U.S. patent application number 10/106409 was filed with the patent office on 2002-11-21 for episode treatment groups of correlated medical claims.
Invention is credited to Dang, Dennis K..
Application Number | 20020173992 10/106409 |
Document ID | / |
Family ID | 23961455 |
Filed Date | 2002-11-21 |
United States Patent
Application |
20020173992 |
Kind Code |
A1 |
Dang, Dennis K. |
November 21, 2002 |
Episode treatment groups of correlated medical claims
Abstract
A computer-implemented method for profiling medical claims to
assist health care managers in determining the cost-efficiency and
service quality of health care providers. The method allows an
objective means for measuring and quantifying health care services.
An episode treatment group (ETG) is a patient classification unit,
which defines groups that are clinically homogenous (similar cause
of illness and treatment) and statistically stable. The ETG grouper
methodology uses service or segment-level claim data as input data
and assigns each service to the appropriate episode. The program
identifies concurrent and recurrent episodes, flags records,
creates new groupings, shifts groupings for changed conditions,
selects the most recent claims, resets windows, makes a
determination if the provider is an independent lab and continues
to collect information until an absence of treatment is
detected.
Inventors: |
Dang, Dennis K.; (Phoenix,
AZ) |
Correspondence
Address: |
David G. Rosenbaum
ROSENBAUM & ASSOCIATES, P.C.
Suite #3653
875 North Michigan Avenue
Chicago
IL
60611
US
|
Family ID: |
23961455 |
Appl. No.: |
10/106409 |
Filed: |
March 25, 2002 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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10106409 |
Mar 25, 2002 |
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09188986 |
Nov 9, 1998 |
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6370511 |
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09188986 |
Nov 9, 1998 |
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08493728 |
Jun 22, 1995 |
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5835897 |
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Current U.S.
Class: |
705/3 ;
705/2 |
Current CPC
Class: |
G06Q 10/087 20130101;
G06Q 40/08 20130101; G16H 40/67 20180101; G16H 70/40 20180101; G06Q
30/02 20130101; G06Q 40/02 20130101 |
Class at
Publication: |
705/3 ;
705/2 |
International
Class: |
G06F 017/60 |
Claims
What is claimed is:
1. A cluster of correlated medical claim records for a single
medical patient, consisting of at least one of a plurality of
medical claim records grouped to a common anchor record.
2. An episode treatment group comprising at least one of a
plurality of clusters according to claim 1.
3. A computer-implemented episode treatment grouping of related
medical claim data encoded as a plurality of machine readable bits
on a machine readable carrier, comprising one anchor record and n
data records linked thereto, the n data records being selected from
the group consisting of ancillary records, facility records and
prescription drug records, where n is an integer greater than or
equal to 0.
4. The episode treatment grouping according to claim 3, wherein the
anchor record further comprises one of a management record and a
surgery record.
5. The episode treatment grouping according to claim 4, wherein the
management record further comprises at least one medical claim data
representing services of a medical care provider engaged in direct
evaluation, management or treatment of a patient.
6. The episode treatment grouping according to claim 4, wherein the
surgery record further comprises at least one medical claim data
representing surgical procedures, performed by a medical care
provider.
7. The episode treatment grouping according to claim 4, wherein the
ancillary record further comprises at least one medical claim data
representing medical care services which are incidental to the
direct evaluation, management and treatment of a medical
patient.
8. The episode treatment grouping according to claim 4, wherein the
facility record represents medical claim data for use of a medical
care facility.
9. The episode treatment grouping according to claim 4, wherein the
drug record further comprises medical claim data representing
pharmaceutical prescriptions.
Description
REFERENCE TO RELATED APPLICATIONS
[0001] This patent application is a divisional application of U.S.
patent application Ser. No. 09/188,986 filed Nov. 9, 1998, which is
a continuation patent application of U.S. patent application Ser.
No. 08/493,728, filed on Jun. 22, 1995, issued as U.S. Pat. No.
5,835,897 on Nov. 10, 1998.
FIELD OF THE INVENTION
[0002] The present invention relates generally to
computer-implemented methods for processing medical claims
information. More particularly, the present invention relates to a
computer-implemented method for receiving input data relating to a
person's medical claim, establishing a management record for the
person, establishing episode treatment groups to define groupings
of medical episodes of related etiology, correlating subsequent
medical claims events to an episode treatment group and
manipulating episode treatment groups based upon time windows for
each medical condition and co-morbidities.
BACKGROUND OF THE INVENTION
[0003] Due to an increase in health care costs and inefficiency in
the health care system, health care providers and service
management organizations need health care maintenance systems which
receive input medical claim data, correlate the medical claim data
and provide a means for quantitatively and qualitatively analyzing
provider performance. Because of the complex nature of medical care
service data, many clinicians and administrators are not able to
efficiently utilize the data. A need exists for a computer program
that transforms inpatient and out patient claim data to actionable
information, which is logically understood by clinicians and
administrators.
[0004] Performance is quickly becoming the standard by which health
care purchasers and informed consumers select their health care
providers. Those responsible for the development and maintenance of
provider networks search for an objective means to measure and
quantify the health care services provided to their clients.
Qualitative and quantitative analysis of medical provider
performance is a key element for managing and improving a health
care network. Operating a successful health care network requires
the ability to monitor and quantify medical care costs and care
quality. Oftentimes, success depends on the providers' ability to
identify and correct problems in their health care system. A need
exists, therefore, for an analytical tool for identifying real
costs in a given health care management system.
[0005] To operate a more efficient health care system, health care
providers need to optimize health care services and expenditures.
Many providers practice outside established utilization and cost
norms. Systems that detect inappropriate coding, eliminate
potentially inappropriate services or conduct encounter-based
payment methodology are insufficient for correcting the
inconsistencies of the health care system. When a complication or
comorbidity is encountered during the course of treatment, many
systems do not reclassify the treatment profile. Existing systems
do not adjust for casemix, concurrent conditions or recurrent
conditions. A system that compensates for casemix should identify
the types of illnesses treated in a given population, determine the
extent of resource application to specific types of illnesses,
measure and compare the treatment patterns among individual and
groups of health care providers and educate providers to more
effectively manage risk. When profiling claims, existing systems
establish classifications that do not contain a manageable number
of groupings, are not clinically homogeneous or are not
statistically stable. A need exists, therefore, for a patient
classification system that accounts for differences in patient
severity and establishes a clearly defined unit of analysis.
[0006] For many years, computer-implemented programs for increasing
health care efficiency have been available for purchase. Included
within the current patent literature and competitive information
are many programs that are directed to the basic concept of health
care systems.
[0007] The Mohlenbrock, et al. patent, U.S. Pat. No. 4,667,292,
issued in 1987, discloses a medical reimbursement computer system
which generates a list identifying the most appropriate
diagnostic-related group (DRG) and related categories applicable to
a given patient for inpatient claims only. The list is limited by a
combination of the characteristics of the patient and an initial
principal diagnosis. A physician can choose a new designation from
a list of related categories while the patient is still being
treated. The manually determined ICD-9 numbers can be applied to an
available grouper computer program to compare the working DRG to
the government's DRG.
[0008] The Mohlenbrock, et al. patent, U.S. Pat. No. 5,018,067,
issued in 1991, discloses an apparatus and method for improved
estimation of health resource consumption through the use of
diagnostic and/or procedure grouping and severity of illness
indicators. This system is a computer-implemented program that
calculates the amount of payment to the health provider by
extracting the same input data as that identified in the
Mohlenbrock '292 Patent teaching the DRG System. The system
calculates the severity of the patient's illness then classifies
each patient into sub-categories of resource consumption within a
designated DRG. A computer combines the input data according to a
formula consisting of constants and variables. The variables are
known for each patient and relate to the number of ICD codes and
the government weighing of the codes. The software program
determines a set of constants for use in the formula for a given
DRG that minimizes variances between the actual known outcomes and
those estimated by use of the formula. Because it is based upon
various levels of illness severity within each diagnosis, the
results of this system provide a much more homogenous grouping of
patients than is provided by the DRGs. Providers can be compared to
identify those providers whose practice patterns are of the highest
quality and most cost efficient. A set of actual costs incurred can
be compared with the estimated costs. After the initial diagnosis,
the system determines the expected costs of treating a patient.
[0009] The Schneiderman patent, U.S. Pat. No. 5,099,424, issued in
1992, discloses a model user application system for clinical data
processing that tracks and monitors a simulated out-patient medical
practice using database management software. The system allows for
a database of patients and the entry of EKG and/or chest x-ray
(CXR) test results into separate EKG/CXR records as distinct
logical entities. This system requires entry of test results that
are not part of the medical claim itself. If not already present,
the entry creates a separate lab record that may be holding blood
work from the same lab test request. Portions of the information
are transferred to the lab record for all request situations.
Although the lab record data routine is limited to blood work, each
time the routine is run, historical parameter data are sent to a
companion lab record along with other data linking both record
types. The system also includes a revision of the system's
specialist record and the general recommendation from an earlier
work for more explicit use in information management.
[0010] The Tawil patent, U.S. Pat. No. 5,225,976, issued in 1993,
discloses an automated health benefit processing system. This
system minimizes health care costs by informing the purchasers of
medical services about market conditions of those medical services.
A database includes, for each covered medical procedure in a
specific geographic area, a list of capable providers and their
charges. A first processor identifies the insured then generates a
treatment plan and the required medical procedures. Next, the first
processor retrieves information related to the medical procedures
and appends the information to the treatment plan. A second
processor generates an actual treatment record including the actual
charges. A third processor compares the plan and the actual records
to determine the amounts payable to the insured and the
provider.
[0011] The Ertel patent, U.S. Pat. No. 5,307,262, issued in 1994,
discloses a patient data quality review method and system. The
system performs data quality checks and generates documents to
ensure the best description of a case. The system provides file
security and tracks the cases through the entire review process.
Patient data and system performance data are aggregated into a
common database that interfaces with existing data systems. Data
profiles categorize data quality problems by type and source.
Problems are classified as to potential consequences. The system
stores data, processes it to determine misreporting, classifies the
case and displays the case-specific patient data and aggregate
patient data.
[0012] The Holloway, et al. patent, U.S. Pat. No. 5,253,164, issued
in 1993, discloses a system and method for detecting fraudulent
medical claims via examination of service codes. This system
interprets medical claims and associated representation according
to specific rules and against a predetermined CPT-4 code database.
A knowledge base interpreter applies the knowledge base using the
rules specified. The database can be updated as new methods of
inappropriate coding are discovered. The system recommends
appropriate CPT codes or recommends pending the claims until
additional information is received. The recommendations are based
on the decision rules that physician reviewers have already used on
a manual basis.
[0013] The Cummings patent, U.S. Pat. No. 5,301,105, issued in
1994, discloses an all care health management system. The
patient-based system includes an integrated interconnection and
interaction of essential health care participants to provide
patients with complete support. The system includes interactive
participation with the patients employers and banks. The system
also integrates all aspects of the optimization of health-inducing
diet and life style factors and makes customized recommendations
for health-enhancing practices. By pre-certifying patients and
procedures, the system enhances health care efficiency and reduces
overhead costs.
[0014] The Dorne patent, U.S. Pat. No. 5,325,293, issued in 1994,
discloses a system and method for correlating medical procedures
and medical billing codes. After an examination, the system
automatically determines raw codes directly associated with all of
the medical procedures performed or planned to be performed with a
particular patient. The system allows the physician to modify the
procedures after performing the examination. By manipulating the
raw codes, the system generates intermediate and billing codes
without altering the raw codes.
[0015] The Kessler, et al. patent, U.S. Pat. No. 5,324,077, issued
in 1994, discloses a negotiable medical data draft for tracking and
evaluating medical treatment. This system gathers medical data from
ambulatory visits using a medical data draft completed by the
provider to obtain payment for services, to permit quality review
by medical insurers. In exchange for immediate partial payment of
services, providers are required to enter data summarizing the
patient's visit on negotiable medical drafts. The partial payments
are incentives to providers for participating in the system.
[0016] The Torma, et al. patent, U.S. Pat. No. 5,365,425, issued in
1994, discloses a method and system for measuring management
effectiveness. Quality, cost and access are integrated to provide a
holistic description of the effectiveness of care. The system
compares general medical treatment databases and surveyed patient
perceptions of care. Adjustments based on severity of illness, case
weight and military costs are made to the data to ensure that all
medical facilities are considered fairly.
[0017] Health Chex's PEER-A-MED computer program is a physician
practice profiling system that provides case-mix adjusted physician
analysis based on a clinical severity concept. The system employs a
multivariate linear regression analysis to appropriately adjust for
case-mix. After adjusting for the complexity of the physician's
caseload, the system compares the relative performance of a
physician to the performance of the peer group as a whole. The
system also compares physician utilization performance for
uncomplicated, commonly seen diagnosis. Because the full spectrum
of clinical care that is rendered to a patient is not represented
in its databases, the system is primarily used as an economic
performance measurement tool. This system categorizes the claims
into general codes including acute, chronic, mental health and
pregnancy. Comorbidity and CPT-4 codes adjust for acuity level. The
codes are subcategorized into twenty cluster groups based upon the
level of severity. The system buckets the codes for the year and
contains no apparent episode building methodology. While the
PEER-A-MED system contains clinically heterogeneous groupings, the
groupings are not episode-based and recurrent episodes cannot be
accounted.
[0018] Ambulatory Care Groups (ACG) provides a patient-based system
that uses the patient and the analysis unit. Patients are assigned
to an diagnosis group and an entire year's claims are bucketed into
thirty-one diagnosis groups. By pre-defining the diagnosis groups,
this is a bucketing-type system and claim management by medical
episode does not occur. The system determines if a claim is in one
of the buckets. Because different diseases could be categorized
into the same ACG, this system is not clinically homogeneous. An
additional problem with ACGs is that too many diagnosis groups are
in each ACG.
[0019] Ambulatory Patient Groups (APGs) are a patient
classification system designed to explain the amount and type of
resources used in an ambulatory visit. Patients in each APG have
similar clinical characteristics and similar resource use and cost.
Patient characteristics should relate to a common organ system or
etiology. The resources used are constant and predictable across
the patients within each APG. This system is an encounter-based
system because it looks at only one of the patient's encounters
with the health care system. This system mainly analyzes outpatient
hospital visits and does not address inpatient services.
[0020] The GMIS system uses a bucketing procedure that profiles by
clumps of diagnosis codes including 460 diagnostic episode clusters
(DECs). The database is client specific and contains a flexible
number and type of analytic data files. This system is
episode-based, but it does not account for recurrent episodes, so a
patient's complete data history within a one-year period is
analyzed as one pseudo-episode. Signs and symptoms do not cluster
to the actual disease state, e.g. abdominal pain and appendicitis
are grouped in different clusters. This system does not use CPT-4
codes and does not shift the DEC to account for acuity changes
during the treatment of a patient.
[0021] Value Health Sciences offers a value profiling system, under
the trademark VALUE PROFILER, which utilizes a DB2 mainframe
relational database with 1,800 groups. The system uses ICD9 and
CPT-4 codes, which are bucket codes. Based on quality and
cost-effectiveness of care, the system evaluates all claims data to
produce case-mix-adjusted profiles of networks, specialties,
providers and episodes of illness. The pseudo-episode building
methodology contains clinically pre-defined time periods during
which claims for a patient are associated with a particular
condition and designated provider. The automated practice review
system analyzes health care claims to identify and correct aberrant
claims in a pre-payment mode (Value Coder) and to profile practice
patterns in a post-payment mode (Value Profiler). This system does
not link signs and symptoms and the diagnoses are non-comprehensive
because the profiling is based on the exclusion of services. No
apparent shifting of episodes occurs and the episodes can only
exist for a preset time because the windows are not recurrent.
[0022] The medical claim profiling programs described in foregoing
patents and non-patent literature demonstrate that, while
conventional computer-implemented health care systems exist, they
each suffer from the principal disadvantage of not identifying and
grouping medical claims on an episodic basis or shifting episodic
groupings based upon complications or co-morbidities. The present
computer-implemented health care system contains important
improvements and advances upon conventional health care systems by
identifying concurrent and recurrent episodes, flagging records,
creating new groupings, shifting groupings for changed clinical
conditions, selecting the most recent claims, resetting windows,
making a determination if the provider is an independent lab and
continuing to collect information until an absence of treatment is
detected.
SUMMARY OF THE INVENTION
[0023] Accordingly, it is a broad aspect of the present invention
to provide a computer-implemented medical claims profiling
system.
[0024] It is a further object of the present invention to provide a
medical claims profiling system that allows an objective means for
measuring and quantifying health care services.
[0025] It is a further object of the present invention to provide a
medical claims profiling system that includes a patient
classification system based upon episode treatment groups.
[0026] It is a further object of the present invention to provide a
medical claims profiling system that groups claims to clinically
homogeneous and statistically stable episode treatment groups.
[0027] It is a further object of the present invention to provide a
medical claims profiling system that includes claims grouping
utilizing service or segment-level claim data as input data.
[0028] It is a further object of the present invention to provide a
medical claims profiling system that assigns each claim to an
appropriate episode.
[0029] It is a further object of the present invention to provide a
medical claims profiling system that identifies concurrent and
recurrent episodes.
[0030] It is a further object of the present invention to provide a
medical claims profiling system that shifts groupings for changed
clinical conditions.
[0031] It is a further object of the present invention to provide a
medical claims profiling system that employs a decisional tree to
assign claims to the most relevant episode treatment group.
[0032] It is a further object of the present invention to provide a
medical claims profiling system that resets windows of time based
upon complications, co-morbidities or increased severity of
clinical conditions.
[0033] It is a further object of the present invention to provide a
health care system that continues to collect claim information and
assign claim information to an episode treatment group until an
absence of treatment is detected.
[0034] It is a further object of the present invention to provide a
health care system that creates orphan records.
[0035] It is a further object of the present invention to provide a
health care system that creates phantom records.
[0036] The foregoing objectives are met by the present system that
allows an objective means for measuring and quantifying health care
services based upon episode treatment groups (ETGs). An episode
treatment group (ETG) is a clinically homogenous and statistically
stable group of similar illness etiology and therapeutic treatment.
ETG grouper method uses service or segment-level claim data as
input data and assigns each service to the appropriate episode.
[0037] ETGs gather all in-patient, ambulatory and ancillary claims
into mutually exclusive treatment episodes, regardless of treatment
duration, then use clinical algorithms to identify both concurrent
and recurrent episodes. ETG grouper method continues to collect
information until an absence of treatment is detected for a
predetermined period of time commensurate with the episode. For
example, a bronchitis episode will have a sixty-day window, while a
myocardial infarction may have a one-year window. Subsequent
records of the same nature within the window reset the window for
an additional period of time until the patient is asymptomatic for
the pre-determined time period.
[0038] ETGs can identify a change in the patient's condition and
shift the patients episode from the initially defined ETG to the
ETG that includes the change in condition. ETGs identify all
providers treating a single illness episode, allowing the user to
uncover specific treatment patterns. After adjusting for case-mix,
ETGs measure and compare the financial and clinical performance of
individual providers or entire networks.
[0039] Medical claim data is input as data records by data entry
into a computer storage device, such as a hard disk drive. The
inventive medical claims profiling system may reside in any of a
number of computer system architectures, i.e., it may be run from a
stand-alone computer or exist in a client-server system, for
example a local area network (LAN) or wide area network (WAN).
[0040] Once relevant medical claim data is input, claims data is
processed by loading the computer program into the computer system
memory. During set-up of the program onto the computer system, the
computer program will have previously set pointers to the physical
location of the data files and look-up tables written to the
computer storage device. Upon initialization of the inventive
computer program, the user is prompted to enter an identifier for a
first patient. The program then checks for open episodes for the
identified patient, sets flags to identify the open episodes and
closes any episodes based upon a predetermined time duration from
date of episode to current date. After all open episodes for a
patient are identified, the new claims data records are read to
memory and validated for type of provider, CPT code and ICD-9 (dx)
code, then identified as a management, surgery, facility,
ancillary, drug or other record.
[0041] As used herein, "Management records" are defined as claims
that represent a service by a provider engaging in the direct
evaluation, management or treatment or a patient. Examples of
management records include office visits and therapeutic services.
Management records serve as anchor records because they represent
focal points in the patient treatment as well as for related
ancillary services.
[0042] "Ancillary records" are claims which represent services
which are incidental to the direct evaluation, management and
treatment of the patient. Examples of ancillary records include
X-ray and laboratory tests.
[0043] "Surgery records" are specific surgical claims. Surgery
records also serve as anchor records.
[0044] "Facility records" are claims for medical care facility
usage. Examples of facility records include hospital room charges
or outpatient surgical room charges.
[0045] "Drug records" are specific for pharmaceutical prescription
claims.
[0046] "Other records" are those medical claim records which are
not management, surgery, ancillary, facility or drug records.
[0047] Invalid records are flagged and logged to an error output
file for the user. Valid records are then processed by an ETG
Assignor Sub-routine and, based upon diagnosis code, is either
matched to existing open episodes for the patient or serve to
create new episodes.
[0048] Management and surgery records serve as "anchor records." An
"anchor record" is a record which originates a diagnosis or a
definitive treatment for a given medical condition. Management and
surgery records serve as base reference records for facility,
ancillary and drug claim records relating to the diagnosis or
treatment which is the subject of the management or surgery record.
Only management and surgery records can serve to start a given
episode.
[0049] If the record is a management record or a surgery record,
the diagnosis code in the claim record is compared with prior
related open episodes in an existing look-up table for a possible
ETG match. If more than one open episode exists, the program
selects the most recent open episode. A positive match signifies
that the current episode is related to an existing open episode.
After the match is determined, the time window is reset for an
additional period of time corresponding to the episode. A loop
shifts the originally assigned ETG based on the additional or
subsequent diagnoses. If any of the additional or subsequent
diagnoses is a defined co-morbidity diagnosis, the patient's
co-morbidity file updated. If no match between the first diagnosis
code and an open episode is found, a new episode is created.
[0050] Grouping prescription drug records requires two tables, a
NDC (National Drug Code) by GDC (Generic Drug Code) table and a GDC
by ETG table. Because the NDC table has approximately 200,000
entries, it has been found impracticable to directly construct an
NDC by ETG table. For this reason the NDC by GDC table serves as a
translation table to translate NDCs to GDCs and construct a smaller
table based upon GDCs. Reading, then from these tables, the NDC
code in the claim data record is read and translated to a GDC code.
The program then identifies all valid ETGs for the GDC codes in the
claim data record then matches those valid ETGs with active
episodes.
[0051] These and other objects, features and advantages of the
present invention will become more apparent to those skilled in the
art from the following more detailed description of the
non-limiting preferred embodiment of the invention taken with
reference to the accompanying Figures.
BRIEF DESCRIPTION OF THE DRAWINGS
[0052] Briefly summarized, a preferred embodiment of the invention
is described in conjunction with the illustrative disclosure
thereof in the accompanying drawings, in which:
[0053] FIG. 1 is a diagrammatic representation of a computer system
used with the computer-implemented method for analyzing medical
claims data in accordance with the present invention.
[0054] FIG. 2 is a flow diagram illustrating the general functional
steps of the computer implemented method for analyzing medical
claims data in accordance with the present invention.
[0055] FIG. 3 is a flow diagram illustrating an Eligible Record
Check routine which validates and sorts patient claim data
records.
[0056] FIGS. 4A to 4F are flow diagrams illustrating the Management
Record Grouping Sub-routine of the ETG Assignor Routine in
accordance with the computer-implemented method of the present
invention.
[0057] FIGS. 5A-5D are flow diagrams illustrating a Surgery Record
Grouping Sub-routine of the ETG Assignor Routine in accordance with
the computer-implemented method of the present invention.
[0058] FIGS. 6A-6E are flow diagrams illustrating a Facility Record
Grouping Sub-routine of the ETG Assignor Routine in accordance with
the computer-implemented method of the present invention.
[0059] FIGS. 7A-B are flow diagrams illustrating an Ancillary
Record Grouping Sub-routine of the ETG Assignor Routine in
accordance with the computer-implemented method of the present
invention.
[0060] FIGS. 8A-8C are flow diagrams illustrating a Drug Record
Grouping Sub-routine of the ETG Assignor Routine in accordance with
the computer-implemented method of the present invention.
[0061] FIG. 9 is a flow diagram illustrating the Episode Definer
Routine in accordance with the computer-implemented method of the
present invention.
[0062] FIG. 10 is diagrammatic timeline illustrating a hypothetical
patient diagnosis and medical claims history during a one year
period and grouping of claim records as management records and
ancillary records with cluster groupings.
[0063] FIG. 11 is a diagrammatic representation of a 1-9 Diagnosis
Code (dx) X ETG table illustrating predetermined table values
called by the Episode Definer Routine of the present invention.
[0064] FIG. 12 is a diagrammatic representation of an 1-9 Diagnosis
Code 9 (dx) X CPT Code table illustrating predetermined table
values called by the Episode Definer Routine of the present
invention.
[0065] FIG. 13 is a diagrammatic representation of a National Drug
Code (NDC) to Generic Drug Code (GDC) conversion table illustrating
predetermined Generic Drug Code values called by the Drug Record
Grouping Sub-routine of the Episode Definer Routine of the present
invention.
[0066] FIG. 14 is a diagrammatic representation of a Generic Drug
Code (GDC) to Episode Treatment Group (ETG) table illustrating
predetermined table values called by the Drug Record Grouping
Sub-routine of the Episode Definer Routine of the present
invention.
DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT
[0067] Referring particularly to the accompanying drawings, the
basic structural elements of a health care management system of the
present invention are shown. Health care management system consists
generally of a computer system 10. Computer system 10 is capable of
running a computer program 12 that incorporates the inventive
method is shown in FIG. 1. The computer system 10 includes a
central processing unit (CPU) 14 connected to a keyboard 16 which
allows the user to input commands and data into the CPU 14. It will
be understood by those skilled in the art that CPU 14 includes a
microprocessor, random access memory (RAM), video display
controller boards and at least one storage means, such as a hard
disk drive or CD-ROM. The computer system 10 also contains a video
display 18 which displays video images to a person using the
computer system 10. The video display screen 18 is capable of
displaying video output in the form of text or other video
images.
[0068] Episode Treatment Groups (ETGs) are used to define the basic
analytical unit in the computer-implemented method of the present
invention. ETGs are episode based and conceptually similar to
Diagnostic Related Groups (DRGs), with a principal difference being
that DRGs are inpatient only. ETGs encompass both inpatient and
outpatient treatment.
[0069] Using ETGs as the basic episodic definer permits the present
invention to track concurrently and recurrently occurring illnesses
and correctly identify and assign each service event to the
appropriate episode. Additionally, ETGs account for changes in a
patient's condition during a course of treatment by shifting from
the initially defined ETG to one which includes the changed
condition once the changed condition is identified.
[0070] The inventive medical claims profiling system defines
Episode Treatment Groups (ETGs). The number of ETGs may vary,
depending upon the definitional specificity the health care
management organization desires. Presently, the inventive system
defines 558 ETGs, which are assigned ETG Numbers 1-900 distributed
across the following medical areas: Infectious Diseases,
Endocrinology, Hematology, Psychiatry, Chemical Dependency,
Neurology, Ophthalmology, Cardiology, Otolaryngology, Pulmonology,
Gastroenterology, Hepatology, Nephrology, Obstetrics, Gynecology,
Dermatology, Orthopedics and Rheumatology, Neonatology,
Preventative and Administrative and Signs and Isolated Signs,
Symptoms and Non-Specific Diagnoses or Conditions. Under the
presently existing system, ETG 900 is reserved to "Isolated Signs,
Symptoms and Non-Specific Diagnoses or Conditions," and is an ETG
designation used where the diagnosis code is incapable of being
assigned to another ETG. A listing of exemplary ETGs for typical
episodes is found at Table 1, below. Those skilled in the art will
understand, however, that the number of ETGs may change, the ETG
numbering system is variable, the ETG classifications may be
defined with relatively broader or narrower degrees of specificity
and the range of medical specialties may be greater or fewer, as
required may be require by the management organization in their
medical claims data analysis protocols.
[0071] An episode may be considered a low outlier or high outlier.
Low outliers are episodes with dollar values below the minimum
amount which is specific to each ETG. Examples of low outliers
include patients which drop from a plan during mid-episode and
patients who use out-of-network providers and do not submit claims.
High outliers are those episodes with high dollar values greater
than the 75th percentile plus 2.5 times the interquartile range,
based upon a predefined database. The low and high outlier points
are pre-determined and hard-coded into the inventive system and
will vary across analysis periods.
[0072] If no ICD-9 (diagnosis code) on a given record matches the
CPT-4 code, i.e., a diagnosis of bronchitis and a CPT of knee
x-ray, an invalid code segment results. The inventive system
outputs invalid records and discontinues the processing of these
records. An invalid ICD-9 code is assigned to ETG 997, an invalid
CPT4 code is assigned to ETG 996 and an invalid provider type is
assigned to ETG 995. A sequential anchor count and a sequential
episode count are incremented after each ETG assignment. Active
open and closed ETG files include ETG number, sequential episode
number, most recent anchor from date of service and most recent
sequential anchor record count. An alternative embodiment creates a
single record for each individual episode containing ETG number,
patient age, patient sex, episode number, total charges, total
payments, earlier anchor record, last anchor record, whether the
episode was closed ("clean finish"), number of days between
database start date and earliest anchor record, whether a number of
days between database start date and earliest anchor record exceeds
the ETG's days interval, patient identification, physician
identification, management charges, management paid, surgery
charges, surgery paid, ancillary charges and ancillary paid.
[0073] The inventive system uses clinical algorithms to identify
both concurrent and recurrent episodes. Subsequent episodes of the
same nature within a window reset the window for an additional
period of time until the patient is asymptomatic for a
pre-determined time period. If an ETG matches a prior ETG, a
recurrent ETG is created and the window is reset. The most recent
claim is selected if more than one matched claim exists. If the ETG
does not match an active ETG, a new concurrent ETG is created.
[0074] Comorbidities, complications or a defining surgery could
require an update of the patient's condition to an ETG requiring a
more aggressive treatment profile. ETG's changes in the patient's
clinical condition and shift the patient's episode from the
initially defined ETG to an ETG which includes the change in
clinical condition.
[0075] If the claim is an ancillary record and it does not match an
active ETG it is designated an "orphan" ancillary record.
[0076] Termination of an episode is detected by an absence of
treatment for a period of time commensurate with the episode.
[0077] If the claim is a prescription drug record, two pre-defined
tables written to the computer data storage medium, are read. The
first of the tables is a National Drug Code (NDC) by Generic Drug
Code (GDC) table. The GDC code is equivalent to the Generic Drug
Code table known in the art. This table acts as a translator table
to translate a large number of NDCs to a smaller set of GCNs. A
second pre-defined table is employed and is constructed as a GDC by
ETG table. The GDC by ETG table is used, in conjunction with the
NDC by GDC translator table, to identify all valid ETGs for a
particular NDC code in the claim record.
[0078] To determine specific treatment patterns and performance
contributions, the computer-implemented method identifies all
providers treating a single illness episode. If a network of
providers contains Primary Care Physicians (PC P), the ETGs clearly
identify each treatment episode by PCP. Financial and clinical
performance of individual providers or entire networks may be
monitored and analyzed. To monitor health care cost management
abilities of providers, components of a provider's treatment plan
may be analyzed by uncovering casemix-adjusted differences in
direct patient management, the use of surgery and the prescribing
of ancillary services. By identifying excessive utilization and
cost areas, continuous quality improvement protocols are readily
engineered based on internally or externally derived benchmarks.
After adjusting for location and using geographically derived
normative charge information, ETG-based analysis compares the cost
performance of providers or entire networks. By using
geographically derived utilization norms, the present invention
forms the methodology base for measuring both prevalence and
incidence rates among a given population by quantifying health care
demand in one population and comparing it to external utilization
norms. This comparison helps to identify health care providers who
practice outside established utilization or cost norms.
[0079] Turning now to FIG. 2, there is illustrated the general
operation of the computer-implemented method of the present
invention. Those skilled in the art will understand that the
present invention is first read from a removable, transportable
recordable medium, such as a floppy disk, magnetic tape or a CD-ROM
onto a recordable, read-write medium, such as a hard disk drive,
resident in the CPU 14. Upon a user's entry of appropriate
initialization commands entered via the keyboard 16, or other input
device, such as a mouse or trackball device, computer object code
is read from the hard disk drive into the memory of the CPU 14 and
the computer-implemented method is initiated. The
computer-implemented method prompts the user by displaying
appropriate prompts on display 18, for data input by the user.
[0080] Those familiar with medical claims information processing
will understand that medical claims information is typically
received by a management service organization on paper forms. If
this is the case, a user first manually sorts claim records by
patient, then input patient data through interfacing with the CPU
14 through the keyboard 16 or other input device.
[0081] Prior to being submitted to the grouping algorithm, records
must be sorted by patient by chronological date of service. An
Eligible Record Check routine 48 to verify the validity and
completeness of the input data. As each record is read by the
software, it first checks the date of service on the record and
compares it to the last service date of all active episodes to
evaluate which episodes have expired in terms of an absence of
treatment. These episodes are closed at step 50. Next the record is
identified as either a management 52, surgery 54, facility 56,
ancillary 58 or drug 60 record. These types of records are
categorized as follows:
[0082] "Management records" are defined as claims which represent a
service by a provider engaging in the direct evaluation, management
or treatment or a patient. Examples of management records include
office visits, surgeries and therapeutic services. Management
records serve as anchor records because they represent focal points
in the patient treatment as well as for related ancillary
services.
[0083] "Ancillary records" are claims which represent services
which are incidental to the direct evaluation, management and
treatment of the patient. Examples of ancillary records include
X-ray and laboratory tests.
[0084] "Surgery records" represent surgical procedures performed by
physicians and other like medical allied personnel. Like management
records, surgery records also serve as anchor records.
[0085] "Facility records" are claims for medical care facility
usage. Examples of facility records include hospital room charges
or ambulatory surgery room charges.
[0086] "Drug records" are specific for pharmaceutical prescription
claims.
[0087] A "cluster" is a grouping of one, and only one, anchor
record, management or surgery, and possibly ancillary, facility
and/or drug records. A cluster represents a group of services in
which the focal point, and therefore the responsible medical
personnel, is the anchor record. An episode is made up of one or
more clusters.
[0088] After the management, surgery, facility, ancillary and drug
records are identified at steps 52, 54, 56, 58 and 60,
respectively, an ETG Assignor Sub-routine is executed at step 62.
The ETG Assignor Sub-routine 62 assigns patient medical claims to
ETGs based one or more cluster of services related to the same
episode, and provides for ETG shifting upon encountering a
diagnosis code or CPT code which alters the relationship between
the diagnosis or treatment coded in the claim record and an
existing ETG assignment. For example, ETG's may be shifted to
account for changes in clinical severity, for a more aggressive ETG
treatment profile if a complication or comorbidity is encountered
during the course of treatment for a given ETG or where a defining
surgery is encountered during the course of treatment for a given
ETG.
[0089] When the last claim data record for a given patient is
processed by the ETG Assignor Routine 62, the Episode Definer
Routine is executed at step 64. Episode Definer Routine 64
identifies all open and closed ETG episodes for the patient and
appropriately shifts any episodes to a different ETG if such ETG is
defined by age and/or the presence or absence of a co-morbidity.
The patient records are then output to a file with each record
containing the ETG number, a sequential episode number, and a
sequential cluster number. Upon input of an identifier for the next
patient, the processing of medical claims for the next patient is
initiated at step 66 by looping back to check for eligible records
for the new patient at step 48.
[0090] Operation of the Eligible Record Check routine 100 is
illustrated in FIG. 3. The patient records input by the user are
read from the recordable read-write data storage medium into the
CPU 14 memory in step 102. From the patient records read to memory
in step 102, a record validation step 104 is carried out to check
provider type, treatment code and diagnosis code against
pre-determined CPT code and diagnosis, code look up tables. The
diagnosis code is preferably the industry standard ICD-9 code and
the treatment code is preferably the industry standard CPT-4 code.
All valid patient records are assigned as one of a) management
record, b) ancillary record, c) surgery record, d) facility record,
e) drug record or f) other record, and coded as follows:
[0091] m=management record;
[0092] a=ancillary record;
[0093] s=surgery record;
[0094] f=facility record;
[0095] d=drug record; or
[0096] o=other record.
[0097] A sort of valid records 106 and invalid records 108 from
step 104 is made. For valid records 106 in step 110, patient age is
then read to memory from the first patient record from step 106.
All valid records are then sorted by record type in step 112, i.e.,
record type m, a, s, f, d or o by a date of service from date
(DOS-from). A sort index of all record-type sorted records from
step 116 is generated and written to the hard disk, and the ETG
Assignor routine 120 is initialized.
[0098] For invalid records 108 identified at step 104, the records
are assigned ETG designations reserved for records having invalid
provider data, invalid treatment code, or invalid diagnosis code,
e.g., ETG 995, 996 and 997, respectively, at step 111. An error log
file is output identifying the invalid records by reserved ETG and
written to disk or displayed for the user and processing of the
invalid records terminates at step 113.
[0099] The computer-implemented method of the present invention
then initializes an Episode Assignor Routine 200, the operation of
which is illustrated in FIGS. 4A-8C. Episode Assignor Routine 200
consists generally of five Sub-routine modules for processing
management records, surgery records, facility records, ancillary
records and drug records and assigning claims to proper ETGs. FIGS.
4A-4F illustrate initial identification of records as management,
surgery, facility ancillary and drug records and the Management
Record Grouping Sub-Routine. FIGS. 5A-5E illustrate operation of
the Surgery Record Grouping routine 400 for matching surgery claim
records to proper ETGs. FIGS. 6A-6E illustrate operation of the
Facility Record Grouping routine 500 for matching facilities
records to proper ETGs. FIGS. 7A-7 illustrate operation of the
Ancillary Record Grouping routine 600 for matching ancillary
records to proper ETGs. Finally, FIGS. 8A-8C illustrate operation
of the Drug Records Grouping routine 700 for matching drug records
to proper ETGs.
[0100] Management Records
[0101] The Episode Assignor routine begins by executing a
Management Records Grouping Sub-routine 200, illustrated in FIGS.
4A-4F, first reads the input claim record for a given patient in
step 202. The first processing of the input claim record entails
categorizing the record as a management, surgery, facility,
ancillary or drug record at step 204. A series of logical operands
208, 210, 212 and 214, read the record and determine whether the
record is a management record at step 204, a surgery record at step
208, a facility record at step 210, an ancillary record at step 212
or a drug record at step 214. If an affirmative response is
returned in response to logical operand 204, grouping of the
management record to an ETG is initialized and processing of the
management record proceeds to step 215. If, however, a negative
response is returned in response to the logical operand 206,
logical operand 208 is executed to determine whether the record is
a surgery record. If an affirmative response is returned from
logical operand 208, the Surgery Record Grouping routine 400 is
initialized. If, however, a negative response to logical operand
208 is returned, logical operand 210 is executed to determine
whether the record is a facility record. If an affirmative response
is returned in response to logical operand 210, the Facility Record
Grouping Sub-routine 500 is executed. If, however, a negative
response is returned in response to the logical operand 210,
logical operand 212 is executed to determine whether the record is
an ancillary record. If an affirmative response is returned from
logical operand 212, the Ancillary Record Grouping Sub-routine 600
is executed. If, however, a negative response to logical operand
212 is returned, logical operand 214 is executed to determine
whether the record is a facility record. At this point all records
except drug records have been selected. Thus, all the remaining
records are drug records and the Drug Record Grouping Sub-routine
700 is executed.
[0102] Returning now to the initialization of the Management Record
Grouping routine 200, and in particular to step 215. Once the
record has been categorized as a management record in step 206, the
DOS-to value is compared to active episodes for the patient to
determine if any active episodes should be closed. Closed episodes
are moved to an archive created on the storage means, such as a
hard disk or CD-ROM.
[0103] The management record is examined and the first diagnosis
code on record is read, a diagnosis code (dx) by ETG table 201 is
read from the storage means and all valid ETGs for the first
diagnosis code on record are identified at step 216. The dx by ETG
table 201 consists of a table matrix having diagnosis codes on a
first table axis and ETG numbers on a second table axis. At
intersection cells of the dx by ETG table are provided table values
which serve as operational flags for the inventive method. In
accordance with the preferred embodiment of the invention, dx by
ETG table values are assigned as follows:
[0104] P=primary, with only one P value existing per ETG;
[0105] S=shift;
[0106] I=incidental;
[0107] A=shift to ETG with C value; and
[0108] C=P, where P' is a shiftable primary value. An illustrative
example of a section of a dx by ETG table is found at FIG. 11.
[0109] ETG validation in step 216 occurs where for a given
diagnosis code on record, the code has either a P, S, I, A or C
dx-ETG table value. The ETGs identified as valid for the first
diagnosis code on record in step 216, are then matched with active
open ETGs in step 217 by comparing the valid ETGs with the open
ETGs identified in step 215. A logical operand is then executed at
step 218 to determine whether a match exists between the valid ETG
from the management record and any open ETGs. A negative response
at step 218 causes execution of another logical operand at step 220
to determine whether for the first diagnosis code is the P value in
the dx-ETG table equal to the ETG for non-specific diagnosis, i.e.,
ETG 900. If an affirmative response is returned at step 216, ETG
identifiers for the second to the fourth diagnosis codes in the
management record are established from the dx-ETG table and the ETG
identifier value is matched to active specific ETGs in step 222 and
execution of the program continues as represented by designator AA
236 bridging to FIG. 5B. If, however, a negative response is
returned from logical operand 220, a value of one is added to the
management record or anchor count and to the episode count and the
ETG with a P value on the dx-ETG table is selected and a new
episode is initialized. Further processing of the new episode by
the program continues as represented by designator F 236 bridging
to FIG. 5C.
[0110] If an affirmative response is returned at logical operand
step 218, the matched active ETG with the most recent DOS-to are
selected at step 230. If a tie is found based upon most recent
DOS-to values, then the most recent DOS-from value is selected for
matching with active ETGs. If a tie is found at most recent
DOS-from values is found, the first encountered ETG is selected and
matched. A value of one is then added to the management record or
anchor record counter at step 232 and further processing continues
as represented by designator G 238 bridging to FIG. 5C.
[0111] Turning now to FIG. 4B, which is a continuation from
designator AA 236 of FIG. 4A, identifier ETGs for the second to
fourth diagnoses in the management record are matched to active
ETGs in logical operand 237. If an affirmative response is returned
in response to logical operand 237, the matched active ETG with the
most recent DOS-to is selected in step 240. If there is a tie
between two or more ETGs with the most recent DOS-to value, the
most recent DOS-from ETG is selected. If, however, there is a tie
between two or more active ETGs with the most recent DOS-from
value, then the first encountered ETG is selected in step 240. A
value of one is then added to the sequential anchor record counter
in step 241 and operation of the computer-implemented method
continues as indicated by designator G 243 bridging to FIG. 5C.
[0112] From logical step 237, if a negative response is returned,
the ETG with the second diagnosis value of P is selected at step
242, then a logical query is made to determine whether the selected
ETG is a non-specific ETG, i.e., ETG 900 at step 244. A negative
response to logical query 244 causes a value of one to be added to
the sequential anchor count and to the sequential episode count at
step 254. If an affirmative response to logical query 244 is
returned, logical queries 246 and 248 are sequentially executed to
select ETGs with the third and fourth diagnosis values of P from
the dx-ETG table written on the storage means, respectively, and
logical query 244 is executed to determine whether the selected ETG
is the non-specific ETG, i.e., ETG 900. If a negative response is
returned to logical query 244 for the ETG selected in step 248, a
value of one is added to the sequential anchor count and to the
sequential episode count in step 254. If an affirmative response is
returned from logical query 244, a value of one is added to the
sequential anchor count and the sequential episode count at step
250.
[0113] From step 250, the non-specific ETG, i.e., ETG 900 is
selected and a new episode is started in the active ETG file. The
updated sequential episode number, the updated sequential anchor
count, the DOS-from and the DOS-to from the record are written to
the new episode in the active ETG file in step 252.
[0114] From step 254, the ETG with a dx-ETG table value of P is
selected and a new episode is started in the active ETG file. The
updated sequential episode number, the updated sequential anchor
count, the DOS-from and the DOS-to from the record are written to
the new episode in the active ETG file in step 256. A comorbidity
file written on the storage means is then updated with all the dx
codes in the management record in step 258. From each of steps 252
and steps 258 a check is made to determine whether the processed
management record is the last record for the patient at logical
step 260. An affirmative response returned to logical step 260
prompts the program operation to the Episode Definer Sub-routine
264, bridging to FIG. 9 with identifier GG, while a negative
response to logical step 260 returns program operation to the
beginning of the ETG Assignor routine 200 and the next patient
record is read at step 262.
[0115] Turning now to FIG. 4C, the bridge reference G 238 is
continued from FIG. 4A. For those records having a match with an
open ETG, a query is made at step 270 of the dx-ETG table 201 to
determine the table value of the dx code for the selected ETG.
Again, valid table values are one of P, S, I, A, or C. If the table
value returned from step 270 is A, the selected ETG in the active
file is changed at step 272 to the ETG number having an equivalent
table value of C for the diagnosis on record. If the table value
returned from step 270 is S, the selected ETG in the active file is
shifted at step 274 to an ETG value having a table value of P for
the diagnosis code on record. If the table value is one of P, I or
C, the ETG remains the same and the selected active ETG's most
recent DOS-to is updated by writing the record date to the ETG
DOS-to field, and the sequential anchor count in the selected
active ETG is updated to reflect writing of the record to the ETG
at step 276.
[0116] At step 278, the record is then written with a sequential
episode number and the sequential anchor count of the selected ETG
from the selected active ETG. In this manner, the record is
identified with the ETG and the specific episode. The patient's
co-morbidity file is flagged with the output read from bridge
designator F at step 234. A patient's comorbidity file is a
predefined list of diagnoses which have been identified as
comorbidities. If during the course of grouping a patient's
records, a management record is encountered which is a comorbidity
diagnosis, the ETG for that diagnosis is flagged or "turned on" in
the comorbidity file. Then, during the execution of the Episode
Definer Routine, all the patient's episodes with an ETG which can
shift based on the presence of a comorbidity and which are "turned
on" are appropriately shifted to the ETG "with comorbidity".
[0117] A loop beginning at step 282 is then executed to determine
whether the ETG assigned by the first diagnosis code should be
shifted to another ETG based upon the second, third and fourth
diagnoses on record. At step 282, the second diagnosis is read from
the patient's claim record and all valid ETGs for the second
diagnosis are read from the dx-ETG table 201. A logical operand 284
is executed to determine whether one of the valid ETGs for the
second diagnosis matches the primary diagnosis ETG. If a negative
response is returned to logical operand 284, a loop back at step
285 is executed to step 282 for the next sequential diagnosis code
on record, i.e., the third and forth diagnosis codes on record. If
an affirmative response is returned to the logical operand 284, the
a logical operand 286 queries the table value of the matched ETG to
determine if a value of A is returned from the dx-ETG table. If a
negative response is returned, the loop back step 285 is
initialized. If an affirmative response is returned, the first dx
ETG is flagged for change to a second dx ETG having an equivalent
table value of C for the second diagnosis code on record at step
288 and all valid ETGs for the current diagnosis code on record are
identified at step 290 from the dx-ETG table. The identified
C-value ETG is then matched with any open active ETGs at step 292.
Program operation then continues at bridge H 292 to FIG. 4D.
[0118] At FIG. 4D the continued operation of the Management
Grouping Sub-routine from bridge H 292 of FIG. 4C. Logical operand
296 queries the open active ETGs to determine whether a valid match
with the identified C-value ETG exists. If a negative response is
returned to logical operand 296, a value of 1 is added to the
sequential episode count at step 297 and a new episode having a P
value ETG is started in the patient's master active ETG file at
step 299. The new episode is written with a sequential episode
number, DOS-from and DOS-to values and forms a phantom management
record. A phantom record is an anchor record, management or
surgery, with more than one diagnosis, which is assigned to one
episode and its corresponding ETG based on one diagnosis, but can
start a new episode(s) or update the most recent date of another
active episode(s) based on other diagnoses on the record.
[0119] If an affirmative response is returned from logical operand
296, the matched active ETG with the most recent DOS-to value is
selected at step 298. If a tie is found based upon most recent
DOS-to values, then the most recent DOS-from value is selected for
matching with active ETGs. If a tie is found at most recent
DOS-from values is found, the first encountered ETG is selected and
matched. The selected ETG's most recent DOS-to and sequential
anchor count are updated in the patient's master active ETG file in
step 300.
[0120] For either the new episode created at step 299 or the
updated ETG from step 300, the patient's co-morbidity file is then
updated with the second diagnosis code on-record at step 302.
Processing then continues to identify all valid ETGs for a third
diagnosis code on record at step 304 and the identified valid ETGs
from step 304 are compared to the active ETGs in the patient's
master active ETG file in step 306.
[0121] Bridge I 308 continues to FIG. 4E, and a logical operand 310
is executed to query the patient's master active ETG file to
determine whether a match exists between the valid ETGs identified
in step 304 with any active ETG from the patients master active ETG
file. If a negative response is returned to logical operand 310, a
value of 1 is added to the sequential episode count at step 311 and
a new episode having a P value ETG is started in the patient's
master active ETG file at step 313. The new episode is written with
a sequential episode number, DOS-from and DOS-to values and forms a
phantom management record.
[0122] If an affirmative response is returned from logical operand
310, the matched active ETG with the most recent DOS-to value is
selected at step 312. Again a decisional hierarchy is executed. If
a tie is found based upon most recent DOS-to values, then the most
recent DOS-from value is selected for matching with active ETGs. If
a tie is found at most recent DOS-from values is found, the first
encountered ETG is selected and matched. The selected ETG's most
recent DOS-to and sequential anchor count are updated in the
patient's master active ETG file in step 314.
[0123] For either the new episode created at step 311 or the
updated ETG from step 314, the patient's co-morbidity file is then
updated with the third diagnosis code on-record at step 316.
Processing then continues to identify all valid ETGs for a fourth
diagnosis code on record at step 318 and the identified valid ETGs
from step 3318 are compared to the active ETGs in the patient's
master active ETG file in step 320. Bridge reference I 322, bridges
to FIG. 4F.
[0124] Turning to FIG. 4F, a logical operand 324 is executed to
query the patient's master active ETG file to determine whether a
match exists between the valid ETGs identified in step 320 with any
active ETG from the patients master active ETG file. If a negative
response is returned to logical operand 324, a value of 1 is added
to the sequential episode count at step 325 and a new episode
having a P value ETG is started in the patient's master active ETG
file at step 337. The new episode is written with a sequential
episode number, DOS-from and DOS-to values and forms a phantom
management record.
[0125] If an affirmative response is returned from logical operand
324, the matched active ETG with the most recent DOS-to value is
selected at step 326. Again a decisional hierarchy is executed. If
a tie is found based upon most recent DOS-to values, then the most
recent DOS-from value is selected for matching with active ETGs. If
a tie is found at most recent DOS-from values is found, the first
encountered ETG is selected and matched. The selected ETG's most
recent DOS-to and sequential anchor count are updated in the
patient's master active ETG file in step 328.
[0126] For either the new episode created at step 337 or the
updated ETG from step 324, the patient's co-morbidity file is then
updated with the fourth diagnosis code on-record at step 330. A
check is then made to determine whether the processed record is the
last record for the patient by execution of logical operand 332 and
reading the input claim records from the storage means. If logical
operand 332 returns an affirmative value, the ETG Definer
Sub-routine is called at step 334, as represented by bridge
reference GG. If, however, a negative response is returned to
logical operand 332, program execution returns to the step 204 of
the Episode Assignor routine 200 and the next patient claim record
is read from the storage means. Surgery Records
[0127] Grouping of Surgery Records to ETGs is governed by the
Surgery Record Grouping Sub-routine 400, the operation of which is
illustrated in FIGS. 5A-5D.
[0128] For those patient claim records identified as Surgery
Records at step 208, the DOS-from value on-record is compared with
the DOS-to value read from the patient master active ETG file at
step 402. This identifies and flags those active ETGs which are to
be closed, the flagged ETGs are then moved to the patient master
closed ETG file. The first diagnosis code on-record is then read
and compared to the dx-ETG table 201 to identify all possible valid
ETGs for the first diagnosis code on-record in step 404.
[0129] Surgery records are coded with treatment codes (CPT codes).
Each surgery record has a single CPT code value. The CPT code
on-record is then read, and compared to a CPT by ETG table 401
previously written to the storage means. The CPT-ETG table will
have pre-determined table values. For example, in accordance with
the preferred embodiment of the invention, the CPT-ETG table 401
has table values of R, W and X, where R is a value shiftable to W
and X is a validator value. All valid ETGs for the on-record CPT
code are identified by this comparison at step 406. A logical
operand 408 is then executed to determine whether there is a match
of valid ETGs returned from the dx-ETG table 201 and the CPT-ETG
table 401. If an affirmative response is returned to logical
operand 408, a second logical operand 410 is executed to determine
whether a match of valid specific ETGs exists. Again, if an
affirmative response is returned from second logical operand 410,
the valid specific ETGs matched in step 410 are then compared at
step 414 with the open active ETGs for the patient read from the
patient's master active ETG file at step 412. If an affirmative
response is returned from step 414, the matched ETG with the most
recent DOS-to is selected at step 416 and a value of 1 is added to
the sequential anchor count in the selected ETG at step 418. In
step 416, if a tie is found based upon most recent DOS-to values,
then a decisional hierarchy is followed to select the most recent
DOS-from value for matching with active ETGs. If a tie is found at
most recent DOS-from values is found, the first encountered ETG is
selected and matched.
[0130] If a negative response is returned to any of logical
operands 408, 410 or 414, second, third and fourth dx codes
on-record are read and all possible valid ETGs are read in step 411
from the dx-ETG table 201. Further processing of the valid ETGs
output from step 411 is continued at FIG. 5B identified by bridge
reference P, 413.
[0131] Turning to FIG. 5B, a logical operand 415 compares the valid
ETGs for the second, third and fourth dx codes with the valid ETGs
for the CPT code on-record in step 411. If a negative response is
returned from logical operand 415, the patient claim record is
assigned to an ETG reserved for match errors between dx code and
CPT code, e.g., ETG 998, and further processing of the match error
ETG bridges at reference R, 431, to FIG. 5D.
[0132] If an affirmative response is returned from logical operand
415, the matched ETGs are compared with active ETGs read from the
patient master active ETG file at step 417 and logical operand 419
is executed at step 419 to determine whether any valid matches
between matched ETGs and active ETGs. If a negative response is
returned to logical operand 419, a value of 1 is added to the
sequential anchor count and to the sequential episode count at step
425 and a new episode is started at step 437 with the first dx code
on-record having a P value for a specific ETG in the dx-ETG table
201. If no specific ETG has a P value, a non-specific ETG having a
P value for the dx code on record is used to start the new episode.
The new episode is started by writing the sequential episode
number, the sequential anchor count, the DOS-from and the DOS-to
values on the record.
[0133] If an affirmative response is returned from logical operand
419, the matched specific ETG with the most recent DOS-to is
selected at step 421. If a tie is found based upon most recent
DOS-to values, then the most recent DOS-from value is selected for
matching with active ETGs. If a tie is found at most recent
DOS-from values is found, the first encountered ETG is selected and
matched. A value of 1 is added to the sequential anchor count at
step 423. Processing the new episode started at step 427 or of the
selected matched specific ETG at step 421 continues to bridge Q,
420, continued at FIG. 5C.
[0134] Turning to FIG. 5C, bridged from reference Q, 420, logical
operand 422 is executed which reads the CPT-ETG table 401 and
determines the table value of the selected ETG from step 421 and
step 427 based on the CPT value on-record. If a table value of R is
returned from the read of the CPT-ETG table 401 at step 422, the
matched ETG in the master active ETG file is shifted at step 424 to
the ETG with an equivalent value of W for the CPT code on-record.
If a table value of X or W is returned from step 422 or from step
242, the dx-ETG table 201 is read at step 426 and the dx code for
the selected matched ETG from the CPT-ETG table 401 or the shifted
ETG from step 424 is read. From the dx-ETG table 201, if a value of
S is returned, the matched ETG in the patient master active ETG
file is shifted at step 428 to the ETG with a table value of P for
the dx code on-record. If a table value of A is returned, the
matched ETG in the patient master active ETG file is changed in
step 430 to an equivalent value of C for the dx code on-record. If
a table value of P, I or C is returned either from logical operand
426, or from the ETG change step 428 or the ETG shift step 430, the
DOS-to and the sequential anchor count of the ETG in the patient
master active ETG file are updated in step 432. The patient claim
record is then assigned and written with the sequential episode
number and the sequential anchor count of the selected ETG at step
434. The patient co-morbidity file is then updated with all
diagnosis codes on-record at step 436.
[0135] FIG. 5D bridges from FIG. 5C with bridge reference BB, 438.
In FIG. 5D, the diagnosis codes on-record which were not used in
the ETG selection described above, are then read from the patient
claim record to identify all possible valid ETGs in the dx-ETG
table 201. The identified possible valid ETGs are then matched
against the patient master active ETG file in step 442 and logical
operand 444 is executed to validate the matches. If an affirmative
response is returned to logical operand 444, for each matched dx
code on-record, the matched active ETG with the most recent DOS-to
is selected at step 446. If a tie is found based upon most recent
DOS-to values, then the most recent DOS-from value is selected for
matching with active ETGs. If a tie is found at most recent
DOS-from values is found, the first encountered ETG is selected and
matched. The selected ETG's most recent DOS-to value is updated to
the date of the patient medical claim, and the sequential anchor
count in the active ETG is updated in step 448.
[0136] If a negative response is returned to logical operand 444, a
value of 1 is added to sequential episode count at step 456 and a
new episode having a P value ETG is started in the patient's master
active ETG file at step 458. The new episode is written with a
sequential episode number, DOS-from and DOS-to values and forms a
phantom surgery record. If an affirmative response is returned to
logical operand 444, the matched active ETG for each diagnosis code
is selected at step 446 on the basis of the most recent DOS-to
value. If a tie is found based upon most recent DOS-to values, then
the most recent DOS-from value is selected for matching with active
ETGs. If a tie is found at most recent DOS-from values is found,
the first encountered ETG is selected and matched. The DOS-to field
of the selected ETG from step 446 is updated in step 448 to the
date of service on-record and the sequential anchor count in the
active ETG file is updated. From either step 458 or from step 448,
the patient co-morbidity file is updated to reference the selected
ETG and a check is made to determine whether the patient claim
record processed in step 429, which assigned an invalid dx-CPT code
match to the record, or from step 450, which updated the
co-morbidity file, is the last record for the patient at logical
operand 462. If an affirmative response is returned to logical
operand 462, record processing proceeds to the Episode Definer
Sub-routine at step 464, bridged by reference GG, to FIG. 9. If,
however, a negative response is returned to logical operand 462, a
loop back 468 to the beginning of the ETG Assigner routine 200 is
executed and the next patient claim record is read.
[0137] Facility Records
[0138] The Facility Record Grouping Sub-routine 500 assigns
facility records to ETGs on the basis of diagnosis codes on-record.
The patient claim record is read and the first diagnosis code
on-record is read to the dx-ETG table 201 to identify all valid
ETGs for the first dx code at step 502. The identified valid ETGs
are then compared to the open active ETGs in the patient master
active ETG file in step 504. Logical operand 506 executes to
determine whether any valid matches exist between identified ETGs
for the dx code and the active ETGs for the patient. If a negative
response is returned to step 506, a value of 1 is added to the
sequential episode count at step 507 and a new episode is started
in step 509 in the patient active ETG file with the ETG
corresponding to the dx-ETG table value of P. If logical operand
507 returns an affirmative response, a query of the matched ETG
value is made at step 508 to determine whether the matched ETG has
a table value of P, C, A or S. If a negative response is returned
to step 508, the matched active ETG with the most recent DOS-.from
value is selected at step 511. If a tie is found based upon most
recent DOS-to values, then the most recent DOS-from value is
selected for matching with active ETGs. If a tie is found at most
recent DOS-from values is found, the first encountered ETG is
selected and matched. If an affirmative response is returned at
step 508, the table value of the matched ETG table value is
identified at step 510. If the table value for the matched ETG in
the dx-ETG table 201 is S, the matched ETG is shifted at step 514
to the ETG having a table value of P for the dx code. If the table
value for the matched ETG returns a value of A, the matched ETG in
the patient master active ETG file is changed at step 512 to an ETG
having an equivalent table value of C for the dx code. If a table
value of either P or C is returned at step 510, the most recent
DOS-to is updated at step 516 in the ETG to the on-record claim
date. Further processing of the claim record from steps 509, 511
and 516 bridges at reference 1, 520, to FIG. 6B. Turning to FIG.
6B, bridged from reference 1, 520, in FIG. 6A, the patient's
co-morbidity file is updated with the first dx code at step 522. A
loop beginning at step 524 is then executed to determine whether
the ETG assigned by the first diagnosis code should be shifted to
another ETG based upon the second, third and fourth diagnoses on
record. At step 524, the second diagnosis is read from the
patient's claim record and all valid ETGs for the second diagnosis
are read from the dx-ETG table 201. A logical operand 526 is
executed to determine whether one of the valid ETGs for the second
diagnosis matches the primary diagnosis ETG. If a negative response
is returned to logical operand 526, a loop back at step 527 is
executed to step 524 for the next sequential diagnosis code on
record, i.e., the third and forth diagnosis codes on record. If an
affirmative response is returned to the logical operand 524, the
logical operand 528 queries the table value of the matched ETG to
determine if a value of A is returned from the dx-ETG table. If a
negative response is returned, the loop back step 527 is
initialized. If an affirmative response is returned, the first dx
ETG is flagged for change to a second dx ETG having an equivalent
table value of C for the second diagnosis code on record at step
530. All valid ETGs for the second diagnosis code on record are
identified at step 532 from the dx-ETG table. The identified ETGs
are then matched with any open active ETGs at step 532. Program
operation then continues at bridge 2, 536 to FIG. 6C.
[0139] At FIG. 6C the continued operation of the Facility Record
Grouping Sub-routine 500 from bridge 2 of FIG. 6b is illustrated.
Logical operand 538 queries the open active ETGs to determine
whether a valid match with the identified ETGs exists. If a
negative response is returned to logical operand 538, the patient
co-morbidity file is updated with the second diagnosis code at step
544. If an affirmative response is returned from logical operand
538, the matched active ETG with the most recent DOS-to value is
selected at step 540. If a tie is found based upon most recent
DOS-to values, then the most recent DOS-from value is selected for
matching with active ETGs. If a tie is found at most recent
DOS-from values is found, the first encountered ETG is selected and
matched. The selected ETG's most recent DOS-to and sequential
anchor count are updated in the patient's master active ETG file in
step 542.
[0140] Processing then continues to identify all valid ETGs for a
third diagnosis code on record at step 546 and the identified valid
ETGs from step 546 are compared to the active ETGs in the patient's
master active ETG file in step 548.
[0141] Bridge 3, 550, continues to FIG. 6D, and a logical operand
552 is executed to query the patient's master active ETG file to
determine whether a match exists between the valid ETGs identified
in step 548 with any active ETG from the patients master active ETG
file. If a negative response is returned to logical operand 538,
the patient's comorbidity file is updated with the third diagnosis
code at 558.
[0142] If an affirmative response is returned from logical operand
552, the matched active ETG with the most recent DOS-to value is
selected at step 554. Again a decisional hierarchy is executed. If
a tie is found based upon most recent DOS-to values, then the most
recent DOS-from value is selected for matching with active ETGs. If
a tie is found at most recent DOS-from values is found, the first
encountered ETG is selected and matched.
[0143] The patient's co-morbidity file is then updated with the
third diagnosis code on-record at step 558. Processing then
continues to identity all valid ETGs for a fourth diagnosis code on
record at step 560 and the identified valid ETGs from step 3318 are
compared to the active ETGs in the patient's master active ETG file
in step 562. Bridge reference 4, 564, bridges to FIG. 6D.
[0144] Turning to FIG. 6D, a logical operand 566 is executed to
query the patient's master active ETG file to determine whether a
match exists between the valid ETGs identified in step 562 with any
active ETG from the patients master active ETG file. If a negative
response is returned to logical operand 566, the patients
comorbidity file is updated with the fourth diagnosis code.
[0145] If an affirmative response is returned from logical operand
566, the matched active ETG with the most recent DOS-to value is
selected at step 568. In the event of a tie, a decisional hierarchy
is executed. If a tie is found based upon most recent DOS-to
values, then the most recent DOS-from value is selected for
matching with active ETGs. If a tie is found at most recent
DOS-from values is found, the first encountered ETG is selected and
matched. The selected ETG's most recent DOS-to are updated in the
patient's master active ETG file in step 570 and the patient's
co-morbidity file is then updated with the fourth diagnosis code
on-record at step 572. A check is then made to determine whether
the processed record is the last record for the patient by
execution of logical operand 574 and reading the input claim
records from the storage means. If logical operand 574 returns an
affirmative value, the ETG Definer Sub-routine is called at step
576, as represented by bridge reference GG. If, however, a negative
response is returned to logical operand 574, program execution
returns to the step 204 of the Episode Assignor routine 200 and the
next patient claim record is read from the storage means at step
578.
[0146] Ancillary Records
[0147] Operation of the Ancillary Record Grouping Sub-routine 600
is illustrated in FIGS. 7A-7B. Like surgery records, ancillary
records are grouped to ETGs on the basis of both dx codes and CPT
code on record. First all valid ETGs for the treatment or CPT code
on-record are identified in step 602 from the CPT-ETG table 401.
Then all valid ETGs for the first dx code on record are identified
in step 604 from the dx-ETG table 201. The ETGs from the CPT-ETG
table 401 are then compared at step 606 to the ETGs from the dx-ETG
table 201 and a logical operand 608 determines whether there is an
ETG match. An affirmative response returned from logical operand
608 continues record processing at bridge D, 610, which continues
on FIG. 7B. A negative response returned from logical operand 608
prompts a look up on the dx-ETG table to determine all valid ETGs
for the second diagnosis code on record in step 611. Step 613 again
compares the valid ETGs for the CPT code on record and with the
valid ETGs for the second dx code on record and a logical operand
614 is executed to match the second dx code ETG with the CPT code
ETG. Again, an affirmative response returned from logical operand
614 continues record processing at bridge D, 610, which continues
on FIG. 7B. If a negative response is returned to logical operand
614, a look up on the dx-ETG table occurs to determine all valid
ETGs for the third diagnosis code on record in step 615. Step 616
again compares the valid ETGs for the CPT code on record and with
the valid ETGs for the third dx code on-record, which bridges E,
619, to FIG. 7B for identification of all valid ETGs for the fourth
dx code on-record at step 625.
[0148] Step 627 then compares the valid ETGs for the CPT code on
record and with the valid ETGs for the fourth dx code on record and
a logical operand 629 is executed to match the fourth dx code ETG
with the CPT code ETG. An affirmative response returned from
logical operand 629 continues to step 616 which compares the
matched ETGs with the ETGs in the patient master active ETG file
and a query is made at logical operand 618 to determine whether any
valid matches exist. If a negative response is returned to logical
operand 629, the record is output to the ETG reserved for a CPT
code-dx code mismatch at step 631 and a check is made at step 635
to determine whether the record is the last record for the
patient.
[0149] If a match is found between the matched ETGs from the dx
code-CPT code comparison in step 616. The matched active ETG with
the most recent DOS-to value is selected. In the event of a tie, a
decisional hierarchy is executed. If a tie is found based upon most
recent DOS-to values, then the most recent DOS-from value is
selected for matching with active ETGs. If a tie is found at most
recent DOS-from values is found, the first encountered ETG is
selected. The sequential episode number of the selected ETG is
assigned to the record and the most recent sequential anchor count
of the episode from the active ETG file is assigned to the record
at step 622.
[0150] If the response to logical operand 618 is negative, the
record is assigned to an orphan record ETG at step 633 and
maintained in the claims records until subsequent record processing
either matches the record to an ETG or the orphan record DOS-from
exceeds a one-year time period, at which time the record is output
to an error log file.
[0151] A check is then made to determine whether this record is the
last record for the patient at step 635. If logical operand 635
returns an affirmative value, the ETG Definer Sub-routine is called
at step 642, as represented by bridge reference GG. If, however, a
negative response is returned to logical operand 635, program
execution returns to the step 204 of the Episode Assignor routine
200 and the next patient claim record is read from the storage
means at step 644.
[0152] Prescription Drug Records
[0153] FIGS. 8A-8C illustrate the operation of the Drug Record
Grouping Sub-routine 700. Drug Record Grouping Sub-routine 700
references two predetermined tables previously written to the
storage means. The first of the tables is a National Drug Code
(NDC) by Generic Drug Code (GDC) table 800. This table acts as a
translator table to translate a large number of NDCs to a smaller
set of GDCs. A second pre-defined table is employed and is
constructed as a GDC by ETG table 900. The GDC by ETG table is
used, in conjunction with the NDC by GDC translator table, to
identify all valid ETGs for a particular NDC code in the claim
record.
[0154] Once identified as a drug record in the initial operation of
the Episode Assignor Routine 200, the drug record is read from
storage to memory in step 702. The NDC code on-record is converted
to a GDC code by reading from the NDC-GDC table 800 in step 704.
Using the GDC number so identified, all possible valid ETGs for the
GDC code are identified in step 706. The possible valid ETGs for
the GDC code are then compared to the patient master active ETG
file in step 708. Following bridge LL, 710, to FIG. 8B, a logical
operand is executed in step 712 based upon the comparison executed
in step 708, to determine whether a match occurs having a table
value of P, A, C or S.
[0155] If a negative response is returned to logical operand 712, a
check is made to determine whether a match having table value I in
the GDC-ETG table 900 exists in step 713. If another negative
response is returned to logical operand 713, the record is flagged
an orphan drug record and assigned to an orphan drug record ETG in
step 715. If an affirmative response is returned to logical operand
713, the ETG with the highest second value is selected in step 718
(e.g. I1, I2, I3 and so on). If more than one ETG having the
highest second value exists, the ETG having the most recent
DOS-from value is selected. If a tie is again encountered, the
first encountered ETG is selected. A sequential episode number and
the most recent sequential anchor count of the episode from the
patient master active ETG file is assigned to the drug record for
the selected ETG in step 720.
[0156] If an affirmative response is returned to logical operand
712, the ETG having the highest second value, in order of P, S, A,
C is selected in step 714 (e.g. P1, then P2 . . . then S1, then S2
. . . and so on). The record is then assigned a sequential episode
number of the selected ETG and the most recent sequential anchor
count of the episode from the patient master active ETG file in
step 716.
[0157] Further processing of the drug record continues from steps
716, 715 and 720 through bridge MM, 724 and is described with
reference to FIG. 8C. A check is made in step 726 to determine
whether the drug record is the last drug record for the patient on
the record date. If a negative response is returned, a loop back to
the top of the Drug Record Grouping Sub-routine 700 is executed. If
an affirmative response is returned at step 726, a check is made to
determine whether the drug record is the last record for the
patient in step 728. If logical operand 728 returns an affirmative
value, the ETG Definer Sub-routine is called at step 732, as
represented by bridge reference GG. If, however, a negative
response is returned to logical operand 728, program execution
returns to the step 204 of the Episode Assignor routine 200 and the
next patient claim record is read from the storage means at step
730.
[0158] The Episode Definer Sub-routine is illustrated with
reference to FIG. 9. Episode Definer Routine 118 is employed to
assign all non-specific claims records, i.e., those initially
assigned to ETG 900, to specific more appropriate ETGs. Episode
Definer routine 750. Once all episodes have been grouped to ETGs,
all ETG episodes in both active and closed ETGs are then identified
in step 752 by patient age and presence or absence of a
comorbidity. The ETG number for each episode is then shifted and
re-written to an ETG appropriate for the patient age and/or
presence or absence of a comorbidity in step 754. All patient
records are then output in step 756 to the display, to a file or to
a printer, along with their shifted ETG number, sequential episode
number of the record and in patient master active and closed ETG
file for the patient. The Episode Definer routine 750 then writes a
single record at step 758 for each episode containing key
analytical information, for example: the ETG number, patient age,
patient sex, the sequential episode number, the total sum charges,
the total sum paid, the earliest anchor record DOS-from value, the
last anchor record DOS-to value, patient identification, physician
identification, management charges, management charges paid,
surgery charges, surgery charges paid, ancillary charges, and
ancillary charges paid.
[0159] After the single record for each episode is written in step
758 for the patient, processing for the next patient begins by
initialization of the next patient master active and closed ETG
file, the next patient co-morbidity file, and the patient age file
in step 760 and the Eligible Record Check Routine is re-initiated
for processing claims records for the next patient at step 762.
EXAMPLE
[0160] FIG. 10 provides an example of Management and Ancillary
record clustering over a hypothetical time line for a single
patient over a one year period from January, 1995 to December,
1995. FIG. 10 depicts time frames of occurrences for claims
classified as management records, i.e., office visit 84, hospital
or emergency room visit 85, and surgery and surgical follow-up 86
and for claims records classified as ancillary records, i.e.,
laboratory tests 87, X-ray and laboratory tests 88 and x-ray 89.
Two time lines are provided. A first timeline 71 includes the
diagnosis and the time duration of the diagnosed clinical
condition. A second timeline 72 includes the claim events which
gave rise to the medical claims. Where claim events occur more than
once, an alphabetic designator is added to the reference numeral to
denote chronological order of the event. For example, the first
office visit is denoted 84a, the second office visit is denoted
84b, the third denoted 84c, etc. Vertical broken lines denote the
beginning and end of each Episode Treatment Group 90, and
facilitate correlation of the episode event, e.g., office visit,
with the resulting diagnosis, e.g., bronchitis.
[0161] A first office visit 84a resulted in a diagnosis of
bronchitis 76. Office visit 84a started an episode 90a for this
patient based upon the bronchitis diagnosis 76. A second office
visit 84b occurred concurrently with the bronchitis episode 90a,
but resulted in a diagnosis of eye infection 77. Because the eye
infection 77 is unrelated to the open bronchitis episode ETG 90a, a
new eye infection episode ETG 90b is started. An X-ray and lab test
88 was taken during the time frame of each of the bronchitis
episode 90a and the eye infection 90b. Based upon the CPT-ETG
table, discussed above, the X-ray and lab test 88 is assigned to
the eye infection episode 90b. A third office visit 84c and x-ray
89a occurred and related to the bronchitis episode 90a rather than
the eye infection episode 90b.
[0162] A fourth office visit 84d occurred and resulted in a
diagnosis of major infection 78 unrelated to the bronchitis
diagnosis 76. Because the major infection 78 is unrelated to the
bronchitis, the fourth office visit 84d opened a new ETG 90c. Two
subsequent lab tests 87a and 87b were both assigned to the only
open episode, i.e., ETG 90c.
[0163] A fifth office visit 84e resulted in a diagnosis of benign
breast neoplasm 79, which is unrelated to the major infection ETG
90c. A fifth office visit 84e opened a new ETG 90d because the
benign breast neoplasm is unrelated to either the bronchitis
episode ETG 90a, the eye infection episode ETG 90b, or the major
infection episode 90c. Sixth office visit 84f was assigned then to
the only open episode, i.e., ETG 90d. Similarly, the surgery and
follow-up records 86a and 86b related to the benign neoplasm ETG
90d and are grouped to that ETG.
[0164] Some months later, the patient has a seventh office visit
84g which resulted in a diagnosis of bronchitis 80. However,
because the time period between the prior bronchitis episode 76 and
the current bronchitis episode 80 exceeds a pre-determined period
of time in which there was an absence of treatment for bronchitis,
the bronchitis episode 90a is closed and the bronchitis episode 90e
is opened. A hospital record 85 occurs as a result of an eye trauma
and eye trauma 81 is the resulting diagnosis. Because the eye
trauma 85 is unrelated to the bronchitis 80, a new eye trauma ETG
90f is started which is open concurrently with the bronchitis ETG
90e. An eighth office visit 84h occurs during the time when both
ETG 90e and ETG 90f are open. Eighth office visit 84h is,
therefore, grouped to the ETG most relevant to the office visit
84h, i.e., ETG 90e. A subsequent x-ray record 89b occurs and is
related to the eye trauma diagnosis and is, therefore, grouped to
ETG 90f. Because and absence of treatment has occurred for the
bronchitis ETG 90e, that ETG 90e is closed.
[0165] Finally, while the eye trauma ETG 90f is open, the patient
has a routine office visit 84h which is unrelated to the open ETG
90f for the eye trauma diagnosis 91. Because it is unrelated to the
open ETG 90f, the routine office visit 84i starts and groups to a
new episode 90g which contains only one management record 84i. An
x-ray record 89c occurs after and is unrelated to the routine
office visit 84i. The only open episode is the eye trauma episode
90f and the x-ray record 89c is, therefore, grouped to the eye
trauma episode 90f. At the end of the year, all open episodes,
i.e., the eye trauma ETG 90f are closed.
[0166] It will be apparent to those skilled in the art, that the
foregoing detailed description of the preferred embodiment of the
present invention is representative of a type of health care system
within the scope and spirit of the present invention. Further,
those skilled in the art will recognize that various changes and
modifications may be made without departing from the true spirit
and scope of the present invention. Those skilled in the art will
recognize that the invention is not limited to the specifics as
shown here, but is claimed in any form or modification falling
within the scope of the appended claims. For that reason, the scope
of the present invention is set forth in the following claims.
1TABLE 1 ETG DESCRIPTION 1 AIDS with major infectious complication
2 AIDS with minor infectious complication 3 AIDS with inflammatory
complication 4 AIDS with neoplastic complication, with surgery 5
AIDS with neoplastic complication, w/o surgery 6 HIV sero-positive
without AIDS 7 Major infectious disease except HIV, with
comorbidity 8 Septicemia, w/o comorbidity 9 Major infectious
disease except HIV and septicemia, w/o comorbidity 10 Minor
infectious disease 11 Infectious disease signs & symptoms 20
Diseases of the thyroid gland, with surgery 21 Hyper-functioning
thyroid gland 22 Hypo-functioning thyroid gland 23 Non-toxic goiter
24 Malignant neoplasm of the thyroid gland 25 Benign neoplasm of
the thyroid gland 26 Other diseases of the thyroid gland 27 Insulin
dependent diabetes, with comorbidity 28 Insulin dependent diabetes,
w/o comorbidity 29 Non-insulin dependent diabetes, with comorbidity
30 Non-insulin dependent diabetes, w/o comorbidity 31 Malignant
neoplasm of the pancreatic gland 32 Benign endocrine disorders of
the pancreas 33 Malignant neoplasm of the pituitary gland 34 Benign
neoplasm of the pituitary gland 35 Hyper-functioning adrenal gland
36 Hypo-functioning adrenal gland 37 Malignant neoplasm of the
adrenal gland 38 Benign neoplasm of the adrenal gland 39
Hyper-functioning parathyroid gland 40 Hypo-functioning parathyroid
gland 41 Malignant neoplasm of the parathyroid gland 42 Benign
neoplasm of the parathyroid gland 43 Female sex gland disorders 44
Male sex gland disorders 45 Nutritional deficiency 46 Gout 47
Metabolic deficiency except gout 48 Other diseases of the endocrine
glands or metabolic disorders, with surgery 49 Other diseases of
the endocrine glands or metabolic disorders, w/o surgery 50
Endocrine disease signs & symptoms 70 Leukemia with bone marrow
transplant 71 Leukemia with splenectomy 72 Leukemia w/o splenectomy
73 Neoplastic disease of blood and lymphatic system except leukemia
74 Non-neoplastic blood disease with splenectomy 75 Non-neoplastic
blood disease, major 76 Non-neoplastic blood disease, minor 77
Hematology signs & symptoms 90 Senile or pre-senile mental
condition 91 Organic drug or metabolic disorders 92 Autism and
childhood psychosis 93 Inorganic psychoses except infantile autism
94 Neuropsychological & behavioral disorders 95 Personality
disorder 96 Mental disease signs & symptoms 110 Cocaine or
amphetamine dependence with complications age less than 16 111
Cocaine or amphetamine dependence with complications age 16+ 112
Cocaine or amphetamine dependence w/o complications age less than
16 113 Cocaine or amphetamine dependence w/o complications age 16+
114 Alcohol dependence with complications, age less than 16 115
Alcohol dependence with complications, age 16+ 116 Alcohol
dependence w/o complications, age less than 16 117 Alcohol
dependence w/o complications, age 16+ 118 Opioid and/or barbiturate
dependence, age less than 16 119 Opioid and/or barbiturate
dependence, age 16+ 120 Other drug dependence, age less than 16 121
Other drug dependence, age 16+ 140 Viral meningitis 141 Bacterial
and fungal meningitis 142 Viral encephalitis 143 Non-viral
encephalitis 144 Parasitic encephalitis 145 Toxic encephalitis 146
Brain abscess, with surgery 147 Brain abscess, w/o surgery 148
Spinal abscess 149 Inflammation of the central nervous system, with
surgery 150 Inflammation of the central nervous system, w/o surgery
151 Epilepsy, with surgery 152 Epilepsy, w/o surgery 153 Malignant
neoplasm of the central nervous system, with surgery 154 Malignant
neoplasm of the central nervous system, w/o surgery 155 Benign
neoplasm of the central nervous system, with surgery 156 Benign
neoplasm of the central nervous system, w/o surgery 157 Cerebral
vascular accident, hemorrhagic, with surgery 158 Cerebral vascular
accident, hemorrhagic, w/o surgery 159 Cerebral vascular accident,
non-hemorrhagic, with surgery 160 Cerebral vascular accident,
non-hemorrhagic, w/o surgery 161 Major brain trauma, with surgery
162 Major brain trauma, w/o surgery 163 Minor brain trauma 164
Spinal trauma, with surgery 165 Spinal trauma, w/o surgery 166
Hereditary and degenerative diseases of the central nervous system,
with surgery 167 Hereditary and degenerative diseases of the
central nervous system, w/o surgery 168 Migraine headache,
non-intractable 169 Migraine headache, intractable 170 Congenial
and other disorders of the central nervous system, with surgery 171
Congenital and other disorders of the central nervous system, w/o
surgery 172 Inflammation of the cranial nerves, with surgery 173
Inflammation of the cranial nerves, w/o surgery 174 Carpal tunnel
syndrome, with surgery 175 Carpal tunnel syndrome, w/o surgery 176
Inflammation of the non-cranial nerves, except carpal tunnel, with
surgery 177 Inflammation of the non-cranial nerves, except carpal
tunnel, w/o surgery 178 Peripheral nerve neoplasm, with surgery 179
Peripheral nerve neoplasm, w/o surgery 180 Traumatic disorder of
the cranial nerves, with surgery 181 Traumatic disorder of the
cranial nerves, w/o surgery 182 Traumatic disorder of the
non-cranial nerves, with surgery 183 Traumatic disorder of the
non-cranial nerves, w/o surgery 184 Congenital disorders of the
peripheral nerves 185 Neurological disease signs & symptoms 200
Internal eye infection with surgery 201 Internal eye infection w/o
surgery 202 External eye infection, with surgery 203 External eye
infection, except conjunctivitis, w/o surgery 204 Conjunctivitis
205 Inflammatory eye disease, with surgery 206 Inflammatory eye
disease, w/o surgery 207 Malignant neoplasm of the eye, internal,
with surgery 208 Malignant neoplasm of the eye, internal, w/o
surgery 209 Malignant neoplasm of the eye, external 210 Benign
neoplasm of the eye, internal 211 Benign neoplasm of the eye,
external 212 Glaucoma, closed angle with surgery 213 Glaucoma,
closed angle w/o surgery 214 Glaucoma, open angle, with surgery 215
Glaucoma, open angle, w/o surgery 216 Cataract, with surgery 217
Cataract, w/o surgery 218 Trauma of the eye, with surgery 219
Trauma of the eye, w/o surgery 220 Congenital anomaly of the eye,
with surgery 221 Congenital anomaly of the eye, w/o surgery 222
Diabetic retinopathy, with surgery 223 Diabetic retinopathy, w/o
surgery with comorbidity 224 Diabetic retinopathy, w/o surgery w/o
comorbidity 225 Non-diabetic vascular retinopathy, with surgery 226
Non-diabetic vascular retinopathy, w/o surgery 227 Other vascular
disorders of the eye except retinopathies, with surgery 228 Other
vascular disorders of the eye except retinopathies, w/o surgery 229
Macular degeneration, with surgery 230 Macular degeneration, w/o
surgery 231 Non-macular degeneration, with surgery 232 Non-macular
degeneration, w/o surgery 233 Major visual disturbances, with
surgery 234 Major visual disturbances, w/o surgery 235 Minor visual
disturbances, with surgery 236 Minor visual disturbances, w/o
surgery 237 Other diseases and disorders of the eye and adnexa 250
Heart transplant 251 AMI, with coronary artery bypass graft 252 AMI
or acquired defect, with valvular procedure 253 AMI, with
angioplasty 254 AMI with arrhythmia, with pacemaker implant 255
AMI, with cardiac catheterization 256 AMI, anterior wall with
complication 257 AMI, anterior wall w/o complication 258 AMI,
inferior wall with complication 259 AMI, inferior wall w/o
complication 260 Ischemic heart disease, w/o AMI, with coronary
artery bypass graft 261 Ischemic heart disease, w/o AMI, with
valvular procedure 262 Ischemic heart disease, w/o AMI, with
angioplasty 263 Ischemic heart disease, w/o AMI, with arrhythmia,
with pacemaker implant 264 Ischemic heart disease, w/o AMI, with
cardiac catheterization 265 Ischemic heart disease, w/o AMI 266
Pulmonary heart disease, w/o AMI 267 Aortic aneurysm, with surgery
268 Aortic aneurysm, w/o surgery 269 Cardiac infection, with
surgery 270 Cardiac infection, w/o surgery 271 Valvular disorder,
with complication 272 Valvular disorder, w/o complication 273 Major
conduction disorder, with pacemaker/defibrillator implant 274 Major
conduction disorder, w/o pacemaker/defibrillator implant 275 Minor
conduction disorder 276 Malignant hypertension with comorbidity 277
Malignant hypertension w/o comorbidity 278 Benign hypertension with
comorbidity 279 Benign hypertension w/o comorbidity 280 Cardiac
congenital disorder, with surgery 281 Cardiac congenital disorder,
w/o surgery 282 Major cardiac trauma, with surgery 283 Major
cardiac trauma, w/o surgery 284 Minor cardiac trauma 285 Other
cardiac diseases 286 Arterial inflammation, with surgery 287 Major
arterial inflammation, w/o surgery 288 Minor arterial inflammation,
w/o surgery 289 Major non-inflammatory arterial disease with
surgery 290 Arterial embolism/thrombosis, w/o surgery 291 Major
non-inflammatory arterial disease, except embolism/ thrombosis, w/o
surgery 292 Atherosclerosis, with surgery 293 Atherosclerosis, w/o
surgery 294 Arterial aneurysm, except aorta, with surgery 295
Arterial aneurysm, except aorta, w/o surgery 296 Other minor
non-inflammatory arterial disease, with surgery 297 Other minor
non-inflammatory arterial disease, w/o surgery 298 Arterial trauma,
with surgery 299 Arterial trauma, w/o surgery 300 Vein
inflammation, with surgery 301 Embolism and thrombosis of the veins
302 Disorder of the lymphatic channels 303 Phlebitis and
thrombophlebitis of the veins 304 Varicose veins of the lower
extremity 305 Other minor inflammatory disease of the veins 306
Venous trauma, with surgery 307 Venous trauma, w/o surgery 308
Other diseases of the veins 309 Cardiovascular disease signs &
symptoms 320 Infection of the oral cavity 321 Inflammation of the
oral cavity, with surgery 322 Inflammation of the oral cavity, w/o
surgery 323 Trauma of the oral cavity, with surgery 324 Trauma of
the oral cavity, w/o surgery 325 Other diseases of the oral cavity,
with surgery 326 Other diseases of the oral cavity, w/o surgery 327
Otitis media, with major surgery 328 Otitis media, with minor
surgery 329 Otitis media, w/o surgery 330 Tonsillitis, adenoiditis
or pharyngitis, with surgery 331 Tonsillitis, adenoiditis or
pharyngitis, w/o surgery 332 Sinusitis and Rhinitis, with surgery
333 Sinusitis and Rhinitis, w/o surgery 334 Other ENT infection,
with surgery 335 Other ENT infection, w/o surgery 336 Major ENT
inflammatory conditions with surgery 337 Major ENT inflammatory
conditions w/o surgery 338 Minor ENT inflammatory conditions with
surgery 339 Minor ENT inflammatory conditions w/o surgery 340 ENT
malignant neoplasm, with surgery 341 ENT malignant neoplasm, w/o
surgery 342 ENT benign neoplasm, with surgery 343 ENT benign
neoplasm, w/o surgery 344 ENT congenital anomalies, with surgery
345 ENT congenital anomalies, w/o surgery 346 Hearing disorders,
with surgery 347 Hearing disorders, w/o surgery 348 ENT trauma,
with surgery 349 ENT trauma, w/o surgery 350 Other ENT disorders,
with surgery 351 Other ENT disorders, w/o surgery 352
Otolaryngology disease signs & symptoms 371 Viral pneumonia,
with comorbidity 372 Viral pneumonia, w/o comorbidity 373 Bacterial
lung infections, with comorbidity 374 Bacterial lung infections,
w/o comorbidity 375 Fungal and other pneumonia, with comorbidity
376 Fungal and other pneumonia, w/o comorbidity 377 Pulmonary TB
with comorbidity 378 Pulmonary TB w/o comorbidity 379 Disseminated
TB with comorbidity 380 Disseminated TB w/o comorbidity 381 Acute
bronchitis, with comorbidity, age less than 5 382 Acute bronchitis,
with comorbidity, age 5+ 383 Acute bronchitis, w/o comorbidity, age
less than 5 384 Acute bronchitis, w/o comorbidity, age 5+ 385 Minor
infectious pulmonary disease other than acute bronchitis 386 Asthma
with comorbidity, age less than 18 387 Asthma with comorbidity, age
18+ 388 Asthma w/o comorbidity, age less than 18 389 Asthma w/o
comorbidity, age 18+ 390 Chronic bronchitis, with complication with
comorbidity 391 Chronic bronchitis with complication w/o
comorbidity 392 Chronic bronchitis, w/o complication with
comorbidity 393 Chronic bronchitis w/o complication w/o comorbidity
394 Emphysema, with comorbidity 395 Emphysema w/o comorbidity 396
Occupational and environmental pulmonary diseases, with comorbidity
397 Occupational and environmental pulmonary diseases, w/o
comorbidity 398 Other inflammatory lung disease, with surgery 399
Other inflammatory lung disease, w/o surgery 400 Malignant
pulmonary neoplasm, with surgery 401 Malignant pulmonary neoplasm,
w/o surgery 402 Benign pulmonary neoplasm, with surgery 403 Benign
pulmonary neoplasm, w/o surgery 404 Chest trauma, with surgery 405
Chest trauma, open, w/o surgery 406 Chest trauma, closed, w/o
surgery 407 Pulmonary congenital anomalies, with surgery 408
Pulmonary congenital anomalies, w/o surgery 409 Other pulmonary
disorders 410 Pulmonology disease signs & symptoms 430
Infection of the stomach and esophagus with comorbidity 431
Infection of the stomach and esophagus w/o comorbidity 432
Inflammation of the esophagus, with surgery 433 Inflammation of the
esophagus, w/o surgery 434 Gastritis and/or duodenitis, complicated
435 Gastritis and/or duodenitis, simple 436 Ulcer, complicated with
surgery 437 Ulcer, complicated w/o surgery 438 Ulcer, simple 439
Malignant neoplasm of the stomach and esophagus, with surgery 440
Malignant neoplasm of the stomach and esophagus, w/o surgery 441
Benign neoplasm of the stomach and esophagus, with surgery 442
Benign neoplasm of the stomach and esophagus, w/o surgery 443
Trauma or anomaly of the stomach or esophagus, with surgery 444
Trauma of the stomach or esophagus, w/o surgery 445 Anomaly of the
stomach or esophagus, w/o surgery 446 Appendicitis, with rupture
447 Appendicitis, w/o rupture 448 Diverticulitis, with surgery 449
Diverticulitis, w/o surgery 450 Other infectious diseases of the
intestines and abdomen 451 Inflammation of the intestines and
abdomen with surgery 452 Inflammation of the intestines and
abdomen, w/o surgery 453 Malignant neoplasm of the intestines and
abdomen, with surgery 454 Malignant neoplasm of the intestines and
abdomen, w/o surgery 455 Benign neoplasm of the intestines and
abdomen, with surgery 456 Benign neoplasm of the intestines and
abdomen, w/o surgery 457 Trauma of the intestines and abdomen, with
surgery 458 Trauma of the intestines and abdomen, w/o surgery 459
Congenital anomalies of the intestines and abdomen, with surgery
460 Congenital anomalies of the intestines and abdomen, w/o surgery
461 Vascular disease of the intestines and abdomen 462 Bowel
obstruction with surgery 463 Bowel obstruction w/o surgery 464
Irritable bowel syndrome 465 Hernias, except hiatal, with surgery
466 Hernias, except hiatal, w/o surgery 467 Hiatal hernia, with
surgery 468 Hiatal hernia, w/o surgery 469 Other diseases of the
intestines and abdomen 470 Infection of the rectum or anus, with
surgery 471 Infection of the rectum or anus, w/o surgery 472
Hemorrhoids, complicated, with surgery 473 Hemorrhoids,
complicated, w/o surgery 474 Hemorrhoids, simple 475 Inflammation
of the rectum or anus, with surgery 476 Inflammation of the rectum
or anus, w/o surgery 477 Malignant neoplasm of the rectum or anus,
with surgery 478 Malignant neoplasm of the rectum or anus, w/o
surgery 479 Benign neoplasm of the rectum or anus, with surgery 480
Benign neoplasm of the rectum
or anus. w/o surgery 481 Trauma of the rectum or anus, open, with
surgery 482 Trauma of the rectum or anus, open, w/o surgery 483
Trauma of the rectum or anus, closed 484 Other diseases and
disorders of the rectum and anus, with surgery 485 Other diseases
and disorders of the rectum and anus, w/o surgery 486
Gastroenterology disease signs & symptoms 510 Liver Transplant
511 Infectious hepatitis, high severity with comorbidity 512
Infectious hepatitis, high severity w/o comorbidity 513 Infectious
hepatitis, low severity with comorbidity 514 Infectious hepatitis,
low severity w/o comorbidity 515 Non-infectious hepatitis, with
complications 516 Non-infectious hepatitis, w/o complications 517
Cirrhosis, with surgery 518 Cirrhosis, w/o surgery 519 Acute
pancreatitis 520 Chronic pancreatitis 521 Cholelithiasis,
complicated 522 Cholelithiasis, simple, with surgery 523
Cholelithiasis, simple, w/o surgery 524 Malignant neoplasm of the
hepato-biliary system, with surgery 525 Malignant neoplasm of the
hepato-biliary system, w/o surgery 526 Benign neoplasm of the
hepato-biliary system, with surgery 527 Benign neoplasm of the
hepato-biliary system, w/o surgery 528 Trauma of the hepato-biliary
system, complicated, with surgery 529 Trauma of the hepato-biliary
system, complicated, w/o surgery 530 Trauma of the hepato-biliary
system, simple 531 Other diseases of the hepato-biliary system,
with surgery 532 Other diseases of the hepato-biliary system, w/o
surgery 533 Hepatology disease signs & symptoms 550 Kidney
Transplant 551 Acute renal failure, with comorbidity 552 Acute
renal failure, w/o comorbidity 553 Chronic renal failure, with ESRD
554 Chronic renal failure, w/o ESRD 555 Acute renal inflammation,
with comorbidity 556 Acute renal inflammation, w/o comorbidity 557
Chronic renal inflammation, with surgery 558 Chronic renal
inflammation, w/o surgery 559 Nephrotic syndrome, minimal change
560 Nephrotic syndrome 561 Other renal conditions 562 Nephrology
disease signs & symptoms 570 Infection of the genitourinary
system with surgery 571 Infection of the genitourinary system w/o
surgery 572 Sexually transmitted infection of the lower
genitourinary system 573 Infection of the lower genitourinary
system, not sexually transmitted 574 Kidney stones, with surgery
with comorbidity 575 Kidney stones, with surgery w/o comorbidity
576 Kidney stones, w/o surgery with comorbidity 577 Kidney stones,
w/o surgery w/o comorbidity 578 Inflammation of the genitourinary
tract except kidney stones, with surgery 579 Inflammation of the
genitourinary tract except kidney stones, w/o surgery 580 Malignant
neoplasm of the prostate, with surgery 581 Malignant neoplasm of
the prostate, w/o surgery 582 Benign neoplasm of the prostate, with
surgery 583 Benign neoplasm of the prostate, w/o surgery 584
Malignant neoplasm of the genitourinary tract, except prostate,
with surgery 585 Malignant neoplasm of the genitourinary tract,
except prostate, w/o surgery 586 Benign neoplasm of the
genitourinary tract, except prostate with surgery 587 Benign
neoplasm of the genitourinary tract, except prostate, w/o surgery
588 Trauma to the genitourinary tract, with surgery 589 Trauma to
the genitourinary tract, w/o surgery 590 Urinary incontinence, with
surgery 591 Urinary incontinence, w/o surgery 592 Other diseases of
the genitourinary tract, with surgery 593 Other diseases of the
genitourinary tract, w/o surgery 594 Urological disease signs &
symptoms 610 Normal pregnancy, normal labor & delivery, with
cesarean section 611 Normal pregnancy, normal labor & delivery,
w/o cesarean section 612 Complicated pregnancy, with cesarean
section 613 Complicated pregnancy, w/o cesarean section 614
Hemorrhage during pregnancy, with cesarean section 615 Hemorrhage
during pregnancy, w/o cesarean section 616 Other condition during
pregnancy, with cesarean section 617 Other condition during
pregnancy, w/o cesarean section 618 Fetal problems during
pregnancy, with cesarean section 619 Fetal problems during
pregnancy, w/o cesarean section 620 Ectopic pregnancy, with surgery
621 Ectopic pregnancy, w/o surgery 622 Spontaneous abortion 623
Non-spontaneous abortion 624 Obstetric signs & symptoms 630
Infection of the ovary and/or fallopian tube, with surgery 631
Infection of the ovary and/or fallopian tube, w/o surgery, with
comorbidity 632 Infection of the ovary and/or fallopian tube, w/o
surgery, w/o comorbidity 633 Infection of the uterus, with surgery
634 Infection of the uterus, w/o surgery, with comorbidity 635
Infection of the uterus, w/o surgery, w/o comorbidity 636 Infection
of the cervix, with surgery 637 Infection of the cervix, w/o
surgery 638 Vaginal infection, with surgery 639 Monilial infection
of the vagina (yeast) 640 Infection of the vagina except monilial
641 Inflammation of the female genital system, with surgery 642
Endometriosis, w/o surgery 643 Inflammatory condition of the female
genital tract except endometriosis, w/o surgery 644 Malignant
neoplasm of the female genital tract, with surgery 645 Malignant
neoplasm of the female genital tract, w/o surgery 646 Benign
neoplasm of the female genital tract, with surgery 647 Benign
neoplasm of the female genital tract, w/o surgery 648 Conditions
associated with menstruation, with surgery 649 Conditions
associated with menstruation, w/o surgery 650 Conditions associated
with female infertility, with surgery 651 Conditions associated
with female infertility, w/o surgery 652 Other diseases of the
female genital tract, with surgery 653 Other diseases of the female
genital tract, w/o surgery 654 Malignant neoplasm of the breast,
with surgery 655 Malignant neoplasm of the breast, w/o surgery 656
Benign neoplasm of the breast, with surgery 657 Benign neoplasm of
the breast, w/o surgery 658 Other disorders of the breast, with
surgery 659 Other disorders of the breast, w/o surgery 660
Gynecological signs & symptoms 670 Major bacterial infection of
the skin, with surgery 671 Major bacterial infection of the skin,
w/o surgery 672 Minor bacterial infection of the skin 673 Viral
skin infection 674 Fungal skin infection, with surgery 675 Fungal
skin infection, w/o surgery 676 Parasitic skin infection 677 Major
inflammation of skin & subcutaneous tissue 678 Minor
inflammation of skin & subcutaneous tissue 679 Malignant
neoplasm of the skin, major, with surgery 680 Malignant neoplasm of
the skin, major, w/o surgery 681 Malignant neoplasm of the skin,
minor 682 Benign neoplasm of the skin 683 Major burns, with surgery
684 Major burns, w/o surgery 685 Major skin trauma, except burns,
with surgery 686 Major skin trauma, except burns, w/o surgery 687
Minor burn 688 Minor trauma of the skin except burn, with surgery
689 Open wound of the skin, w/o surgery 690 Minor trauma of the
skin except burn and open wound, w/o surgery 691 Other skin
disorders 692 Dermatological signs & symptoms 710 Infection of
the large joints with comorbidity 711 Infection of the large joints
w/o comorbidity 712 Infection of the small joints with comorbidity
713 Infection of the small joints w/o comorbidity 714 Degenerative
orthopedic diseases with hip or spine surgery 715 Degenerative
orthopedic diseases with large joint surgery 716 Degenerative
orthopedic diseases with hand or foot surgery 717 Juvenile
rheumatoid arthritis with complication with comorbidity 718
Juvenile rheumatoid arthritis with complication w/o comorbidity 719
Juvenile rheumatoid arthritis w/o complication with comorbidity 720
Juvenile rheumatoid arthritis w/o complication w/o comorbidity 721
Adult rheumatoid arthritis with complication with comorbidity 722
Adult rheumatoid arthritis with complication w/o comorbidity 723
Adult rheumatoid arthritis w/o complication with comorbidity 724
Adult rheumatoid arthritis w/o complication w/o comorbidity 725
Lupus, with complication 726 Lupus, w/o complication 727 Autoimmune
rheumatologic disease except lupus 728 Inflammation of the joints
other than rheumatoid arthritis, with comorbidity 729 Inflammation
of the joints other than rheumatoid arthritis, w/o comorbidity 730
Degenerative joint disease, generalized 731 Degenerative joint
disease, localized with comorbidity 732 Degenerative joint disease,
localized w/o comorbidity 733 Infections of bone, with surgery 734
Infections of bone, w/o surgery 735 Maxillofacial fracture or
dislocation, with surgery 736 Maxillofacial fracture or
dislocation, w/o surgery 737 Pelvis fracture or dislocation, with
surgery 738 Pelvis fracture or dislocation, w/o surgery 739 Hip
and/or femur fracture or dislocation, with surgery 740 Hip and/or
femur fracture or dislocation, open, w/o surgery 741 Hip and/or
femur fracture or dislocation, closed, w/o surgery 742 Upper
extremity fracture or dislocation, with surgery 743 Upper extremity
fracture or dislocation, open, w/o surgery 744 Upper extremity
fracture or dislocation, closed, w/o surgery 745 Lower extremity
fracture or dislocation, with surgery 746 Lower extremity fracture
or dislocation, open, w/o surgery 747 Lower extremity fracture or
dislocation, closed, w/o surgery 748 Trunk fracture or dislocation,
with surgery 749 Trunk fracture or dislocation, open, w/o surgery
750 Trunk fracture or dislocation, closed, w/o surgery 751
Malignant neoplasm of the bone and connective tissue, head and neck
752 Malignant neoplasm of the bone and connective tissue other than
head and neck 753 Benign neoplasm of the bone and connective
tissue, head and neck 754 Benign neoplasm of the bone and
connective tissue other than head and neck 755 Internal derangement
of joints, with surgery 756 Internal derangement of joints, w/o
surgery 757 Major orthopedic trauma other than fracture or
dislocation, with surgery 758 Major orthopedic trauma other than
fracture or dislocation, w/o surgery 759 Major neck and back
disorders, with surgery 760 Major neck and back disorders, w/o
surgery 761 Bursitis and tendinitis, with surgery 762 Bursitis and
tendinitis, w/o surgery 763 Minor orthopedic disorder except
bursitis and tendinitis, with surgery 764 Minor neck and back
disorder, except bursitis and tendinitis, w/o surgery 765 Minor
orthopedic disorder other than neck and back, except bursitis and
tendinitis, w/o surgery 766 Orthopedic congenital and acquired
deformities, with surgery 767 Orthopedic congenital and acquired
deformities, w/o surgery 768 Orthopedic and rheumatological signs
& symptoms 780 Uncomplicated neonatal management 781
Chromosomal anomalies 782 Metabolic related disorders originating
the antenatal period 783 Chemical dependency related disorders
originating in the antenatal period 784 Mechanical related
disorders originating in the antenatal period 785 Other disorders
originating in the antenatal period 786 Other major neonatal
disorders, perinatal origin 787 Other minor neonatal disorders,
perinatal origin 788 Neonatal signs & symptoms 790 Exposure to
infectious diseases 791 Routine inoculation 792 Non-routine
inoculation 793 Prophylactic procedures other than inoculation and
exposure to infectious disease 794 Routine exam 795 Contraceptive
management, with surgery 796 Contraceptive management, w/o surgery
797 Conditional exam 798 Major specific procedures not classified
elsewhere 799 Minor specific procedures not classified elsewhere
800 Administrative services 801 Other preventative and
administrative services 810 Late effects and late complications 811
Environmental trauma 812 Poisonings and toxic effects of drugs 900
Isolated signs, symptoms and non-specific diagnoses or conditions
990 Drug record, no drug module 991 Orphan drug record 992 Non-Rx
NDC code 993 Invalid NDC code 994 Invalid provider type, e.g.,
dentist 995 Record outside date range 996 Invalid CPT-4 code 997
Invalid Dx code 998 Inappropriate Dx-CPT-4 matched record 999
Orphan record
* * * * *