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# ضمان مجلس الضمان الصحي Council of Health Insurance ## Guidelines for Implementing Saudi Billing System Codes in Information Systems # Implementing SBS codes in information systems July 2024 ## Purpose This file provides detailed instructions on how a computer system using SBS codes must validate the codes being used for a specific version of the SBS code System. NPHIES and all other local information systems must all be conformant with these rules. ## General Information A version of the SBS code system will be released for use from a specific date - The SBS code system version effective date. ## File content and structure The implementation guide provides details for implementation of the excel or csv files. Excel file - this file has implementation guidelines within it and includes both the tabular list and technical list content. The csv files have no guidelines other than those provided in this document and are designed for direct upload into systems. The structure of this file includes the following columns of data. ### File names * SBS_V3_Code_list – excel file including guidance – includes the Tabular List and Technical List data * SBS_V3 Tabular list – csv file for implementation – this file includes only codes which are active and appropriate for use in V3 implementations. * SBS_V3 Technical List – csv file for technical implementation in systems – this file includes active and inactive codes, as well as maps from inactive to active codes, and verification rules for age/sex associated with some codes. * Implementation SBS in information Systems – detailed instructions for technical implementation. For maintenance it should be noted that CHI may update the effective data and inactive as at dates if schedules change | Column Title | Explanation # Implementing SBS codes in information systems July 2024 | (Re)Activation date | Where a code which was previously made inactive is reactivated the inactive date is still indicated but also an activation date is provided. If an activation date is included the code is no longer inactive and becomes active on the date given in this field | |---|---| | Revised date | The date when a code revision is to be active. The revised descriptions and instructions must be used from the revised date forward. | | Update Type | This is a flag to indicate the type of change made and must be applied in the following sequence: <br> N = new code <br> U = unchanged - the code, instructions and description have not changed <br> R = revised description - the description (sort, long or both) has been modified <br> I = code inactive (if this applies any revision to this code is not counted) This code has been retired and is not to be used after the inactive date. <br> A = reactivated - where a code that was previously made inactive has been made active again. | | Inactive code mapping | Each inactive code is mapped to a code (which could be new, revised, or unchanged). In some cases, where the concept is no longer valid (not clinically possible) there may be no map - the entry of '-' in this field indicates that this code has no map and should not be used. <br> Otherwise, the inactive code may be replaced with the code shown in the inactive code mapping. <br> It is permitted to replace the inactive code with the inactive code mapping code for data after the inactive date. | | SBS code | Where there is more than one code required to represent a single inactive code, the codes are presented as NNNNNNNN, NNNNNNNNN. In this case both codes are used. | | SBS code - Hyphenated | The SBS code without punctuation (decoration) – useful for storage and searching. This is the code which is to be used in messages and reporting. It is recommended that it be used for data capture by coders as it reduces keystrokes and potential errors. | | Code Short Description | The SBS code with punctuation which is used when displaying SBS codes as the codes are easier to read when presented this way. | | Code Long Description | An abbreviated description of what this code represents. This is used in reporting. It includes abbreviations. <br> The full name of the procedure being coded – without abbreviations – this is recommended as the description to be displayed when a code is entered to allow the coder to confirm their data entry and coding. | | Chapter | The broad group into which this code has been assigned | | Chapter Description | Textual description of the content within this chapter | | Block Number | This is a 4-digit number to be displayed as [NNNN] after the SBS code. | | Block Description | Textual description of the small group of similar procedures to which this code has been assigned. | Classified as عام / Public 3 | Page # Implementing SBS codes in information systems July 2024 | Clinical explanation | Information which provides clinical detail about the intervention/procedure/service to assist the user in selecting the appropriate code. | |---|---| | Includes | Synonyms, eponyms, or services that are represented by this code. Inclusions must be followed by all coders and must not be coded separately. | | Excludes | This means that the intervention/procedure/service is NOT CODED HERE. Terms listed in this area are to be coded elsewhere | | Guidelines | Information about code usage or block details | | Sex | This is a code that is only valid if the individuals' biological sex = the sex indicated in the patient's record. <br> 1 = male <br> 2 = female <br> If a patient sex is recorded as 8 unknown, or 9 unspecified. The system must match either sex. | | SType | Level of error when the information provided for the episode of care or service do not match the documented sex rule <br> 1: error – this entry must be rejected <br> 2: warning – this entry must deliver a warning to the user that this code is unusual for the patient's sex. The entry is acceptable but should be checked. | | AgeL | The age from which this rule applies (inclusive). Age is calculated as age at the start of a service or specific service date. <br> This is represented by a leading character e.g. <br> Agel of 210 means that the patient must be 10 years of age (the 2 means years) | | AgeH | The age up to which this rule applies (inclusive). <br> e.g. 260 means that the patient must be 60 years of age or less at the time of the service or admission date (for inpatients) <br> Example: AgeL 210 with AgeH 260 = person must have age from 10 to 60 years of age inclusive. | | AType | Level of error when the information provided for the episode of care or service do not match the documented age rule <br> 1: error – this entry must be rejected <br> 2: warning – this entry must deliver a warning to the user that this code is unusual for the patient's sex. The entry is acceptable but should be checked. | Note: the SBS_V3 tabular list file does not include all the instructions and standards needed to code consistently and accurately. The tabular list PDF should be used as the authoritative source for clinical coding. ## Rules ### Code must be valid code * All codes entered must be codes in the SBS, ACHI or ICD-10-AM data file 4 | Page Classified as عام / Public # Implementing SBS codes in information systems July 2024 * To be valid the * 'Effective as at' must be on or before the SBS Code system version implementation date AND * 'Inactive date' must be empty after the SBS Code system version implementation date. ## Code structure Codes may be stored in any format, but when displayed must have the format: NNNNN-NN-NN When the code is reported or transmitted to NPHIES the format shall be: NNNN-NN-NN ## Code must be clinically possible This means that conditions or procedures that are only relevant for males must not be assigned to females and so forth. It also means that conditions or procedures which are only possible for children or adults or those in a specific age range must not be assigned to those outside the acceptable range. The SBS code system release file includes instructions for these rules. Example: A code for caesarean delivery of a baby should not be acceptable in software where the patient is male, or if the patient is only 3 years old. To test these criteria the software must have access to the patient's age (or preferably their date of birth), and their biological sex in order to compare these values to the acceptable range. The Age column in the SBS release file includes the age at admission within which a patient must fall for this code to be valid. These ranges may be in days or if it is not specified, assume it is in years of age. Example: Age in years will begin with 2 and is followed by the low then high age e.g. 210 low age means the person must be 10 years of age or older with 260 high age means that the person must be younger than 60 years of age These ages are applicable to the patient age at admission or date of service. Sex 1 = the patient must be a male or have a sex value of unspecified or indeterminate for this code to be valid in their episode of care. This means that a person with sex of female in their details would not be able to have this code used in their episode of care. This would be true for a procedure such as prostatectomy (which is an organ not present in a female body). Sex 2 = the patient must be female or have a sex value of unspecified or indeterminate for this code to b valid in their episode of care. Classified as عام / Public 5 | Page # Implementing SBS codes in information systems July 2024 ## Release file information ### About The about sheet in the excel version of the release file SBS V3 ECL Code List includes acknowledgements, and effective use date information ### Contents This sheet has a brief explanation and ## Conformance All vendors must pass a conformance test confirming they have implemented these rules. Conformance is tested for each version of the SBS code system and information systems which are not conformant by the SBS Code system version implementation date will not be able to access NPHIES. ### Suggested Requirements: * Formal conformance assessment. This will require: * A set of codes to be entered into the test system which are not conformant to the rules outlined in the version release file * Clear action/notifications given to users for these errors * A set of codes to be entered into the test system which are conformant to the rules outlined in the version release file – these translations are to be accepted by NPHIES. * The software vendor is notified of * successful test – and receive a statement of conformance which is valid for this SBS code system version. * Unsuccessful test – the specific rules which did not pass the test are to be notified to the vendor to give them the opportunity to fix any conformance issues. The vendor may then resubmit for conformance testing. * The CHI Clinical Classifications web page should display recognition of those vendors/implementations which are conformant. * In future NPHIES shall develop an organization conformance management system which maintains details of conformance of software for an organization, so that the system is able to control access and use of NPHIES based upon that conformance. Classified as عام / Public 6|Page