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Have you ever heard of Triple Aim in healthcare? The slide briefly introduces how to turn millions of healthcare data into useful insights and predictions for Triple Aim. What aspects do we usually use data for analysis? Reports for enrollment and ED visits demonstrate the aspects you can dig into. What is the structure for claims? How to use quality measures? It also has emergency department (ED) visits as the example to show how to use the codes in claims to dig out ED visits. Lastly, it explains common diagnosis and procedure coding in healthcare, including ICD, CPT, and HCPCS.
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INTRO OF DATA ANALYSIS
IN HEALTHCARE
Yaxing Liu, PhD
Analysis, Reporting, Action with Triple Aim
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Todd Park, CTO, Department of Health and Human Services
Source: http://www.forbes.com/sites/nicoleperlroth/2011/11/02/tim‐oreilly‐the‐worlds‐7‐most‐powerful‐data‐scientists/
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Triple Aim
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Better Care
Lower Cost
Better Population Health
In 2011, current estimates by World Health Organization put U.S. health care spending at approximately 17.9% of GDP.
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Healthcare Ecosystem
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Source: http://www.infosys.com/industries/healthcare/industry‐offerings/Pages/interface‐factory‐CoE.aspx
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Data Warehouse Modeling
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From the book: Healthcare Risk Adjustment and Predictive Modeling
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Programs
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ACO: Accountable Care Organizations.
HIE: Health Information Exchanges.
Patient‐center care.
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Chronic Condition
Development
Enrollment
TrendCosts
Chronic care reporting Utilization Quality measures Enrollments/trends Costs: PMPM HEDIS measures
Reporting
Priority Score ED Visits ReadmissionHospital
Admissions
Prediction
Care AlertsChronic Care Management
Identifyhigh‐risk/high‐opportunitypatients
Automated Tracking
Medication scheduling and reminder
Screening/Assessment/Care Plan
Transitional Support
Actions?
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Medicaid Enrollment
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Source: https://www.ccwdata.org/cs/groups/public/documents/digitalmedia/a2_race_2009_image.jpg
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Medicaid Enrollment
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Source: https://www.ccwdata.org/cs/groups/public/documents/digitalmedia/a2_age_2000_2009_image.jpg
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Track Enrollment Trends
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Enrollment Analysis
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PMPM Cost
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Source: http://www.objectivehealth.com/our‐offerings/strategy‐solution/value‐based‐care
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Cost and Savings
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State Fiscal Year
Per‐Member,Per‐Month
Total Annual Savings
2007 $8.73 103,000,000
2008 $15.69 204,000,000
2009 $20.89 295,000,000
2010 $25.40 $382,000,000
$984,000,000
Source: https://www.communitycarenc.org/our-results/ccnc-saves-money/
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When
• Admit date
• Discharge date
Who
• Member
• Provider
Why
• PRIMARY_DIAGNOSIS
• SECONDARY_DIAGNOSIS
• DISCHARGE_STATUS_CODE_DESC
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PROCEDURE_CODE
• Hospital outpatient and Acute Inpatient ED claims are identified by revenue center codes equal to ‘0450’,’0451’,’0452’,’0456’, ‘0459’
• PROCEDURE_CODE = '450'
Revenue center code: 0981.
• Revenue_Codex in (450, 451, 452, 456, 459)
Place of Service
• [PLACE_OF_SERVICE] like '%emerg%'
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ED Visits Reports Number of visits: 129.8 million
Number of injury‐related visits: 37.9 million
Number of visits per 100 persons: 42.8
Percent of visits with patient seen in fewer than 15 minutes: 25.1%
Percent of visits resulting in hospital admission: 13.3%
Percent of visits resulting in transfer to a different (psychiatric or other) hospital: 2.1%
• Source: National Hospital Ambulatory Medical Care Survey: 2010 Emergency Department Summary Tables, tables 1, 4, 14, 24
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Claim Header + Claim Line
• Claim Num
• Claim Type
• Claim Status: Paid, adjusted, denied, rejected
• Dates
• Amount
Data Dictionary
• Medicare:
• https://www.ccwdata.org/web/guest/data‐dictionaries
Form
• UB‐04
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Inpatient
Outpatient
SNF/swing bed
Hospice
Physician encounter
DME
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Patient
• Age
• Race
• Gender
Provider
• NPI / name / address
Diagnosis/procedure
• CPT
• HCPCS
• ICD9‐CM Diagnosis, ICD9‐CM Procedure, ICD10
• LOINC
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Origin
• The International Classification of Diseases (ICD) is updated and maintained by the World Health Organization (WHO)
• ICD‐9‐CM developed in 1970s
• WHO’s 9th revision of ICD (ICD‐9) had attained wide international recognition by 1970s
Modifiction
• The U.S. National Center for Health Statistics, part of Centers for Disease Control, modified ICD‐9 with clinical information
• Result was the International Classification of Diseases, 9th Revision, Clinical Modification (ICD‐9‐CM), commonly referred to as ICD‐9, which precisely delineates the clinical picture of each patient, providing exact information beyond that needed for statistical groupings and analysis of healthcare trends
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Professional (CMS‐1500)
• diagnosis codes
• V‐codes (V01‐V91)
• E‐codes (E000‐E999)
Institutional (UB‐04)
• diagnosis codes
• V‐codes
• E‐codes
• procedure codes
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Definition
•3 digits followed by a decimal, then followed by no, 1, or 2 digits,3‐5 characters in length
•First digit may be alpha (E or V) or numeric; digits 2‐5 are numeric
•All claims, whether CMS‐1500 or UB‐04, must have at least one ICD‐9 diagnosis code
•On UB‐04, the first diagnosis code must describe the principal reason for the care provided.
Guideline
•Providers should code only the current condition that prompted the patient’s visit
•When the diagnostic statement identifies an acute condition, providers should use the code that specifies “acute” whenever it is available
•Providers should be as specific as possible in specifying diagnosis
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Include:
• ICD‐10‐CM – diagnosis codes
• ICD‐10‐PCS (Procedure Coding System) –procedure codes, only for UB‐04 (primarily hospitals)
Definition
• 3‐7 characters in length
• First digit is alpha; digits 2 and 3 are numeric; digits 4‐7 are alpha or numeric
• specific
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Definition
• 2 digits followed by a decimal, then no, 1, or 2 digits
• Used to document procedures performed during the encounter
• Ranked in priority of significance
• Used only on UB‐04 claims
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CMS ICD‐9 coding guidelines Identify each service, procedure, or supply with an ICD‐9 diagnosis
code to describe the diagnosis, symptom, complaint, condition, or problem
Identify services or visits for circumstances other than disease or injury, such as follow‐up care after chemotherapy, with V codes provided for this purpose
Code the principal diagnosis first, followed by the secondary, tertiary, and so on.
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CPT: Current Procedural Terminology
• Developed and maintained by the American Medical As sociation (AMA) in 1966
• Five‐digit codes with descriptions
• CPT and HCPCS codes also used to reimburse most non
• ‐physician
• health professionals
Six major sections
• Evaluation and management (E&M) (99201‐99499)
• Anesthesiology (00100‐01999)
• Surgery (10040‐69990)
• Radiology (70010‐79999)
• Pathology and laboratory (80048‐89399)
• Medicine (90281‐99199 and 99500‐99999)
Subsections
• Procedures are divided into subsections according to body part, service, or diagnosis
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Definition
• HCPCS means HCFA Common Procedure Coding System
• Allows providers and medical suppliers to report professional services, procedures and supplies
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CMS NDC 5‐4‐2 Segmentation
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The first segment: the labeler code assigned by FDA. A labeler is any firm that manufactures, repacks, or distributes a drug product.
The second segment: the product code, identifies a specific drug, strength, and dosage form of that drug.
The third segment, known as the package code, identifies the package size.
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NDC Examples
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NDC Codes NDC Descriptions
99073070827 FreeStyle Lite Test Strips‐ 100 ct
99073070822 FreeStyle Lite Test Strips‐ 50 ct
99073070819 NFRS FreeStyle Lite Test Strips 50 ct
99073071230 NFRS FreeStyle Insulinx Test Strips 50 ct
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HEDIS measures
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