System and Method for Grouping Claim Records Associated with a Procedure

Abstract

A system and computer-implemented method for grouping medical records implements a multi-level analysis of the records. The level of analysis for each record is determined based upon the time proximity of each record to the defining medical procedure or service (anchor procedure) to be analyzed. Once an anchor procedure is identified, claim records are processed to determine whether any of the records should be grouped with the anchor procedure into a procedure episode group (PEG). First, the date of service for each claim record is identified to determine whether the claim record falls within time window. The claim records falling within the window then are assessed to determine whether each claim record is sufficiently related to the anchor procedure (for example, by determining whether the diagnostic, procedure, or episode treatment group coding of each claim record is associated with the anchor procedure). The requisite level of relationship between the claim records and the anchor procedure depends upon the position of the records within the time window. Only those claim records having the requisite relationship level associated with the portion of the time window in which they fall are included in the PEG.

1 - 11 . (canceled) 
     
     
         12 . A computer-implemented method of grouping health-related claim records, comprising:
 using a computer processor to:
 identify an anchor procedure from a set of claim records, the anchor procedure comprising a major therapeutic procedure or a hospital admission, an associated date of service and an associated time window that is divided into a temporally close portion in relation to the anchor procedure date of service and a temporally further portion in relation to the anchor procedure date of service that is different from the temporally close portion, the temporally close portion having an associated first claim assessment process and the temporally further portion having an associated second claim assessment process different from the first claim analysis process; 
 identify from the set of claim records a plurality of claim records falling within the time window based on a date of service associated with each claim record from the set; 
 assess the identified claim records falling into the temporally close portion of the time window using the first claim analysis process to confirm the identified claim records fall into the temporally close portion of the time window and have a first level of relationship with the anchor procedure; and 
 assess the identified claim records falling into the temporally further portion of the time window using the second claim analysis process to confirm that the identified claim records fall into the temporally further portion of the time window and have a second level of relationship with the anchor procedure; and 
 group the identified claim records respectively having the first and second level of relationship with the anchor procedure into a procedure episode group. 
   
     
     
         13 . The computer-implemented method of  claim 12 , wherein the anchor procedure is a multi-claim anchor procedure. 
     
     
         14 . The computer-implemented method of  claim 12 , further comprising:
 using the processor to:
 assess the identified claim records falling into a temporally furthest portion of the time window using a third claim analysis process. 
   
     
     
         15 . The computer-implemented method of  claim 12 , wherein the anchor procedure corresponds to a procedure code associated with treatment of a condition or disease. 
     
     
         16 . The computer-implemented method of  claim 12 , wherein the anchor procedure corresponds to an anchor category and wherein the first claim analysis process determines whether the identified claim records relate to the anchor category. 
     
     
         17 . The computer-implemented method of  claim 16 , wherein the second claim analysis process determines whether the identified claim records relate to the anchor category and further determines whether the identified claim records are associated with at least one of a target category or a target procedure associated with the anchor category. 
     
     
         18 . The computer-implemented method of  claim 12 , wherein the anchor procedure comprises orthopedic surgery, back surgery, cardiac surgery, abdominal surgery, skin and plastic surgery, eye surgery, gynecologic surgery, urologic surgery, ear-nose-throat surgery, or a combination thereof. 
     
     
         19 . A computer-implemented method of grouping health-related claim records, comprising:
 using a computer processor to:
 identify an anchor procedure from a set of claim records, an associated date of service and an associated time window; 
 identify from the set of claim records a plurality of claim records falling within the time window based on a date of service associated with each claim record from the set, the identified claim records including a first plurality of claim records having a first temporal relationship to the associated date of service and a second plurality of claim records having a second temporal relationship to the associated date of service different than the first temporal relationship; 
 assess the first plurality of claim records using a first claim analysis process to confirm the first plurality of claim records have the first temporal relationship to the associated date of service and a first level of relationship with the anchor procedure; 
 assess the second plurality of claim records using a second claim analysis process to confirm the second plurality of claim records have the second temporal relationship to the associated date of service and a second level of relationship with the anchor procedure; and 
 group the identified claim records respectively having the first and second level of relationship with the anchor procedure into a procedure episode group. 
   
     
     
         20 . The computer-implemented method of  claim 19 , wherein the first plurality of claim records is associated with a first sub-window portion of the time window and the second plurality of claim records is associated with a second sub-window portion of the time window different than the first sub-window. 
     
     
         21 . The computer-implemented method of  claim 20 , wherein the first sub-window is temporally closer in proximity to the date of service than the second sub-window portion of the assigned time window. 
     
     
         22 . The computer-implemented method of  claim 19 , wherein the anchor procedure is a multi-claim anchor procedure. 
     
     
         23 . The computer-implemented method of  claim 19 , further comprising:
 using the processor to:
 identify, with the procedure episode group, a sequence of care for the anchor procedure. 
   
     
     
         24 . The computer-implemented method of  claim 23 , further comprising:
 using the processor to:
 assess the sequence of care based on one or more quality markers. 
   
     
     
         25 . The computer-implemented method of  claim 19 , wherein the anchor procedure comprises a hospital admission. 
     
     
         26 . One or more non-transitory computer readable storage media encoded with instructions executable by a processor of a computing system, the instructions comprising instructions for:
 identifying an anchor procedure from a set of claim records, an associated date of service and an associated time window that is divided into a temporally close portion in relation to the anchor procedure date of service and a temporally further portion in relation to the anchor procedure date of service that is different from the temporally close portion, the temporally close portion having an associated first claim assessment process and the temporally further portion having an associated second claim assessment process different from the first claim analysis process;   identify from the set of claim records a plurality of claim records falling within the time window based on a date of service associated with each claim record from the set;   assessing the identified claim records falling into the temporally close portion of the time window using the first claim analysis process to confirm the identified claim records fall into the temporally close portion of the time window and have a first level of relationship with the anchor procedure; and   assessing the identified claim records falling into the temporally further portion of the time window using the second claim analysis process to confirm that the identified claim records fall into the temporally further portion of the time window and have a second level of relationship with the anchor procedure; and   grouping the identified claim records respectively having the first and second level of relationship with the anchor procedure into a procedure episode group.   
     
     
         27 . The non-transitory computer readable storage media of  claim 26 , wherein the instructions further comprise instructions for:
 excluding identified claim records falling into the temporally close portion of the time window not having the first level of relationship with the anchor procedure.   
     
     
         28 . The non-transitory computer readable storage media of  claim 26 , wherein the instructions further comprise instructions for:
 identifying, with the procedure episode group, a sequence of care for the anchor procedure.   
     
     
         29 . The non-transitory computer readable storage media of  claim 28 , wherein the instructions for identifying, with the procedure episode group, a sequence of care for the anchor procedure include instructions for assessing the sequence of care based on one or more quality markers. 
     
     
         30 . The non-transitory computer readable storage media of  claim 26 , wherein the anchor procedure is a surgical procedure, a therapeutic procedure, a hospital admission, or a combination thereof. 
     
     
         31 . The non-transitory computer readable storage media of  claim 30 , wherein the anchor procedure comprises orthopedic surgery, back surgery, cardiac surgery, abdominal surgery, skin and plastic surgery, eye surgery, gynecologic surgery, urologic surgery, ear-nose-throat surgery, or a combination thereof. 
     
     
         32 . The non-transitory computer readable storage media of  claim 26 , wherein the anchor procedure corresponds to an anchor category and wherein the anchor category includes one or more diagnostic codes.