US20080059231A1 - Cluster of correlated medical claims in an episode treatment group - Google Patents

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.

Description

REFERENCE TO RELATED APPLICATIONS
• 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
• 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
• 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.
• 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.
• 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.
• 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.
• The Mohlenbrock, et al., 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.
• The Mohlenbrock, et al., 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.
• The Schneiderman 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.
• The Tawil 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.
• The Ertel 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.
• The Holloway, et al., 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.
• The Cummings, 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.
• The Dorne, 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.
• The Kessler, et al., 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.
• The Torma, et al., 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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
• Accordingly, it is a broad aspect of the present invention to provide a computer-implemented medical claims profiling system.
• 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.
• 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.
• 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.
• 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.
• It is a further object of the present invention to provide a medical claims profiling system that assigns each claim to an appropriate episode.
• It is a further object of the present invention to provide a medical claims profiling system that identifies concurrent and recurrent episodes.
• It is a further object of the present invention to provide a medical claims profiling system that shifts groupings for changed clinical conditions.
• 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.
• 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.
• 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.
• It is a further object of the present invention to provide a health care system that creates orphan records.
• It is a further object of the present invention to provide a health care system that creates phantom records.
• 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.
• 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.
• ETGs can identify a change in the patient's condition and shift the patient's 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.
• 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).
• 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.
• 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.
• “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.
• “Surgery records” are specific surgical claims. Surgery records also serve as anchor records.
• “Facility records” are claims for medical care facility usage. Examples of facility records include hospital room charges or outpatient surgical room charges.
• “Drug records” are specific for pharmaceutical prescription claims.
• “Other records” are those medical claim records which are not management, surgery, ancillary, facility or drug records.
• 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.
• 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.
• 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.
• 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.
• 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
• Briefly summarized, a preferred embodiment of the invention is described in conjunction with the illustrative disclosure thereof in the accompanying drawings, in which:
• 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.
• 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.
• FIG. 3 is a flow diagram illustrating an Eligible Record Check routine which validates and sorts patient claim data records.
• FIGS. 4A to4F 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.
• 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.
• 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.
• 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.
• 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.
• FIG. 9 is a flow diagram illustrating the Episode Definer Routine in accordance with the computer-implemented method of the present invention.
• 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.
• FIG. 11 is a diagrammatic representation of a I-9 Diagnosis Code (dx) X ETG table illustrating predetermined table values called by the Episode Definer Routine of the present invention.
• FIG. 12 is a diagrammatic representation of an I-9 Diagnosis Code 9 (dx) X CPT Code table illustrating predetermined table values called by the Episode Definer Routine of the present invention.
• 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.
• 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
• 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 acomputer system10.Computer system10 is capable of running acomputer program12 that incorporates the inventive method is shown inFIG. 1. Thecomputer system10 includes a central processing unit (CPU)14 connected to akeyboard16 which allows the user to input commands and data into theCPU14. It will be understood by those skilled in the art thatCPU14 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. Thecomputer system10 also contains avideo display18 which displays video images to a person using thecomputer system10. Thevideo display screen18 is capable of displaying video output in the form of text or other video images.
• 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.
• 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.
• 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, Opthalmology, 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.
• 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.
• 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 toETG 997, an invalid CPT-4 code is assigned toETG 996 and an invalid provider type is assigned toETG 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.
• 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.
• 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.
• If the claim is an ancillary record and it does not match an active ETG it is designated an “orphan” ancillary record.
• Termination of an episode is detected by an absence of treatment for a period of time commensurate with the episode.
• 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.
• 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 (PCP), 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.
• Turning now toFIG. 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 theCPU14. Upon a user's entry of appropriate initialization commands entered via thekeyboard16, 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 theCPU14 and the computer-implemented method is initiated. The computer-implemented method prompts the user by displaying appropriate prompts ondisplay18, for data input by the user.
• 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 theCPU14 through thekeyboard16 or other input device.
• Prior to being submitted to the grouping algorithm, records must be sorted by patient by chronological date of service. An Eligible Record Check routine48 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 atstep50. Next the record is identified as either amanagement52,surgery54,facility56, ancillary58 ordrug60 record. These types of records are categorized as follows:
• “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.
• “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.
• “Surgery records” represent surgical procedures performed by physicians and other like medical allied personnel. Like management records, surgery records also serve as anchor records.
• “Facility records” are claims for medical care facility usage. Examples of facility records include hospital room charges or ambulatory surgery room charges.
• “Drug records” are specific for pharmaceutical prescription claims.
• 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.
• After the management, surgery, facility, ancillary and drug records are identified atsteps52,54,56,58 and60, respectively, an ETG Assignor Sub-routine is executed atstep62. TheETG Assignor Sub-routine62 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.
• When the last claim data record for a given patient is processed by theETG Assignor Routine62, the Episode Definer Routine is executed atstep64.Episode Definer Routine64 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 atstep66 by looping back to check for eligible records for the new patient atstep48.
• Operation of the Eligible Record Check routine100 is illustrated inFIG. 3. The patient records input by the user are read from the recordable read-write data storage medium into theCPU14 memory instep102. From the patient records read to memory instep102, arecord validation step104 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:
• • m=management record;
  • a=ancillary record;
  • s=surgery record;
  • f=facility record;
  • d=drug record; or
  • o=other record.
• A sort ofvalid records106 andinvalid records108 fromstep104 is made. Forvalid records106 instep110, patient age is then read to memory from the first patient record fromstep106. All valid records are then sorted by record type instep112, 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 step116 is generated and written to the hard disk, and the ETG Assignor routine120 is initialized.
• Forinvalid records108 identified atstep104, 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, atstep111. 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 atstep113.
• The computer-implemented method of the present invention then initializes an Episode Assignor Routine200, the operation of which is illustrated inFIGS. 4A-8C. Episode Assignor Routine200 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 routine400 for matching surgery claim records to proper ETGs.FIGS. 6A-6E illustrate operation of the Facility Record Grouping routine500 for matching facilities records to proper ETGs.FIGS. 7A-7 illustrate operation of the AncillaryRecord Grouping routine600 for matching ancillary records to proper ETGs. Finally,FIGS. 8A-8C illustrate operation of the Drug Records Grouping routine700 for matching drug records to proper ETGs.
• Management Records
• The Episode Assignor routine begins by executing a Management Records Grouping Sub-routine200, illustrated inFIGS. 4A-4F, first reads the input claim record for a given patient instep202. The first processing of the input claim record entails categorizing the record as a management, surgery, facility, ancillary or drug record atstep204. A series oflogical operands208,210,212 and214, read the record and determine whether the record is a management record atstep204, a surgery record atstep208, a facility record atstep210, an ancillary record atstep212 or a drug record atstep214. If an affirmative response is returned in response tological operand204, grouping of the management record to an ETG is initialized and processing of the management record proceeds to step215. If, however, a negative response is returned in response to the logical operand206,logical operand208 is executed to determine whether the record is a surgery record. If an affirmative response is returned fromlogical operand208, the Surgery Record Grouping routine400 is initialized. If, however, a negative response tological operand208 is returned,logical operand210 is executed to determine whether the record is a facility record. If an affirmative response is returned in response tological operand210, the FacilityRecord Grouping Sub-routine500 is executed. If, however, a negative response is returned in response to thelogical operand210,logical operand212 is executed to determine whether the record is an ancillary record. If an affirmative response is returned fromlogical operand212, the AncillaryRecord Grouping Sub-routine600 is executed. If, however, a negative response to,logical operand212 is returned,logical operand214 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 DrugRecord Grouping Sub-routine700 is executed.
• Returning now to the initialization of the Management Record Grouping routine200, and in particular to step215. Once the record has been categorized as a management record in step206, 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.
• The management record is examined and the first diagnosis code on record is read, a diagnosis code (dx) by ETG table201 is read from the storage means and all valid ETGs for the first diagnosis code on record are identified atstep216. The dx by ETG table201 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:
• P=primary, with only one P value existing per ETG;
• S=shift;
• I=incidental;
• A=shift to ETG with C value; and
• C=P, where P′ is a shiftable primary value.
• An illustrative example of a section of a dx by ETG table is found atFIG. 1.
• ETG validation instep216 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 instep216, are then matched with active open ETGs instep217 by comparing the valid ETGs with the open ETGs identified instep215. A logical operand is then executed atstep218 to determine whether a match exists between the valid ETG from the management record and any open ETGs. A negative response atstep218 causes execution of another logical operand atstep220 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 atstep216, 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 instep222 and execution of the program continues as represented bydesignator AA236 bridging toFIG. 5B. If, however, a negative response is returned fromlogical operand220, 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 bydesignator F236 bridging toFIG. 5C.
• If an affirmative response is returned atlogical operand step218, the matched active ETG with the most recent DOS-to are selected atstep230. 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 atstep232 and further processing continues as represented bydesignator G238 bridging toFIG. 5C.
• Turning now toFIG. 4B, which is a continuation fromdesignator AA236 ofFIG. 4A, identifier ETGs for the second to fourth diagnoses in the management record are matched to active ETGs inlogical operand237. If an affirmative response is returned in response tological operand237, the matched active ETG with the most recent DOS-to is selected instep240. 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 instep240. A value of one is then added to the sequential anchor record counter instep241 and operation of the computer-implemented method continues as indicated bydesignator G243 bridging toFIG. 5C.
• Fromlogical step237, if a negative response is returned, the ETG with the second diagnosis value of P is selected atstep242, then a logical query is made to determine whether the selected ETG is a non-specific ETG, i.e.,ETG 900 atstep244. A negative response tological query244 causes a value of one to be added to the sequential anchor count and to the sequential episode count atstep254. If an affirmative response tological query244 is returned,logical queries246 and248 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, andlogical query244 is executed to determine whether the selected ETG is the non-specific ETG, i.e.,ETG 900. If a negative response is returned tological query244 for the ETG selected instep248, a value of one is added to the sequential anchor count and to the sequential episode count instep254. If an affirmative response is returned fromlogical query244, a value of one is added to the sequential anchor count and the sequential episode count atstep250.
• Fromstep250, 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 instep252.
• Fromstep254, 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 instep256. A comorbidity file written on the storage means is then updated with all the dx codes in the management record instep258.
• From each ofsteps252 and steps258 a check is made to determine whether the processed management record is the last record for the patient atlogical step260. An affirmative response returned tological step260 prompts the program operation to theEpisode Definer Sub-routine264, bridging toFIG. 9 with identifier GG, while a negative response tological step260 returns program operation to the beginning of the ETG Assignor routine200 and the next patient record is read atstep262.
• Turning now toFIG. 4C, thebridge reference G238 is continued fromFIG. 4A. For those records having a match with an open ETG, a query is made atstep270 of the dx-ETG table201 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 fromstep270 is A, the selected ETG in the active file is changed atstep272 to the ETG number having an equivalent table value of C for the diagnosis on record. If the table value returned fromstep270 is S, the selected ETG in the active file is shifted atstep274 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 atstep276.
• Atstep278, 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 atstep234. 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”.
• A loop beginning atstep282 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. Atstep282, 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 table201. Alogical operand284 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 tological operand284, a loop back atstep285 is executed to step282 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 thelogical operand284, the alogical operand286 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 backstep285 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 atstep288 and all valid ETGs for the current diagnosis code on record are identified atstep290 from the dx-ETG table. The identified C-value ETG is then matched with any open active ETGs atstep292. Program operation then continues atbridge H292 toFIG. 4D.
• AtFIG. 4D the continued operation of the Management Grouping Sub-routine frombridge H292 ofFIG. 4C. Logical operand296 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 operand296, a value of 1 is added to the sequential episode count atstep297 and a new episode having a P value ETG is started in the patient's master active ETG file atstep299. 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.
• If an affirmative response is returned from logical operand296, the matched active ETG with the most recent DOS-to value is selected atstep298. 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 instep300.
• For either the new episode created atstep299 or the updated ETG fromstep300, the patient's co-morbidity file is then updated with the second diagnosis code on-record atstep302. Processing then continues to identify all valid ETGs for a third diagnosis code on record atstep304 and the identified valid ETGs fromstep304 are compared to the active ETGs in the patient's master active ETG file instep306.
• Bridge1308 continues toFIG. 4E, and alogical operand310 is executed to query the patient's master active ETG file to determine whether a match exists between the valid ETGs identified instep304 with any active ETG from the patients master active ETG file. If a negative response is returned tological operand310, a value of 1 is added to the sequential episode count atstep311 and a new episode having a P value ETG is started in the patient's master active ETG file atstep313. The new episode is written with a sequential episode number, DOS-from and DOS-to values and forms a phantom management record.
• If an affirmative response is returned fromlogical operand310, the matched active ETG with the most recent DOS-to value is selected atstep312. 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 instep314.
• For either the new episode created atstep311 or the updated ETG fromstep314, the patient's co-morbidity file is then updated with the third diagnosis code on-record atstep316. Processing then continues to identify all valid ETGs for a fourth diagnosis code on record atstep318 and the identified valid ETGs from step3318 are compared to the active ETGs in the patient's master active ETG file instep320. Bridge reference1322, bridges toFIG. 4F.
• Turning toFIG. 4F, alogical operand324 is executed to query the patient's master active ETG file to determine whether a match exists between the valid ETGs identified instep320 with any active ETG from the patients master active ETG file. If a negative response is returned tological operand324, a value of 1 is added to the sequential episode count atstep325 and a new episode having a P value ETG is started in the patient's master active ETG file at step337. The new episode is written with a sequential episode number, DOS-from and DOS-to values and forms a phantom management record.
• If an affirmative response is returned fromlogical operand324, the matched active ETG with the most recent DOS-to value is selected atstep326. 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 instep328.
• For either the new episode created at step337 or the updated ETG fromstep324, the patient's co-morbidity file is then updated with the fourth diagnosis code on-record atstep330. A check is then made to determine whether the processed record is the last record for the patient by execution oflogical operand332 and reading the input claim records from the storage means. Iflogical operand332 returns an affirmative value, the ETG Definer Sub-routine is called atstep334, as represented by bridge reference GG. If, however, a negative response is returned tological operand332, program execution returns to thestep204 of the Episode Assignor routine200 and the next patient claim record is read from the storage means.
• Surgery Records
• Grouping of Surgery Records to ETGs is governed by the SurgeryRecord Grouping Sub-routine400, the operation of which is illustrated inFIGS. 5A-5D.
• For those patient claim records identified as Surgery Records atstep208, the DOS-from value on-record is compared with the DOS-to value read from the patient master active ETG file atstep402. 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 table201 to identify all possible valid ETGs for the first diagnosis code on-record instep404.
• 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 table401 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 table401 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 atstep406. Alogical operand408 is then executed to determine whether there is a match of valid ETGs returned from the dx-ETG table201 and the CPT-ETG table401. If an affirmative response is returned tological operand408, a secondlogical operand410 is executed to determine whether a match of valid specific ETGs exists. Again, if an affirmative response is returned from secondlogical operand410, the valid specific ETGs matched instep410 are then compared at step414 with the open active ETGs for the patient read from the patient's master active ETG file atstep412. If an affirmative response is returned from step414, the matched ETG with the most recent DOS-to is selected atstep416 and a value of 1 is added to the sequential anchor count in the selected ETG atstep418. Instep416, 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.
• If a negative response is returned to any oflogical operands408,410 or414, second, third and fourth dx codes on-record are read and all possible valid ETGs are read instep411 from the dx-ETG table201. Further processing of the valid ETGs output fromstep411 is continued atFIG. 5B identified by bridge reference P,413.
• Turning toFIG. 5B, alogical operand415 compares the valid ETGs for the second, third and fourth dx codes with the valid ETGs for the CPT code on-record instep411. If a negative response is returned fromlogical operand415, 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, toFIG. 5D.
• If an affirmative response is returned fromlogical operand415, the matched ETGs are compared with active ETGs read from the patient master active ETG file atstep417 andlogical operand419 is executed atstep419 to determine whether any valid matches between matched ETGs and active ETGs. If a negative response is returned tological operand419, a value of 1 is added to the sequential anchor count and to the sequential episode count atstep425 and a new episode is started at step437 with the first dx code on-record having a P value for a specific ETG in the dx-ETG table201. 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.
• If an affirmative response is returned fromlogical operand419, the matched specific ETG with the most recent DOS-to is selected atstep421. 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 atstep423. Processing the new episode started atstep427 or of the selected matched specific ETG atstep421 continues to bridge Q,420, continued atFIG. 5C.
• Turning toFIG. 5C, bridged from reference Q,420,logical operand422 is executed which reads the CPT-ETG table401 and determines the table value of the selected ETG fromstep421 and step427 based on the CPT value on-record. If a table value of R is returned from the read of the CPT-ETG table401 atstep422, the matched ETG in the master active ETG file is shifted atstep424 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 fromstep422 or fromstep242, the dx-ETG table201 is read atstep426 and the dx code for the selected matched ETG from the CPT-ETG table401 or the shifted ETG fromstep424 is read. From the dx-ETG table201, if a value of S is returned, the matched ETG in the patient master active ETG file is shifted atstep428 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 instep430 to an equivalent value of C for the dx code on-record. If a table value of P, I or C is returned either fromlogical operand426, or from theETG change step428 or theETG shift step430, the DOS-to and the sequential anchor count of the ETG in the patient master active ETG file are updated instep432. The patient claim record is then assigned and written with the sequential episode number and the sequential anchor count of the selected ETG atstep434. The patient co-morbidity file is then updated with all diagnosis codes on-record atstep436.
• FIG. 5D bridges fromFIG. 5C with bridge reference BB,438. InFIG. 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 table201. The identified possible valid ETGs are then matched against the patient master active ETG file instep442 andlogical operand444 is executed to validate the matches. If an affirmative response is returned tological operand444, for each matched dx code on-record, the matched active ETG with the most recent DOS-to is selected atstep446. 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 instep448.
• If a negative response is returned tological operand444, a value of 1 is added to sequential episode count atstep456 and a new episode having a P value ETG is started in the patient's master active ETG file atstep458. 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 tological operand444, the matched active ETG for each diagnosis code is selected atstep446 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 fromstep446 is updated instep448 to the date of service on-record and the sequential anchor count in the active ETG file is updated. From eitherstep458 or fromstep448, 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 instep429, which assigned an invalid dx-CPT code match to the record, or fromstep450, which updated the co-morbidity file, is the last record for the patient atlogical operand462. If an affirmative response is returned tological operand462, record processing proceeds to the Episode Definer Sub-routine atstep464, bridged by reference GG, toFIG. 9. If, however, a negative response is returned tological operand462, a loop back468 to the beginning of the ETG Assigner routine200 is executed and the next patient claim record is read.
• Facility Records
• The FacilityRecord Grouping Sub-routine500 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 table201 to identify all valid ETGs for the first dx code atstep502. The identified valid ETGs are then compared to the open active ETGs in the patient master active ETG file instep504. Logical operand506 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 step506, a value of 1 is added to the sequential episode count atstep507 and a new episode is started instep509 in the patient active ETG file with the ETG corresponding to the dx-ETG table value of P. Iflogical operand507 returns an affirmative response, a query of the matched ETG value is made atstep508 to determine whether the matched ETG has a table value of P, C, A or S. If a negative response is returned to step508, the matched active ETG with the most recent DOS-from value is selected atstep511. 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 atstep508, the table value of the matched ETG table value is identified atstep510. If the table value for the matched ETG in the dx-ETG table201 is S, the matched ETG is shifted atstep514 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 atstep512 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 atstep510, the most recent DOS-to is updated atstep516 in the ETG to the on-record claim date. Further processing of the claim record fromsteps509,511 and516 bridges atreference1,520, toFIG. 6B.
• Turning toFIG. 6B, bridged fromreference1,520, inFIG. 6A, the patient's co-morbidity file is updated with the first dx code atstep522. A loop beginning atstep524 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. Atstep524, 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 table201. Alogical operand526 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 tological operand526, a loop back atstep527 is executed to step524 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 thelogical operand524, thelogical operand528 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 backstep527 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 atstep530. All valid ETGs for the second diagnosis code on record are identified atstep532 from the dx-ETG table. The identified ETGs are then matched with any open active ETGs atstep532. Program operation then continues atbridge2,536 toFIG. 6C.
• AtFIG. 6C the continued operation of the FacilityRecord Grouping Sub-routine500 frombridge2 ofFIG. 6bis illustrated.Logical operand538 queries the open active ETGs to determine whether a valid match with the identified ETGs exists. If a negative response is returned tological operand538, the patient co-morbidity file is updated with the second diagnosis code atstep544. If an affirmative response is returned fromlogical operand538, the matched active ETG with the most recent DOS-to value is selected atstep540. 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 instep542.
• Processing then continues to identify all valid ETGs for a third diagnosis code on record atstep546 and the identified valid ETGs fromstep546 are compared to the active ETGs in the patient's master active ETG file instep548.
• Bridge3,550, continues toFIG. 6D, and alogical operand552 is executed to query the patient's master active ETG file to determine whether a match exists between the valid ETGs identified instep548 with any active ETG from the patients master active ETG file. If a negative response is returned tological operand538, the patient's comorbidity file is updated with the third diagnosis code at558.
• If an affirmative response is returned fromlogical operand552, the matched active ETG with the most recent DOS-to value is selected atstep554. 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 patient's co-morbidity file is then updated with the third diagnosis code on-record atstep558. Processing then continues to identify all valid ETGs for a fourth diagnosis code on record atstep560 and the identified valid ETGs from step3318 are compared to the active ETGs in the patient's master active ETG file instep562.Bridge reference4,564, bridges toFIG. 6D.
• Turning toFIG. 6D, alogical operand566 is executed to query the patient's master active ETG file to determine whether a match exists between the valid ETGs identified instep562 with any active ETG from the patients master active ETG file. If a negative response is returned tological operand566, the patients comorbidity file is updated with the fourth diagnosis code.
• If an affirmative response is returned fromlogical operand566, the matched active ETG with the most recent DOS-to value is selected atstep568. 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 instep570 and the patient's co-morbidity file is then updated with the fourth diagnosis code on-record atstep572. A check is then made to determine whether the processed record is the last record for the patient by execution oflogical operand574 and reading the input claim records from the storage means. Iflogical operand574 returns an affirmative value, the ETG Definer Sub-routine is called atstep576, as represented by bridge reference GG. If, however, a negative response is returned tological operand574, program execution returns to thestep204 of the Episode Assignor routine200 and the next patient claim record is read from the storage means atstep578.
• Ancillary Records
• Operation of the AncillaryRecord Grouping Sub-routine600 is illustrated inFIGS. 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 instep602 from the CPT-ETG table401. Then all valid ETGs for the first dx code on record are identified instep604 from the dx-ETG table201. The ETGs from the CPT-ETG table401 are then compared atstep606 to the ETGs from the dx-ETG table201 and alogical operand608 determines whether there is an ETG match. An affirmative response returned fromlogical operand608 continues record processing at bridge D,610, which continues onFIG. 7B. A negative response returned fromlogical operand608 prompts a look up on the dx-ETG table to determine all valid ETGs for the second diagnosis code on record in step611. Step613 again compares the valid ETGs for the CPT code on record and with the valid ETGs for the second dx code on record and alogical operand614 is executed to match the second dx code ETG with the CPT code ETG. Again, an affirmative response returned fromlogical operand614 continues record processing at bridge D,610, which continues onFIG. 7B. If a negative response is returned tological operand614, a look up on the dx-ETG table occurs to determine all valid ETGs for the third diagnosis code on record in step615. Step616 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, toFIG. 7B for identification of all valid ETGs for the fourth dx code on-record at step625.
• Step627 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 operand629 is executed to match the fourth dx code ETG with the CPT code ETG. An affirmative response returned from logical operand629 continues to step616 which compares the matched ETGs with the ETGs in the patient master active ETG file and a query is made atlogical operand618 to determine whether any valid matches exist. If a negative response is returned to logical operand629, the record is output to the ETG reserved for a CPT code-dx code mismatch at step631 and a check is made at step635 to determine whether the record is the last record for the patient.
• If a match is found between the matched ETGs from the dx code-CPT code comparison instep616. 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 step622.
• If the response tological operand618 is negative, the record is assigned to an orphan record ETG atstep633 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.
• A check is then made to determine whether this record is the last record for the patient at step635. If logical operand635 returns an affirmative value, the ETG Definer Sub-routine is called atstep642, as represented by bridge reference GG. If, however, a negative response is returned to logical operand635, program execution returns to thestep204 of the Episode Assignor routine200 and the next patient claim record is read from the storage means atstep644.
• Prescription Drug Records
• FIGS. 8A-8C illustrate the operation of the DrugRecord Grouping Sub-routine700. DrugRecord Grouping Sub-routine700 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) table800. 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 table900. 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.
• Once identified as a drug record in the initial operation of the Episode Assignor Routine200, the drug record is read from storage to memory instep702. The NDC code on-record is converted to a GDC code by reading from the NDC-GDC table800 instep704. Using the GDC number so identified, all possible valid ETGs for the GDC code are identified instep706. The possible valid ETGs for the GDC code are then compared to the patient master active ETG file instep708. Following bridge LL,710, toFIG. 8B, a logical operand is executed instep712 based upon the comparison executed instep708, to determine whether a match occurs having a table value of P, A, C or S.
• If a negative response is returned tological operand712, a check is made to determine whether a match having table value I in the GDC-ETG table900 exists in step713. If another negative response is returned to logical operand713, the record is flagged an orphan drug record and assigned to an orphan drug record ETG instep715. If an affirmative response is returned to logical operand713, the ETG with the highest second value is selected in step718 (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 instep720.
• If an affirmative response is returned tological operand712, the ETG having the highest second value, in order of P, S, A, C is selected in step714 (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 instep716.
• Further processing of the drug record continues fromsteps716,715 and720 through bridge MM,724 and is described with reference toFIG. 8C. A check is made instep726 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 DrugRecord Grouping Sub-routine700 is executed. If an affirmative response is returned atstep726, a check is made to determine whether the drug record is the last record for the patient instep728. Iflogical operand728 returns an affirmative value, the ETG Definer Sub-routine is called atstep732, as represented by bridge reference GG. If, however, a negative response is returned tological operand728, program execution returns to thestep204 of the Episode Assignor routine200 and the next patient claim record is read from the storage means atstep730.
• The Episode Definer Sub-routine is illustrated with reference toFIG. 9. Episode Definer Routine118 is employed to assign all non-specific claims records, i.e., those initially assigned toETG 900, to specific more appropriate ETGs.Episode Definer routine750. Once all episodes have been grouped to ETGs, all ETG episodes in both active and closed ETGs are then identified instep752 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 instep754. All patient records are then output instep756 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. TheEpisode Definer routine750 then writes a single record atstep758 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.
• After the single record for each episode is written instep758 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 instep760 and the Eligible Record Check Routine is re-initiated for processing claims records for the next patient atstep762.
EXAMPLE
• 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 visit84, hospital oremergency room visit85, and surgery and surgical follow-up 86 and for claims records classified as ancillary records, i.e., laboratory tests87, X-ray andlaboratory tests88 andx-ray89. Two time lines are provided. Afirst timeline71 includes the diagnosis and the time duration of the diagnosed clinical condition. A second timeline72 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 denoted84a, the second office visit is denoted84b, the third denoted84c, etc. Vertical broken lines denote the beginning and end of eachEpisode Treatment Group90, and facilitate correlation of the episode event, e.g., office visit, with the resulting diagnosis, e.g., bronchitis.
• Afirst office visit84aresulted in a diagnosis ofbronchitis76. Office visit84astarted anepisode90afor this patient based upon thebronchitis diagnosis76. Asecond office visit84boccurred concurrently with thebronchitis episode90a, but resulted in a diagnosis ofeye infection77. Because theeye infection77 is unrelated to the openbronchitis episode ETG90a, a new eyeinfection episode ETG90bis started. An X-ray andlab test88 was taken during the time frame of each of thebronchitis episode90aand theeye infection90b. Based upon the CPT-ETG table, discussed above, the X-ray andlab test88 is assigned to theeye infection episode90b. Athird office visit84cand x-ray89aoccurred and related to thebronchitis episode90arather than theeye infection episode90b.
• Afourth office visit84doccurred and resulted in a diagnosis ofmajor infection78 unrelated to thebronchitis diagnosis76. Because themajor infection78 is unrelated to the bronchitis, thefourth office visit84dopened anew ETG90c. Two subsequent lab tests87aand87bwere both assigned to the only open episode, i.e.,ETG90c.
• Afifth office visit84eresulted in a diagnosis ofbenign breast neoplasm79, which is unrelated to themajor infection ETG90c. Afifth office visit84eopened anew ETG90dbecause the benign breast neoplasm is unrelated to either thebronchitis episode ETG90a, the eyeinfection episode ETG90b, or themajor infection episode90c.Sixth office visit84fwas assigned then to the only open episode, i.e.,ETG90d. Similarly, the surgery and follow-up records86aand86brelated to thebenign neoplasm ETG90dand are grouped to that ETG.
• Some months later, the patient has a seventh office visit84gwhich resulted in a diagnosis ofbronchitis80. However, because the time period between theprior bronchitis episode76 and thecurrent bronchitis episode80 exceeds a pre-determined period of time in which there was an absence of treatment for bronchitis, thebronchitis episode90ais closed and thebronchitis episode90eis opened. Ahospital record85 occurs as a result of an eye trauma andeye trauma81 is the resulting diagnosis. Because theeye trauma85 is unrelated to thebronchitis80, a new eye trauma ETG90fis started which is open concurrently with thebronchitis ETG90e. Aneighth office visity84hoccurs during the time when bothETG90eand ETG90fare open.Eighth office visity84his, therefore, grouped to the ETG most relevant to theoffice visity84h, i.e.,ETG90e. Asubsequent x-ray record89boccurs and is related to the eye trauma diagnosis and is, therefore, grouped to ETG90f. Because and absence of treatment has occurred for thebronchitis ETG90e, thatETG90eis closed.
• Finally, while the eye trauma ETG90fis open, the patient has aroutine office visit84hwhich is unrelated to the open ETG90ffor the eye trauma diagnosis91. Because it is unrelated to the open ETG90f, theroutine office visity84istarts and groups to anew episode90gwhich contains only onemanagement record84i. Anx-ray record89coccurs after and is unrelated to theroutine office visity84i. The only open episode is the eye trauma episode90fand thex-ray record89cis, therefore, grouped to the eye trauma episode90f. At the end of the year, all open episodes, i.e., the eye trauma ETG90fare closed.
• 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.

  TABLE 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	Congenital 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

Claims (16)

1-2. (canceled)

3. A computer-implemented process for profiling medical claim data including:

(a) storing a plurality of episode treatment groups, wherein each episode treatment group is associated with one or more diagnosis codes or treatment codes and has an associated dynamic time window;

(b) reading medical claim data records associated with one or more patients into a computer memory;

(c) validating each of the medical claim data records for at least one of a diagnosis code and a treatment code;

(d) reading at least one pre-defined relation between the at least one of the diagnosis code and the treatment code and one or more of the stored episode treatment groups; and

(e) grouping the validated medical claim data records to at least one of the plurality of episode treatment groups based on the pre-defined relationship and the dynamic time window associated with each episode treatment group, each of the at least one of a plurality of episode treatment groups further comprising one anchor record and at least one data record linked thereto, the at least one data records being selected from the group consisting of ancillary records, facility records and prescription drug records.

4. The process as claimed inclaim 3, wherein each of the at least one of a plurality of episode treatment groups contain at least one cluster of medical claim data records.

5. The process as claimed inclaim 4, wherein the at least one cluster further comprises at least one ancillary record and at least one anchor record.

6. The process as claimed inclaim 3, wherein the step (e) further comprises differentiating patient severity based upon data relating to at least one of patient age, complicating conditions, co-morbidities and major surgeries.

7. The process as claimed inclaim 3, further comprising outputting and discontinuing processing of invalid data records.

8. The process as claimed inclaim 7 wherein outputting and discontinuing processing of invalid data records includes assigning a different episode treatment group to a medical claim data record containing at least one of an invalid diagnosis code, an invalid treatment code and an invalid provider type.

9. The process as claimed inclaim 3, further comprising the step of identifying valid episode treatment groups by comparing current treatment codes to prior related episodes in look-up tables.

10. The process as claimed inclaim 3, further comprising the step of flagging valid claim records with a diagnosis code identifier.

11. The process as claimed inclaim 10, wherein the step of flagging valid claim records comprises the step of incrementing a sequential anchor count and a sequential episode count for each episode treatment group assignment.

12. The process as claimed inclaim 3, further comprising resetting the dynamic time window of the medical episode when a second medical claim data records matches an open medical episode, the dynamic time window being reset for an additional period of time until no other data records are grouped to the open medical episode within the reset dynamic time window.

13. The process as claimed inclaim 12, wherein the step of resetting the dynamic time window of the medical episode, further comprises the step of selecting a most recent claim record if more than one matched claim record exists.

14. The process as claimed inclaim 3, wherein a medical claim data record is shifted to a different one of the plurality of episode treatment groups upon receipt of a second medical claim record containing changes in patient condition comprising at least one of comorbidity, complication and defining surgery.

15. The process as claimed inclaim 3, wherein a medical claim data record originally assigned to a first episode treatment group based upon a first diagnosis in the medical claim record is shifted to a second episode treatment group based on at least one of a second, third and fourth diagnosis in the medical claim data record.

16. The process as claimed inclaim 9, wherein the step of identifying valid episode treatment groups further comprises the step of comparing pharmaceutical claim data in a patient's medical claim data to open episode treatment groups for the patient by analyzing Generic Drug Codes by episode treatment group and National Drug Code by Generic Drug Codes look-up tables.

17. The process as claimed inclaim 3, further comprising the step of identifying medical providers treating episodes treatment groups by identifying each episode treatment group by Primary Care Physician.

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