Identifying Emergency Department Visits in Medicare Claims Data

Introduction

Emergency department (ED) utilization serves as a foundational metric across health services research. Because ED visits are high-cost and high-intensity, the identification of these events is critical for measurement and evaluation of healthcare quality(1). Health researchers rely heavily on administrative datasets like Medicare claims to do this work. Because there are multiple conceptual frameworks for measuring utilization within administrative datasets, navigating these records requires careful methodological consideration.

Missing Prescribed Date in 2019 TAF Pharmacy File

Background

The TAF Pharmacy files (TAF RX) are a CMS Research Identifiable File (RIF) that contains pharmacy prescription fill and over the counter (OTC) drug information covered by Medicaid. They are sourced from the T-MSIS, which is a repository of service utilization and reimbursement records from state Medicaid agencies. This file contains multiple record types including fee-for-service, when the state reimburses providers for services they provide, and managed care, when the state works with a health plan to administer Medicaid services.

Identifying Clinical Trials in CMS FFS Claims Data

Can we use the Claims Processing Manual to define service utilization?

The Claims Processing Manual (CPM) is the rulebook for submitting claims to CMS. It covers a wide range of medical coding instructions by clinical setting and form. As the main source of instruction on claims processing and assuming that providers are incentivized to follow submission requirements for reimbursement, it should be a reliable source for defining research methodology.

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