for theatre, a procedure room or an angiography suite (in dollars and cents).

The theatre charge includes ex-gratia and patient portion theatre charges.

Omit decimal point.

Zero prefix.

All values must be greater than or equal to zero.

An entry of ‘000000000’ means that no theatre charge was charged.

A blank filled data item is valid if the theatre charge was not separately identified but was charged under another charge item.

10

Theatre benefit

76

1

N

9

MAA

A theatre benefit must reflect the gross benefit paid for theatre, a procedure room, or an angiography suite (in dollars and cents).

The theatre benefit includes ex-gratia theatre benefits.

Omit decimal point.

Zero prefix.

All values must be greater than or equal to zero.

An entry of ‘000000000’ means that no theatre benefit was paid.

11

Labour ward charge

85

1

N

9

MAA

A labour ward charge must reflect the gross amount charged for a labour ward (in dollars and cents).

The labour ward charge includes ex-gratia and patient portion labour ward charges.

Omit decimal point.

Zero prefix.

All values must be greater than or equal to zero.

An entry of ‘000000000’ means that no labour ward charge was charged.

A blank filled data item is valid if the labour ward charge was not separately identified but was charged under another charge item.

12

Labour ward benefit

94

1

N

9

MAA

A labour ward benefit must reflect the gross benefit paid for a labour ward (in dollars and cents).

The labour ward benefit includes ex-gratia labour ward benefits.

Omit decimal point.

Zero prefix.

All values must be greater than or equal to zero.

An entry of ‘000000000’ means no labour ward benefit was paid.

A blank filled data item is valid if the labour ward benefit was not separately identified but was paid under another benefit item.

13

ICU charge

103

1

N

9

MAA

An ICU charge must reflect the gross amount charged for ICU (in dollars and cents).

The ICU charge:

   (a)  includes ex-gratia and patient portion ICU charges; and

   (b)  includes NICU and PICU; and

   (c)  does not include CCU, HDU or SCN.

Omit decimal point.

Zero prefix.

All values must be greater than or equal to zero.

An entry of ‘000000000’ means that no ICU charge was charged.

A blank filled data item is valid if the ICU charge was not separately identified but was charged under another charge item.

14

ICU benefit

112

1

N

9

MAA

An ICU benefit must reflect the gross benefit paid for the ICU (in dollars and cents).

The ICU benefit:

   (a)  includes ex-gratia ICU benefits; and

   (b)  includes NICU and PICU; and

   (c)  does not include CCU, HDU or SCN.

Omit decimal point.

Zero prefix.

All values must be greater than or equal to zero.

An entry of ‘000000000’ means that no ICU benefit was paid.

A blank filled data item is valid if an ICU benefit was not separately identified but was paid under another benefit item.

15

Prosthesis charge

121

1

N

9

MAA

A prosthesis charge must reflect the gross amount charged for a prosthesis including any handling fee and patient portion (in dollars and cents).

The prosthesis charge includes ex-gratia prosthesis charges.

Omit decimal point.

Zero prefix.

All values must be greater than or equal to zero.

An entry of ‘000000000’ means that no prosthesis charge was charged.

 

A blank filled data item is valid if the prosthesis charge was not separately identified but was charged under another charge item.

16

Prosthesis benefit

130

1

N

9

MAA

A prosthesis benefit must reflect the gross benefit paid for a prosthesis including any handling fee (in dollars and cents).

The prosthesis benefit includes ex-gratia prosthesis benefits.

Omit decimal point.

Zero prefix.

All values must be greater than or equal to zero.

An entry of ‘000000000’ means that no prosthesis benefit was paid.

A blank filled data item is valid if the prosthesis benefit was not separately identified but was paid under another benefit item.

17

Pharmacy charge

139

1

N

9

MAA

A pharmacy charge must reflect the gross amount charged for pharmacy (in dollars and cents).

The pharmacy charge:

   (a)  includes ex-gratia and patient portion pharmacy charges; and

   (b)  does not include discharge medications.

Omit decimal point.

Zero prefix.

All values must be greater than or equal to zero.

An entry of ‘000000000’ means that no pharmacy charge was charged.

A blank filled data item is valid if the pharmacy charge was not separately identified but was charged under another charge item.

18

Pharmacy benefit

148

1

N

9

MAA

A pharmacy benefit must reflect the gross benefit paid for pharmacy (in dollars and cents).

The pharmacy benefit:

   (a)  includes ex-gratia pharmacy benefits; and

   (b)  does not include discharge medications.

Omit decimal point.

Zero prefix.

All values must be greater than or equal to zero.

An entry of ‘000000000’ means that no pharmacy benefit was paid.

A blank filled data item is valid if the pharmacy benefit was not separately identified but was paid under another benefit item.

19

Bundled charge

157

1

N

9

MAA

A bundled charge must reflect the gross bundled amount charged (in dollars and cents).

A bundled charge includes ex-gratia and patient portion bundled charges.

A bundled charge refers to an aggregate of 2 or more charges charged by a hospital, for example case payments by DRG.

Omit decimal point.

Zero prefix.

All values must be greater than or equal to zero.

An entry of ‘000000000’ means that no bundled charge was charged.

A blank filled data item is valid if the bundled charge was not separately identified but was charged under another charge item.

20

Bundled benefit

166

1

N

9

MAA

A bundled benefit must reflect the gross bundled benefit paid (in dollars and cents).

Bundled benefits include ex-gratia bundled benefits.

A bundled benefit refers to an aggregate of 2 or more benefits paid by a fund, for example case payments by DRG.

Omit decimal point.

Zero prefix.

All values must be greater than or equal to zero.

An entry of ‘000000000’ means that no bundled benefit was paid.

A blank filled data item is valid if the bundled benefit was not separately identified but was paid under another benefit item.

21

Other charges

175

1

N

9

MAA

Other charges must reflect the gross amount charged (in dollars and cents) for any chargeable item that does not fall into another charge item in this Part.

This item must only include charges that may be charged to a fund and that are not reported under accommodation, bundled, ICU, labour, pharmacy, prosthesis or theatre.

This item does not include ex-gratia charges, television, phone calls, extra meals, front end deductible, reversals or journal adjustments.

Omit decimal point.

Zero prefix.

All values must be greater than or equal to zero.

An entry of ‘000000000’ means that no other charges were charged.

A blank filled data item is valid if the charges covered by this item were not separately identified but were charged under another charge item.

22

Other benefits

184

1

N

9

MAA

Other benefits must reflect the gross benefit paid (in dollars and cents) for any chargeable item that does not fall into another benefit item in this Part.

This item must only include benefits that may be paid by a fund and that are not reported under accommodation, bundled, ICU, labour, pharmacy, prosthesis or theatre.

This item does not include ex-gratia benefits, television, phone calls, extra meals, front end deductible, reversals or journal adjustments.

Omit decimal point.

Zero prefix.

All values must be greater than or equal to zero.

An entry of ‘000000000’ means that no other benefits were paid.

A blank filled data item is valid if the benefits covered by this item were not separately identified but were paid under another benefit item.

23

Front end deductible

193

1

N

9

MAA

The amount of front end deductible (excess) (in dollars and cents) deducted from the benefit that would otherwise be payable by the fund to a hospital.

Omit decimal point.

Zero prefix.

An entry of ‘000000000’ means that this item does not apply.

24

Ancillary cover status

202

1

A

1

MAA

Y means that a patient has ancillary cover.

N means that a patient does not have ancillary cover.

25

Ancillary charges

203

1

N

9

OPA

Ancillary charges must reflect the total amount charged (in dollars and cents) for in-hospital benefits claimed under an ancillary table.

Omit decimal point.

Zero prefix.

All values must be greater than or equal to zero.

An entry of ‘000000000’ means that no ancillary charges were charged.

26

Ancillary benefits

212

1

N

9

OPA

Ancillary benefits must reflect the total benefit paid (in dollars and cents) for in-hospital benefits paid under an ancillary table.

Omit decimal point.

Zero prefix.

All values must be greater than or equal to zero.

An entry of ‘000000000’ means that no ancillary benefits were paid.

27

Medical item charges

221

1

N

9

MAA

Medical item charges must reflect the total amount charged for medical items (in dollars and cents) that are set out in the medical records associated with the episode.

Omit decimal point.

Zero prefix.

An entry of ‘000000000’ means that no medical item charges were charged.

28

Total medical benefits

230

1

N

9

MAA

Total medical benefits must reflect the total medical benefits paid by Medicare and the fund (in dollars and cents).

Total medical benefits are set out in the medical records associated with the episode.

Omit decimal point.

Zero prefix.

An entry of ‘000000000’ means that no medical benefits under this item were paid.

29

Date of birth

239

1

DDMMYYYY

8

MAA

NHDD ID 000036, V4.

The date of birth of the member.

30

Postcode

247

1

N

4

MAA

The patient’s residential postcode.

The postcode must be a valid Australian postcode.

Zero prefix if the postcode is not a 4 digit number.

9999 = unknown postcode.

8888 = overseas.

31

Sex

251

1

N

1

MAA

NHDD ID 002024, V4.

1 = male.

2 = female.

3 = intersex or indeterminate.

9 = not stated/inadequately described.

32

Admission date

252

1

DDMMYYYY

8

MAA

NHDD ID 000008, V4.

The date on which an admitted patient commences an episode of care through formal admission or statistical admission.

33

Separation date

260

1

DDMMYYYY

8

MAA

NHDD ID 000043, V4.

The date on which an admitted patient completes an episode of care through formal separation or statistical separation.

34

Hospital type

268

1

N

1

MAA

1 = public.

2 = private.

3 = private day facility.

4 = public day facility.

9 = other/unknown.

35

ICU days

269

1

N

3

MAA

The number of days that a patient spent in 1 or more of the following:

   (a)  ICU;

   (b)  NICU;

   (c)  PICU.

This excludes any day that the patient spent in a CCU, HDU or SCN.

Zero prefix if the number of days is not a 3 digit number.

An entry of ‘000’ must be reported if no days were spent in ICU, NICU or PICU.

36

DRG code

272

1

X

4

OPA

The DRG code that describes the episode of care.

The code ‘GEN’ means a generated episode that is unsuitable for grouping according to fund practices.

If the fund’s DRG code is known, that code must be reported. If the fund’s DRG code is unknown then the hospital’s DRG code is to be reported.

If a DRG version is reported, then a DRG code must be reported.

A DRG code must be a code that is a valid DRG code in relation to the DRG version reported.

37

DRG version

276

1

N

2

OPA

31 = version 3.1.

32 = version 3.2.

41 = version 4.1.

42 = version 4.2.

50 = version 5.0.

51 = version 5.1.

nx = version n.x.

If the DRG code is reported then a DRG version must be reported.

38

Admission time

278

1

hhmm

4

MAA

(same day patients only)

NHDD ID 000358, V2.

Admission time is the time that an admitted patient commences an episode of care through formal admission or statistical admission.

39

Weight of infant, neonate or stillborn

282

1

N

4

MAA

NHDD ID 000010, V3.

For live births, the birth weight is preferably to be measured within the first hour of life before significant postnatal weight loss has occurred. Although statistical tabulations include 500 gram groupings for birth weight, infant weights must not be recorded in those groupings. The actual weight of the infant must be recorded to the degree of accuracy to which it is measured.

In perinatal collections, the birth weight is to be provided for live born and stillborn babies.

Weight on the date the infant is admitted must be recorded if the infant’s weight is less than or equal to 9000g and the infant’s age is less than 365 days.

Zero prefix if the number is not a 4 digit number.

Zero fill this item if it is not applicable.

40

Hours of mechanical ventilation

286

1

N

4

MAA

The total number of hours (rounded) for which a patient received mechanical ventilation in an ICU during an episode.

ICU:

   (a)  includes NICU and PICU; and

   (b)  excludes CCU, (unless ventilation occurred in a combined ICU/CCU), HDU and SCN.

Zero prefix if the number is not a 4 digit number.

An entry of ‘0000’ must be reported if the patient did not receive any mechanical ventilation.

41

Mode of separation

290

1

N

2

MAA

NHDD ID 000096, V3.

1 = discharge or transfer to an acute hospital.

2 = discharge or transfer to a nursing home.

3 = discharge or transfer to a psychiatric hospital.

4 = discharge or transfer to other health care accommodation (including mothercraft hospitals and hostels recognised by the Department, unless this is the patient’s usual place of residence).

5 = statistical discharge — type change.

6 = left against medical advice or was discharged at own risk.

7 = statistical discharge from leave.

8 = died.

9 = other (including discharge of patient to usual residence, own accommodation or welfare institution (including prisons, hostels and group homes providing primarily welfare services)).

If the data item is reported in this format, left justify and include a blank space after the code number.

Data may also be reported in the old format which allows for a zero prefix, for example: 01, 02, 03, 09.

42

Separation time

292

1

hhmm

4

MAA

(same day patients only)

NHDD ID 000644, V1.

Separation time is the time when a patient completes an episode of care through formal separation or statistical separation.

43

Source of referral

296

1

N

1

MAA

0 = born in hospital.

1 = admitted patient transferred from another hospital.

2 = statistical admission or type change.

4 = from Accident/ Emergency.

5 = from community health service.

6 = from Outpatients department.

7 = from nursing home.

8 = by outside medical practitioner.

9 = other.

44

Care type

297

1

N

3

MAA

NHDD ID 000168, V4.

10 = acute care.

20 = rehabilitation care.

21 = rehabilitation care delivered in a designated unit.

22 = rehabilitation care according to a designated program.

23 = rehabilitation care is the principal clinical intent.

30 = palliative care.

31 = palliative care delivered in a designated unit.

32 = palliative care according to a designated program.

33 = palliative care is the principal clinical intent.

40 = geriatric evaluation and management.

50 = psychogeriatric care.

60 = maintenance care.

70 = newborn care.

80 = other admitted patient care.

90 = organ procurement — posthumous.

100 = hospital boarder.

Left justified.

If the code in the data item consists of 2 numeric characters, insert a blank space after the code number.

45

Total leave days

300

1

N

4

MAA

NHDD ID 000163, V3.

The sum of leave days for all leave periods during an episode.

Zero prefix if the number of days is not a 4 digit number.

An entry of ‘0000’ must be reported if the patient has no leave days.

46

Non-certified days of stay

304

1

N

4

OPH

The number of days, exceeding 35 days, that a patient spent in a hospital without certification.

Zero prefix if the number of days is not a 4 digit number.

An entry of ‘0000’ must be reported if the patient does not have any days without certification.

47

Principal diagnosis code

308

1

X

5

MAA

NHDD ID 000136, V3.

The diagnosis code that represents the diagnosis that was established after study of the patient to be the main cause for occasioning the patient's episode of care or attendance at a health care facility.

The principal diagnosis code must be in ICD-10-AM and selected according to the National Coding Standards.

Strip hyphen and dots.

48

Additional diagnosis code

313

49

X

5

MAA

NHDD ID 0000005, V5.

A condition or complaint that:

   (a)  co-exists with the principal diagnosis; or

   (b)  arises during an episode of care or attendance at a health care facility.

Up to 49 additional diagnoses may be entered.

The additional diagnosis code must be in ICD-10-AM and selected according to the National Coding Standards.

Strip hyphen and dots.

Strip morphology codes.

A blank filled data item is valid if there are no additional diagnosis codes (or less than 49 repetitions).

49

Procedure codes

558

50

X

7

MAA

NHDD ID 000137, V5.

The ICD-10-AM codes for all procedures that are undertaken during an episode of care.

No more than 50 procedure codes may be entered.

The procedure codes must be selected according to the National Coding Standards.

Strip hyphen and dots.

A blank filled data item is valid if there are no ICD-10-AM procedure codes (or less than 50 repetitions).

50

Same day status

908

1

N

1

MAA

This data item indicates whether the patient is to be admitted to a facility for an overnight stay.

0 = patient with a valid arrangement allowing overnight stay for a procedure that would normally be performed on a same day basis.

1 = same day patient.

2 = overnight patient (other than type 0 above).

51

Principal MBS item number

909

1

X

14

OPH

For the purposes of Hospital Casemix Protocol reporting, a principal MBS item number is the MBS item or ADA code selected on the basis of:

   (a)  the patient’s first visit to a theatre, procedure room or coronary angiography suite; and

   (b)  the MBS item with the highest medicare benefit amount.

The MBS item or ADA code:

   (a)  does not necessarily relate to the medical item charged by the medical practitioner; and

   (b)  may not correspond to the principal procedure code.

For example, renal dialysis, coronary angiography or angioplasty, same day chemotherapy, lithotripsy, ECT and sleep studies must have a MBS item number reported, although they are undertaken in a procedure room rather than a theatre.

If possible, the miscellaneous service codes are to be reported in the miscellaneous service code data item (item 68).

A blank filled data item is valid if there was no applicable MBS item or ADA code, or the procedure occurred in a public hospital.

52

Principal MBS item date

923

1

DDMMYYYY

8

OPH

The date on which the principal MBS item (set out at item 51) was carried out.

A blank filled data item is valid if there was no principal MBS item or the procedure was performed in a public hospital.

53

Minutes of operating theatre time

931

1

N

4

OPH

NHDD ID 000094, V1.

The time in minutes that a patient spent in an operating theatre during the patient’s first visit to a theatre, procedure room or coronary angiography suite beginning when the patient entered the operating theatre or procedure room and ending when the patient left the operating theatre or procedure room.

For example, a coronary angiography or angioplasty, lithotripsy and ECT must have an MBS item number reported although they are carried out in a procedure room instead of a theatre.

Zero prefix if the number is not a 4 digit number.

An entry of ‘0000’ must be reported if the patient did not spend any time in the operating theatre.

A blank filled data item is valid if there is no applicable MBS item.

54

Secondary MBS item numbers

935

9

X

14

OPH

Additional MBS item numbers or ADA codes are MBS items performed in a theatre, procedure room or angiography suite that are not the principal MBS item or ADA code.

The secondary MBS item or ADA code relates to the theatre and not to the medical item charged by the medical practitioner.

The secondary MBS item or ADA code may not correspond to the Procedure Codes (ICD-10-AM).

If possible, the miscellaneous service codes are to be reported in the miscellaneous service code data item (set out in item 68).

Up to 9 codes may be entered.

Left justify.

A blank filled data item is valid if there is no additional item or code (or less than 9 repetitions).

55

Number of outreach (hospital-in-the-home care) days

1061

1

N

4

OPH (hospital-in-home episodes only)

NHDD ID 000640, V1.

The number of days that benefits are paid by a fund to a Commonwealth approved outreach (hospital-in-the-home care) service provided by a hospital or day hospital facility with an approved outreach program.

Zero fill if this item is not applicable.

This data item is mandatory for private hospitals and private day facilities with approved outreach programs.

56

Total psychiatric care days

1065

1

N

3

MAA

NHDD ID 000164, V2.

The total number of days of a stay that a person was an admitted patient, or resident in a designated psychiatric unit, less the sum total of leave days during the stay in the designated unit.

Zero prefix if the number is not a 3 digit number.

An entry of ‘000’ must be reported if the patient did not have any psychiatric care days.

57

Mental health legal status

1068

1

N

1

OPH

NHDD ID 000092, V3.

An indication of whether the person is treated on an involuntary basis under the relevant State or Territory mental health legislation during a hospital stay or treatment by a community based service.

Involuntary patients are persons who are detained in a hospital or compulsorily treated in the community under mental health legislation for the purpose of assessment or to be provided with appropriate treatment or care.

1 = involuntary patient.

2 = voluntary patient.

3 = not permitted to be reported under the laws of a State or Territory.

8 = not applicable.

58

ICU hours

1069

1

N

4

OPA

The number of hours spent by the patient in 1 or more of ICU, NICU or PICU.

This excludes any hours that the patient spent in CCU, HDU or SCN.

Zero prefix if the number of hours is not a 4 digit number.

An entry of ‘0000’ must be reported if the patient did not spend any hours in ICU, NICU or PICU.

59

Urgency of admission

1073

1

N

1

MAA

NHDD ID 000425, V1.

An indication of the admission status of the patient.

1 = urgency status assigned — emergency.

2 = urgency status assigned — elective.

3 = urgency status not assigned.

9 = not known or not reported.

60

Inter-hospital contracted patient

1074

1

N

1

OPH

NHDD ID 000079, V2.

An indication of the status of a service provided in a hospital.

1 = inter-hospital contracted patient from public sector.

2 = inter-hospital contracted patient from private sector.

3 = other.

9 = not reported.

61

Palliative care status

1075

1

N

1

OPH

An indication that the episode involved palliative care.

1 = patient required palliative care during episode.

2 = no palliative care required during episode.

This data item is required because some States do not statistically discharge a patient to palliative care.

62

Re-admission within 28 days

1076

1

N

1

MAA

The re-admission of a patient to a hospital within 28 days of the patient’s previous discharge from a hospital in relation to the treatment of the patient for a similar or related condition.

1 = Unplanned and previously treated at this hospital.

2 = Unplanned and previously treated at another hospital.

3 = Planned.

8 = Not applicable or not known.

63

Unplanned theatre visit during episode

1077

1

 

1

MAA

The patient required a theatre visit that was unanticipated or unplanned at the time of the patient’s admission.

1 = yes.

2 = no.

64

Provider number of hospital from which the patient was transferred

1078

1

X

8

MAA

If a patient has been transferred from another hospital, the hospital provider number of that hospital is to be reported.

This must be the Commonwealth provider number of the hospital.

The provider number must be 8 characters in length and in upper case.

A blank filled data item is valid if the patient was not transferred.

65

Provider number of hospital to which the patient was transferred

1086

1

X

8

MAA

If a patient has been transferred to another hospital, the hospital provider number of that hospital is to be reported.

This must be the Commonwealth provider number of the hospital.

The provider number must be 8 characters in length and in upper case.

A blank filled data item is valid if the patient was not transferred.

66

Discharge intention on admission

1094

1

N

1

OPA

The intended mode of separation when the patient was admitted.

1 = Discharge to an acute hospital.

2 = Discharge to a nursing home.

3 = Discharge to a psychiatric hospital.

4 = Discharge to a palliative care unit or hospice.

5 = Discharge to other health care accommodation.

8 = To pass away.

9 = Discharge to usual residence.

67

Person identifier

1095

1

X

21

MAA

NHDD ID 002020, v2.

This is a unique fund-specific person identifier that is used in an establishment or agency regardless of any change in a person’s membership.

68

Miscellaneous service codes

1116

10

X

11

OPH

Any miscellaneous service code that is used for billing.

Up to 10 codes may be entered.

A blank filled data item is valid if there were no miscellaneous service codes or less than 10 repetitions.

69

Outreach (hospital-in-the-home-care) charges

1226

1

N

9

MAA

Outreach charges must reflect the gross amount charged (in dollars and cents) for a Commonwealth approved outreach (hospital-in-the-home care) service.

This charge includes ex-gratia and patient portion outreach charges.

Omit decimal point.

Zero prefix.

All values must be greater than or equal to zero.

An entry of ‘000000000’ means that there were no outreach charges charged.

A blank filled data item is valid if the outreach charge was not separately identified but was charged under another charge item.

70

Outreach (hospital-in-the-home-care) benefits

1235

1

N

9

MAA

Outreach benefits must reflect the gross benefits paid (in dollars and cents) for a Commonwealth approved outreach (hospital-in-the-home care) service.

This benefit includes ex-gratia outreach benefits.

Omit decimal point.

Zero prefix.

All values must be greater than or equal to zero.

An entry of ‘000000000’ means that there were no outreach benefits paid.

A blank filled data item is valid if the outreach benefits were not separately identified but were paid under another benefits item.

71

SCN charges

1244

1

N

9

MAA

SCN charges must reflect the gross amount charged for SCN (in dollars and cents). These charges:

   (a)  include ex-gratia and patient portion SCN charges; and

   (b)  exclude NICU charges.

Omit decimal point.

Zero prefix.

All values must be greater than or equal to zero.

An entry of ‘000000000’ means that no SCN charges were charged.

A blank filled data item is valid if the SCN charges were not separately identified but were charged under another charge item.

72

SCN benefits

1253

1

N

9

MAA

SCN benefits must reflect the gross benefit paid for SCN (in dollars and cents). These benefits:

   (a)  include ex-gratia SCN benefits; and

   (b)  exclude NICU benefits.

Omit decimal point.

Zero prefix.

All values must be greater than or equal to zero.

An entry of ‘000000000’ means that no SCN benefits were paid.

A blank filled data item is valid if the SCN benefits were not separately identified but were paid under another benefit item.

73

CCU charges

1262

1

N

9

MAA

CCU charges must reflect the gross amount charged for CCU (in dollars and cents). These charges include ex-gratia and patient portion CCU charges.

Omit decimal point.

Zero prefix.

All values must be greater than or equal to zero.

An entry of ‘000000000’ means that no CCU charges were charged.

A blank filled data item is valid if the CCU charges were not separately identified but were charged under another charge item.

74

CCU benefit

1271

1

N

9

MAA

CCU benefits must reflect the gross benefit paid for CCU (in dollars and cents). These benefits include ex-gratia CCU benefits.

Omit decimal point.

Zero prefix.

All values must be greater than or equal to zero.

An entry of ‘000000000’ means that no CCU benefits were paid.

A blank filled data item is valid if the CCU benefits were not separately identified but were paid under another benefit item.

75

SCN hours

1280

1

N

4

OPA

The number of hours that a patient spent in SCN.

This item excludes the number of hours that the patient spent in CCU, HDU, ICU, NICU or PICU.

Zero prefix if the number of hours is not a 4 digit number.

An entry of ‘0000’ must be reported if the patient did not spend any time in SCN.

76

CCU hours

1284

1

N

4

OPA

The number of hours that a patient spent in CCU.

This item excludes the number of hours that the patient spent in HDU, ICU, NICU, PICU or SCN.

Zero prefix if the number of hours is not a 4 digit number.

An entry of ‘0000’ must be reported if the patient did not spend any time in CCU.

77

SCN days

1288

1

N

3

MAA

The number of days that a patient spent in SCN.

This item excludes the number of days that the patient spent in CCU, HDU, ICU, NICU or PICU.

Zero prefix if the number of days is not a 3 digit number.

An entry of ‘000’ must be reported if the patient did not spend any days in SCN.

78

CCU days

1291

1

N

3

MAA

The number of days that a patient spent in CCU.

This item excludes the number of days that the patient spent in HDU, ICU, NICU, PICU or SCN.

Zero prefix if the number of days is not a 3 digit number.

An entry of ‘000’ must be reported if the patient did not spend any days in CCU.

79

Number of qualified days for newborns

1294

1

N

4

MAA

NHDD ID 000346, V12.

The number of qualified days for newborns during a newborn episode of care.

Zero prefix if the number of days is not a 4 digit number.

An entry of ‘0000’ must be reported if the patient did not have any qualified newborn days.

80

Outreach (hospital-in-the-home-care) commencement date

1298

1

DDMMYYYY

8

MAA

The date on which an admitted patient commences an episode of outreach (hospital-in-the-home care) service.

81

Outreach (hospital-in-the-home-care) completed date

1306

1

DDMMYYYY

8

MAA

The date on which an admitted patient completes an episode of outreach (hospital-in-the-home care) service.

82

Number of Outreach (hospital-in-the-home-care) visit days

1314

1

N

4

MAA

The number of days that a patient in an approved outreach (hospital-in-the-home care) program received services.

Zero prefix if the number of days is not a 4 digit number.

An entry of ‘0000’ must be reported if the patient did not receive an outreach (hospital-in-the-home care) visit day.

83

Palliative care days

1318

1

N

4

OPH

The number of days that a patient is in palliative care including care provided:

   (a)  in a palliative care unit; or

   (b)  in a designated palliative care program; or

   (c)  under the principal clinical management of a palliative care specialist, or in the treating medical practitioner’s opinion, if the principal clinical intention of the care is palliation.

Zero fill this item if it is not applicable.

If the entire episode is palliative, provide the total length of stay in days.

 

Total record length

1321

 

 

 

 

 

 

Part 3          File structure and record content — medical record

 

Item

Data item

Start position

Repetitions

Format of data item

Size of data item

Required

Description of data item

1

Fund/Payer identifier

1

1

A

3

MAA

Fund identifier selected from the list set out in Part 6.

2

Link identifier

4

1

X

24

MAA

A unique identifier of an episode that links data items from this Part to Parts 2, 4 and 5.

The fund may encrypt the membership identifier.

3

MBS item or ADA code

28

1

X

14

MAA

The MBS item or ADA code charged by the medical provider.

4

Item charge

42

1

N

9

MAA

The amount that the patient was charged for the MBS item (in dollars and cents).

Omit the decimal point.

Zero prefix.

An entry of ‘0000000000’ means that no amount was paid.

5

Medicare benefit

51

1

N

9

MAA

The medicare benefit amount paid to the patient (in dollars and cents).

Omit the decimal point.

Zero prefix.

An entry of ‘000000000’ means that no amount was paid.

6

Fund medical benefit

60

1

N

9

MAA

The amount (excluding medicare benefit) paid by the fund (in dollars and cents).

Omit the decimal point.

Zero prefix.

An entry of ‘000000000’ means that no amount was paid.

7

MBS date of service

69

1

DDMMYYYY

8

MAA

Date when the MBS item or service was performed.

8

Medical payment type

77

1

N

1

MAA

1 = Medical purchaser provider agreement.

2 = Hospital purchaser provider agreement and practitioner agreement.

3 = (No) gap cover scheme.

4 = (Known) gap cover scheme.

5 = 100% MBS fee charged.

6 = No arrangement.

9

Gap cover scheme identifier

78

1

X

5

MAA

Approved gap scheme identifier.

A blank filled data item indicates that there was no gap cover scheme arrangement for the entire episode.

Gap cover scheme identifier must be in the format: <Fund ID><two digit code>, for example MBF01.

10

MBS fee

83

1

N

9

MAA

The MBS or derived fee for the item (in dollars and cents).

Omit the decimal point.

Zero prefix.

 

Total record length

91

 

 

 

 

 

 

Part 4          File structure and record content — prosthetic record

 

Item

Data item

Start Position

Repetitions

Format of data item

Size of data item

Required

Description of data item

1

Fund identifier

1

1

A

3

MAA

Fund identifier selected from the list set out in the table in Part 6.

2

Link identifier

4

1

X

24

MAA

A unique identifier of an episode that links the data items from this Part to Parts 2, 3 and 5.

The fund may encrypt the membership identifier.

3

Prosthetic item

28

1

X

5

MAA

The billing codes are contained in the prosthesis list that is approved by the Minister and maintained by the Department.

If a handling fee is charged, the fee is to be reported as ‘PHFEE’.

If the prothesis is an ex-gratia prosthetic item, the item is to be reported as ‘EXGRA’.

 

 

 

 

 

 

 

Note   The prosthesis list can be found at: www.health.gov.au/internet/wcms/
publishing.nsf/content/health-privatehealth-prostheseslist.htm.

4

Number of prosthetic items

33

1

N

3

MAA

Number of prosthetic items used for a specific item.

5

Total prosthetic item charge

36

1

N

9

MAA

The total maximum charge (excluding any handling fee) for a prosthesis item in dollars and cents.

Omit the decimal point.

Zero prefix.

6

Prosthetic item benefit

45

1

N

9

MAA

The total maximum benefit (excluding any handling fee) for the prosthesis item in dollars and cents.

Omit the decimal point.

Zero prefix.

 

Total record length

53

 

 

 

 

 

 

Part 5          File structure and record content — AN-SNAP record

 

Item

Data item

Start position

Repetitions

Format of data item

Size of data item

Required

Description of data item

1

Fund identifier

1

1

A

3

MAA

Fund identifier selected from the list set out in the table in Part 6.

2

Link identifier

4

1

X

24

MAA

A unique identifier of an episode that links the data items from this Part to Parts 2, 3 and 4.

The fund may encrypt the membership identifier.

3

Episode type

28

1

A

1

MAA

O = overnight admitted patient.

S = same day admitted patient.

4

Admission FIM item scores

29

18

N

1

MAA

The FIM score on admission for each of the 18 FIM motor and cognition items.

Each item has a maximum score of 7 and a minimum score of 1. Total scores for the items may range from 18 to 126.

Admission data must be collected no later than 72 hours after admission.

The Guide for Uniform Data Set for Medical Rehabilitation procedures for scoring the FIM must be followed.

FIM scores are as follows:

   (a)  no helper needed:

         7 = complete independence;

         6 = modified independence;

   (b)  helper needed:

         5 = supervision or set up;

         4 = minimal assistance;

         3 = moderate assistance;

         2 = maximal assistance;

         1 = total assistance.

5

Discharge FIM item scores

47

18

N

1

MAA

The FIM score on discharge for each of the 18 FIM motor and cognition items.

Each item has a maximum score of 7 and a minimum score of 1. Total scores for the items may range from 18 to 126.

Discharge data must be collected no later than 72 hours before discharge.

The Guide for Uniform Data Set for Medical Rehabilitation procedures for scoring the FIM must be followed.

FIM scores are as follows:

   (a)  no helper needed:

         7 = complete independence;

         6 = modified independence;

   (b)  helper needed:

         5 = supervision or set up;

         4 = minimal assistance;

         3 = moderate assistance;

         2 = maximal assistance;

         1 = total assistance.

6

Functional impairment codes

65

1

N

7

MAA

The Impairment Code ((version 5.0 UDS) excluding ‘Medically Complex’) that most accurately describes the primary reason for a patient’s admission in relation to a rehabilitation episode.

To be coded as accurately as possible and, if possible, avoids the use of impairment group 13 (‘other disabling impairments’).

An entry must contain the information set out in paragraphs (a), (b) and (c) in the sequence set out in those paragraphs:

   (a)  2 digits representing the impairment group; and

   (b)  a decimal point; and

   (c)  no more than 4 digits representing more specific categories within impairment groups.

7

Assessment only

72

1

N

1

OPA

AN-SNAP has separate classes for assessment only episodes.

An assessment only episode occurs when a patient was seen only once for assessment or treatment and no further intervention by a service team is planned to occur in the next 90 days.

If the patient arranges or has a subsequent treatment within 90 days of the first treatment, the episode is regarded as assessment only.

If the patient arranges a subsequent assessment (but not a treatment), the episode is an assessment only assessment.

Report:

1 = Yes; or

2 = No.

8

AN-SNAP class

73

1

N

3

OPA

This item relates to the AN-SNAP class to which an episode is assigned. This class is derived from items 1, 2, 4 and 5 in this Part together with the patient’s ‘age’ (based on the patient’s date of birth).

A blank filled data item is valid if the class is unknown.

 

Total record length

75

 

 

 

 

 


Part 6          Registered health benefits organisations

 

Item

Name

Identifier

1

Acorn Prudential Limited

UAF

2

Australasian Conference Association Ltd (trading as ACA Health Benefits Fund)

ACA

3

Australian Health Management Group Limited

AHM

4

Australian Unity Health Limited

AUF

5

BUPA Australia Health Pty Ltd

HBA

6

CBHS Friendly Society Limited

CBH

7

Cessnock District Health Benefits Fund Limited

CDH

8

Credicare Health Fund Limited

CPS

9

Defence Health Limited

AHB

10

GMHBA Limited

GMH

11

Grand United Corporate Health Limited

FAI

12

HBF Health Funds Inc

HBF

13

Health Care Insurance Ltd

HCI

14

Healthguard Health Benefits Fund Limited (trading as Central West Health, CY Health and GMF Health)

HHB

15

Health Insurance Fund of WA

HIF

16

Health-Partners Inc

SPS

17

Hospitals Contribution Fund of Australia Limited, The

HCF

18

Latrobe Health Services Inc

LHS

19

Lysaght Peoplecare Ltd

LHM

20

Manchester Unity Australia Ltd

MUI

21

MBF Alliances Pty Ltd

SGI

22

MBF Australia Ltd

MBF

23

Medibank Private Limited

MBP

24

Mildura District Hospital Fund Limited

MDH

25

N.I.B. Health Funds Limited

NIB

26

Navy Health Ltd

NHB

27

Phoenix Health Fund Limited

PWA

28

Queensland Country Health Limited

MIM

29

Queensland Teachers’ Union Health Fund Ltd

QTU

30

Railway and Transport Health Fund Ltd

RTE

31

Reserve Bank Health Society Ltd

RBH

32

South Australian Police Employees’ Health Fund Inc

SPE

33

St Luke’s Medical and Hospital Benefits Association Limited

SLM

34

Teachers Federation Health Ltd

NTF

35

The Doctors’ Health Fund Ltd

AMA

36

Transport Health Pty Ltd

TFS

37

United Ancient Order of Druids Friendly Society Limited

UAD

38

Westfund Ltd

WDH

 


Note

1.       All legislative instruments and compilations are registered on the Federal Register of Legislative Instruments kept under the Legislative Instruments Act 2003. See www.frli.gov.au.