SAS Programming with Medicare Administrative Data. Matthew Gillingham

Part B. Home health agencies are entities that provide skilled professional care in a beneficiary’s home.

      These agencies provide services to Medicare beneficiaries like occupational therapy, physical therapy, skilled nursing care, and even speech therapy and services like counseling that can help a beneficiary cope with the impacts of their illness on their mental health.

      Medicare pays for home health services in units of 60-day episodes based on a prospective payment predetermined rate. Patients receiving five or more visits are assigned to 1 of 153 home health resource groups (HHRGs) based on clinical and functional status and service use which are adjusted for the geographical area where services are delivered.

Hospice Claims Data

      The hospice claims data contain information on final action claims data submitted for hospice (also referred to as “end of life” or palliative care) services.11 Hospice programs provide care for Medicare beneficiaries who are terminally ill. The focus of hospice care is on the comfort of the patient and not on healing or curing an illness.

      A beneficiary qualifies for hospice services if the beneficiary has Medicare Part A and is terminally ill. A beneficiary is considered terminally ill if the beneficiary’s doctor certifies that the beneficiary has less than six months to live, should the beneficiary’s illness follow a normal progression.

      Hospice services include physical care provided by doctors and nurses, care provided by hospice aides, occupational therapy, physical therapy, medical equipment and supplies, drugs, and even grief counseling and respite care (care provided in a facility designed to give family members a break from giving care) for the beneficiary’s family members. All hospice services are covered as long as they are related to the beneficiary’s terminal illness (services not related to the terminal illness are covered by other Medicare benefits). Many of these services may involve pain management, and services may take place in a facility or the patient’s home.

      Hospice care is insured in benefit periods, meaning that a Medicare beneficiary can get hospice care for two 90-day benefit periods and then an unlimited number of 60-day benefit periods. The doctor must certify that the beneficiary is terminally ill at the beginning of each period. Medicare beneficiaries have the right to stop hospice care at any time for any reason, and the right to change hospice providers once each benefit period.

Commonly Retained Elements in Administrative Claims Data

      With about 47 million beneficiaries to account for, Medicare administrative claims files can be very large. Generally, the carrier claim file is the largest Medicare claims dataset used for research purposes. The large size makes sense because the file contains claims for the most common type of service, a visit to the doctor!

      One very common way of easing the use of large datasets is to limit the files to contain only the key variables needed for your project. In Chapter 4, we will start the process for planning our project at which time we will begin to form a good idea of the variables we will need for the successful completion of our sample research programming project. At a minimum, when performing research, it is standard practice to keep the following variables in the administrative claims files:12

      • The Medicare beneficiary’s identifier:13 Commonly referred to as the HICAN (usually pronounced “high-can”) or HIC, this variable may not exist as its own data element in the Medicare research files we will receive. Although the data we will work with contains a ready-made, scrambled beneficiary identifier called a BENE_ID, you may have to create the HIC by concatenating the beneficiary’s Claim Account Number (CAN) and the beneficiary’s identification code (also known as the BIC). A beneficiary’s identifier can change over time if a beneficiary’s status changes (e.g., a beneficiary remarries). Therefore, it is important to have a master beneficiary identifier when looking at administrative claims and enrollment data over time.

      • The provider identifier: A Medicare provider performed the services appearing on a claim, and each provider has a unique identifier that is reported on the claim record. For example, the National Provider Identifier (NPI) can be used to identify the provider that performed the services billed on the claim (known as the “performing” or “rendering” provider). The NPI is a 10-character identification number uniquely assigned to a Medicare provider. This identifier must be used by the provider for all financial transactions with Medicare. The NPI is known as an intelligence-free identification number, meaning that it does not contain any information about the provider, like specialty or Medicare region. We will see that the provider identifier for hospitals found in inpatient claims data does contain embedded intelligence.

      • Codes identifying services: The services performed by the Medicare provider can be identified using procedure codes represented by Healthcare Common Procedure Coding System (HCPCS) codes. HCPCS Level I codes, also known as Current Procedural Terminology (CPT) codes, are five digit character codes describing medical services, and are a copyrighted coding schema of the American Medical Association (AMA). HCPCS Level II codes are five character alphanumeric codes defining services not described by the Level I codes.14 In other cases, revenue center codes and ICD-9-CM procedure codes (more on this below) can be used to identify services Revenue center codes correspond to cost center units (or divisions) within a hospital, like emergency departments.

      • Codes identifying the beneficiary’s medical condition: The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is the United States’ method of assigning medical diagnoses to patients (like diabetes, COPD, or prostate cancer). As of the writing of this text, in October 2014, ICD-9-CM will be replaced by ICD-10-CM.15 ICD-9-CM can also be used to identify procedures in inpatient, skilled nursing facility, and outpatient claims.

      • Dates of service: This refers to the dates of service of the procedures performed by the provider. This can include specific dates of service for specific procedures (from detail service lines), or admission and discharge dates (header information) from a stay in an institution (like a hospital).

      • Payment information: The total cost of a claim includes the amount paid by Medicare, as well as deductible and coinsurance payments. We are interested in the total cost to Medicare for the services on a claim, so we will utilize only the Medicare payment variables (without using information such as deductibles and coinsurance payments).

      This list is by no means exhaustive. In some cases, investigators need to look at payment information like deductibles and coinsurance, provider identifiers like Tax Identification Numbers or CMS Certification Numbers, and information on the provider’s medical specialty. In your work, you may need to utilize information in inpatient claims data such as the source of admission to the hospital, the discharge status or discharge destination, and a Diagnosis Present on Admission (POA) indicator (a field that identifies whether a diagnosis was already present upon admission to the hospital). In addition, some investigators may wish to review the Medicare Severity-Diagnosis Related Group (MS-DRG), a patient classification system comprised of a set of codes developed for Medicare. MS-DRGs use information from a beneficiary’s paid hospital claims (like age and medical diagnosis) to classify hospital services provided to patients. Finally, you may wish to review the level of hospice care provided (e.g., routine home care, inpatient respite care, and continuous home care).