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.

Introduction

When analyzing data for research, it is sometimes necessary to code time windows. In this article we present several examples of programming common administrative healthcare data analytics that involve time in SAS.

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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.

What are Professional and Technical Components and Why Do They Matter?

Professional and technical components are HCPCS modifiers that splits Medicare payment into supervision/interpretative and equipment/facility costs. This allows separate entities to bill for their portion of a service. For example, one facility may manage diagnostic testing while a physician or other health care provider handles interpretation(1). This can also apply in situations where an independent diagnostic facility has two different service locations(2).

The combination of PROC FORMAT and PROC FREQ can be used to quickly identify missingness, or values that are invalid or not present, in data. Straightforward logic and low line count make this code digestible for both new and experienced SAS programmers.

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.

Introduction

Converting raw data into research insights requires the creation of an analytic file – a refined dataset customized for a specific study. Building these files involves aggregating large-scale data into target units, such as hospitals(1) or individual patients(2). Though the process is complex, it is a cornerstone of well-conducted research. This article offers practical guidance and key considerations for constructing these essential datasets.