Have you ever heard of Triple Aim in healthcare? The slide briefly introduces how to turn millions of healthcare data into useful insights and predictions for Triple Aim. What aspects do we usually use data for analysis? Reports for enrollment and ED visits demonstrate the aspects you can dig into. What is the structure for claims? How to use quality measures? It also has emergency department (ED) visits as the example to show how to use the codes in claims to dig out ED visits. Lastly, it explains common diagnosis and procedure coding in healthcare, including ICD, CPT, and HCPCS.
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Intro of data analysis in healthcare for triple aim
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INTRO OF DATA ANALYSIS
IN HEALTHCARE
Analysis, Reporting, Action with
Triple Aim
Yaxing Liu, PhD
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Todd Park, CTO,
Department of Health and Human Services
Source: http://www.forbes.com/sites/nicoleperlroth/2011/11/02/tim‐oreilly‐the‐worlds‐7‐most‐powerful‐data‐scientists/
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Claim Header + Claim Line
• Claim Num
• Claim Type
• Claim Status: Paid, adjusted, denied, rejected
• Dates
• Amount
Data Dictionary
• Medicare:
• https://www.ccwdata.org/web/guest/data‐dictionaries
Form
• UB‐04
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Inpatient
Outpatient
SNF/swing bed
Hospice
Physician encounter
DME
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Patient
• Age
• Race
• Gender
Provider
• NPI / name / address
Diagnosis/procedure
• CPT
• HCPCS
• ICD9‐CM Diagnosis, ICD9‐CM Procedure, ICD10
• LOINC
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Origin
• The International Classification of Diseases (ICD) is updated and maintained
by the World Health Organization (WHO)
• ICD‐9‐CM developed in 1970s
• WHO’s 9th revision of ICD (ICD‐9) had attained wide international recognition
by 1970s
Modifiction
• The U.S. National Center for Health Statistics, part of Centers for Disease
Control, modified ICD‐9 with clinical information
• Result was the International Classification of Diseases, 9th Revision, Clinical
Modification (ICD‐9‐CM), commonly referred to as ICD‐9, which precisely
delineates the clinical picture of each patient, providing exact information
beyond that needed for statistical groupings and analysis of healthcare trends
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Professional (CMS‐1500)
• diagnosis codes
• V‐codes (V01‐V91)
• E‐codes (E000‐E999)
Institutional (UB‐04)
• diagnosis codes
• V‐codes
• E‐codes
• procedure codes
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Definition
• 3 digits followed by a decimal, then followed by no, 1, or 2 digits,3‐5 characters in length
• First digit may be alpha (E or V) or numeric; digits 2‐5 are numeric
• All claims, whether CMS‐1500 or UB‐04, must have at least one ICD‐9 diagnosis code
• On UB‐04, the first diagnosis code must describe the principal reason for the care provided.
Guideline
• Providers should code only the current condition that prompted the patient’s visit
• When the diagnostic statement identifies an acute condition, providers should use the code
that specifies “acute” whenever it is available
• Providers should be as specific as possible in specifying diagnosis
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Include:
• ICD‐10‐CM – diagnosis codes
• ICD‐10‐PCS (Procedure Coding System) –procedure
codes, only for UB‐04 (primarily hospitals)
Definition
• 3‐7 characters in length
• First digit is alpha; digits 2 and 3 are numeric; digits
4‐7 are alpha or numeric
• specific
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CPT: Current Procedural Terminology
• Developed and maintained by the American Medical As sociation (AMA) in 1966
• Five‐digit codes with descriptions
• CPT and HCPCS codes also used to reimburse most non
• ‐physician
• health professionals
Six major sections
• Evaluation and management (E&M) (99201‐99499)
• Anesthesiology (00100‐01999)
• Surgery (10040‐69990)
• Radiology (70010‐79999)
• Pathology and laboratory (80048‐89399)
• Medicine (90281‐99199 and 99500‐99999)
Subsections
• Procedures are divided into subsections according to body part, service, or diagnosis
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