PHC4 Laboratory Data Reporting Manual

1 Laboratory data Reporting Manual . Pennsylvania Health Care Cost Containment Council October 2016. Version 225 Market Street, Suite 400, Harrisburg, PA 17101. Phone: 717-232-8958 Fax: 717-772-1401. Laboratory data Reporting Manual . Table of Contents OVERVIEW .. 3. data File 3. Where to Send the data .. 3. Laboratory data Collection Requirements .. 3. data FILE LAYOUT .. 10. data ELEMENT 11. VALIDATIONS AND EDITS .. 14. APPENDIX .. 16. October 2016 Page 2 of 18 Version Laboratory data Reporting Manual . OVERVIEW. Hospitals are required to submit Laboratory data for inpatient discharges as described throughout this Manual . Whether hospitals develop their own internal mechanisms/processes to submit the Laboratory data to phc4 or engage the services of a third-party vendor to do so, the hospitals are ultimately responsible to assure that the submission meets the file specifications and requirements in this Manual .

2 data File Format The data file format is a fixed-width delimited flat text file. Each line of the text file must contain a single record. Each record must be 94 characters long, with a carriage return-line feed after each record. Standard text characters with ASCII values between 32 and 126 are accepted. Characters not accepted: o ASCII values 31 or less (pagination characters such as but not limited to tabs or page breaks). o ASCII values 127 and higher (characters such as non-Latin characters such as Greek or Cyrillic letters - , , , Ф, etc., and letters with accent marks such as tildes, umlauts, graves, etc. - , , , , etc.). The text file may be compressed into a zip file prior to sending.

3 Where to Send the data The Laboratory data file must be submitted using phc4 's secure portal at The Laboratory data file can be submitted at the same time as the billing (UB-04) data file, or it can be submitted after the billing data file has been submitted for the collection period. data Reporting schedules are located on phc4 's website at Laboratory data Collection Requirements Discharges for which Laboratory data is to be Submitted Hospitals are required to submit Laboratory data for particular discharges as identified by a list of 35 Diseases, Procedures, and Medical Conditions. This list is updated annually (effective with October 1 discharges) and can be downloaded from the phc4 website at October 2016 Page 3 of 18 Version Laboratory data Reporting Manual .

4 It is recognized that Laboratory data might not be available for all discharges on this list or for all 29 tests collected by phc4 (see Laboratory Tests below). Laboratory test results from inpatient discharges that are not included on the list of 35. Diseases, Procedures, and Medical Conditions are not required but will be accepted. Source Documents Laboratory test results should be obtained from Laboratory reports generated by each hospital's clinical Laboratory system/ Laboratory information system. Results produced by Point-of-Care Testing (POCT) devices are acceptable when the test specimen used is blood, the point of care device is in compliance with Laboratory regulations, and the test result is obtained from a Laboratory report that is part of the permanent medical record.

5 Test results from a glucometer, chemsticks, etc. that are not displayed on a Laboratory report generated from the clinical Laboratory system/ Laboratory information system should not be submitted. An O2 saturation result taken from a pulse oximeter device should not be submitted for the arterial blood gas - O2 saturation. Laboratory Test Collection Timeframe Laboratory test results should be submitted using the following timeframe (referred throughout this document as the collection timeframe ): For patients admitted prior to 6:00 , submit the highest and/or lowest test result(s) for the select Laboratory test(s) collected on that calendar day (Day 1, the day of admission) only.

6 As an example, for a patient admitted at 2:00 on January 1, submit the following Laboratory test results as available: The highest test result (one result) from specimens collected on Day 1 (January 1) for the 15 tests that require the highest test result. The lowest test result (one result) from specimens collected on Day 1 (January 1) for the 4 tests that require the lowest test result. Both the highest and the lowest test results (two results) from specimens collected on Day 1 (January 1) for the 10 tests that require both the highest and the lowest test results. For patients admitted at or after 6:00 , submit the highest and/or lowest test result(s) for the select Laboratory test(s) collected on that calendar day (Day 1, the day of admission).

7 Through the next calendar day (Day 2). As an example, for a patient that is admitted at 7:00. on January 1, submit the following Laboratory test results as available: . Laboratory tests collected on Day 1 prior to the time of admission are acceptable as long as the test result is generated by the hospitals' own clinical Laboratory system/ Laboratory information system. October 2016 Page 4 of 18 Version Laboratory data Reporting Manual . The highest test result (one result) from specimens collected on Day 1 (January 1). through Day 2 (January 2) for the 15 tests that require the highest test result. The lowest test result (one result) from specimens collected on Day 1 (January 1).

8 Through Day 2 (January 2) for the 4 tests that require the lowest test result. Both the highest and the lowest test results (two results) from specimens collected on Day 1 (January 1) through Day 2 (January 2) for the 10 tests that require both the highest and the lowest test results. Note Regarding Laboratory Collection Timeframe for Cardiac Surgery Records The intention for risk adjustment of cardiac surgery records* is to continue using the Laboratory test results from specimens collected prior to the anesthesia start time and within the Laboratory test collection timeframe specified above. The Laboratory test results to be used in risk adjustment will be identified by comparing the Anesthesia Start Date and Anesthesia Start Time submitted in the cardiac surgery supplemental clinical data with the Date Specimen Collected and Time Specimen Collected submitted in the Laboratory data .

9 As such, when Laboratory test results within the collection timeframe are available for both prior to and after the anesthesia start date and time for the first CABG and/or valve surgery, hospitals may choose to only submit Laboratory test results collected prior to the anesthesia start date and time following all other specifications and requirements in this Manual . For example: A patient is admitted at 4:00 and has a CABG procedure performed at 7:00 (start time of anesthesia). Laboratory test results from Day 1 up to 7:00 would be considered for submission. A patient is admitted at 9:00 and has a CABG procedure performed on Day 2 at 8:00 (start time of anesthesia).

10 Laboratory test results from Day 1 and Day 2 up to 8:00 would be considered for submission. A patient is admitted at 4:00 and has a CABG procedure performed on Day 5. Laboratory test results from Day 1 would be considered for submission. Hospitals will continue to have the option to review and update the Laboratory test results for cardiac surgery records, if applicable, by using the Laboratory data Administration tool. * The ICD-10-PCS procedure codes that define the cardiac surgery study population are available in the Cardiac Surgery Supplemental Clinical data Reporting Manual available at October 2016 Page 5 of 18 Version Laboratory data Reporting Manual . Laboratory Tests The Laboratory tests and submission criteria are located in Table 1.