selected episode grouping issues
DESCRIPTION
Selected Episode Grouping Issues. Frederick Thomas, Ph.D. Centers for Medicare & Medicaid Services. Medical Episode Grouper (MEG). Etiology Based Disease Staging Framework Initially developed in 1983 Ongoing private development by Thomson /Jefferson Medical School - PowerPoint PPT PresentationTRANSCRIPT
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Selected Episode Grouping Selected Episode Grouping IssuesIssues
Frederick Thomas, Ph.D.Frederick Thomas, Ph.D.Centers for Medicare & Medicaid Centers for Medicare & Medicaid
ServicesServices
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Medical Episode Grouper (MEG)Medical Episode Grouper (MEG)
• Etiology BasedEtiology Based• Disease StagingDisease Staging Framework Framework
• Initially developed in 1983 Initially developed in 1983 • Ongoing private development by Ongoing private development by
Thomson /Jefferson Medical SchoolThomson /Jefferson Medical School• 575 categories plus stages within each 575 categories plus stages within each
categorycategory
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MEG Grouping Structure MEG Grouping Structure (v 7.25)(v 7.25)Episode Group # CONDITION DXCAT MDC
1 Aneurysm, Abdominal CVS01 CVS2 Aneurysm, Thoracic CVS02 CVS3 Anomaly: Patent Ductus Arteriosus CVS03 CVS6 Arrhythmias CVS06 CVS
491 Schizophrenia PSY80 PSY347 Fracture: Femur, Except Head or NeckMUS07 MUS348 Fracture: Femur, Head or Neck MUS08 MUS400 Epilepsy NEU07 NEU401 Guillain-Barre Syndrome NEU08 NEU402 Headache NEU09 NEU
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Episode Treatment Groups Episode Treatment Groups (ETG)(ETG)
• Base Category ETGs (n=330)Base Category ETGs (n=330)• Resource consumption basis, with Resource consumption basis, with
clinical homogeneity clinical homogeneity • ETG grouping structure allows for ETG grouping structure allows for
presence of surgery, presence of presence of surgery, presence of comorbidities, body areascomorbidities, body areas
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ETG 9 Digit CodingETG 9 Digit Coding Structure Structure (v 7.0)(v 7.0)
• Base ETG: 4 digitsBase ETG: 4 digits• EXPANSION ATTRIBUTES:EXPANSION ATTRIBUTES:
• Body location: 5Body location: 5thth, 6, 6thth digits digits• Complications indicator: 7Complications indicator: 7thth
• Co-morbidity indicator: 8Co-morbidity indicator: 8thth • Surgery indicator: 9Surgery indicator: 9thth
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Example v 7. CodingExample v 7. Coding
721: Joint degeneration, localized, with surgery 712201
Joint degeneration, localized - foot & ankle
722: Joint degeneration, localized, w/o surgery 712202
Joint degeneration, localized - knee & lower leg
712203Joint degeneration, localized - thigh, hip & pelvis
712204Joint degeneration, localized - hand, wrist & forearm
712205Joint degeneration, localized - elbow & upper arm
etc.
Prior to v 7.0 ETG With Release 7.0: [Surgery, complications, co-morbidities are additional categories]
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Severity AdjustmentSeverity Adjustment
Used to help identify Used to help identify complexity and resource use complexity and resource use
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MEG SeverityMEG Severity• MEG: MEG: disease stage from 2disease stage from 2ndnd Dx Dx (3 (3
severity levels generally for each MEG)severity levels generally for each MEG)• Examples of Dx that define stages: Examples of Dx that define stages:
respiratory failure, shock (along with base respiratory failure, shock (along with base condition)condition)
• Conditions such as diabetes, ESRD not in Conditions such as diabetes, ESRD not in stagesstages
• User determines severity modelUser determines severity model• Disease Staging levels along with other Disease Staging levels along with other
information used to adjust costsinformation used to adjust costs
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Disease Staging ClassificationDisease Staging ClassificationScale: likelihood of mortalityScale: likelihood of mortality
Base Category MEGs(n=575) Base Category MEGs(n=575)
Stage 1Stage 1 Disease with no complicationsDisease with no complications
Stage 2Stage 2 Disease has local complicationsDisease has local complications
Stage 3Stage 3 Multiple site involvement; Multiple site involvement; systemic systemic complicationscomplications
Stage 4Stage 4 DeathDeath
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Disease Staging ExampleDisease Staging Example
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ETG SeverityETG Severity
• In ETG v 7.0, up to 4 levels are identified In ETG v 7.0, up to 4 levels are identified in about 125 ETGsin about 125 ETGs
• Severity models use Dx, age, gender to Severity models use Dx, age, gender to create severity profiles create severity profiles
• This model is used to assign a severity This model is used to assign a severity level to each ETG episodelevel to each ETG episode
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ETG Severity ScoreETG Severity Score
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ETG Severity Threshold ExampleETG Severity Threshold Example
00.5
1
1.52
2.53
3.54
4.5
5
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
Percentile
Rel
ativ
e Se
verit
y
Severity Level Threshold 1 1.0 2 1.4 3 1.7
3
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10% 25% 50% 75% 90% Average
MEG $72 $154 $511 $5,684 $13,471 $5,019
ETG1 $66 $118 $307 $1,257 $5,842 $2,0382 $97 $194 $621 $3,509 $9,007 $3,0633 $128 $339 $1,584 $8,025 $18,144 $6,245
CHF Episode Cost Distribution
Comparsion: CHF Adjusted CostsComparsion: CHF Adjusted Costs
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Comparing Grouper Logic Comparing Grouper Logic
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Some ETG / MEG groups have Some ETG / MEG groups have almost identical Dxalmost identical Dx
MEG 9 ETG 386800
398.91 RHEUMATIC HEART FAILURE428 HEART FAILURE*
428.0 428.0 CONGESTIVE HEART FAILURE428.1 428.1 LEFT HEART FAILURE
Example: CHFExample: CHF
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Some use same DX codes, but Some use same DX codes, but split into different groupssplit into different groups
MEG 49 MEG 50Type 1 Type 2
250 DIABETES MELLITUS*250.0 UNCOMP*
250.00 250.00 UNCOMPL TYPE II250.01 250.01 UNCOMPL TYPE I
250.02 250.02 DMII WO CMP UNCNTRLD250.03 250.03 DMI WO CMP UNCNTRLD
ETG 163000
Example: DiabetesExample: Diabetes
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Most Dx are differentMost Dx are differentMEG 360 Fracture, ETG 713103 CLOSED
Dislocation, or Sprain: Fracture or Dislocation - Hip or Pelvis MUS20 thigh, hip & pelvis
718.25 718.25718.35 718.35718.75718.85718.95
Severity Level 1 733.14733.15
808808.0
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Examples of other Logic Examples of other Logic DifferencesDifferences
• Specificity Logic (MEGs): Non-specific Dx Specificity Logic (MEGs): Non-specific Dx MEGs are grouped with specific Dx MEGs MEGs are grouped with specific Dx MEGs
• Incidental logic (ETG): some Dx cannot Incidental logic (ETG): some Dx cannot open episodes when another is already open episodes when another is already openopen
• Ranking logic (ETG): to evaluate some Ranking logic (ETG): to evaluate some claim combinationsclaim combinations
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Types of EpisodesTypes of Episodes• Chronic:Chronic: conditions such as COPD, CHF conditions such as COPD, CHF
• Usually a calendar year (12 months duration)Usually a calendar year (12 months duration)
• Acute:Acute: conditions such as fracture, AMI, conditions such as fracture, AMI, pneumoniapneumonia
• Episode ends when no more activity for that Episode ends when no more activity for that condition is found, i.e, a “clean period”condition is found, i.e, a “clean period”
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Resulting Cost DifferencesResulting Cost Differences Cost per Episode Type 2004/5
1,880
2,313
1,824
1,175
-
500
1,000
1,500
2,000
2,500
MEG ETG
Ave
rage
Cos
t per
Epi
sode
Typ
e Chronic EpisodesAcute Episodes
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Philosophical Issue Philosophical Issue Example Example
Bundling physician claims Bundling physician claims with an inpatient staywith an inpatient stay
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Inconsistency of Dx on Physician Inconsistency of Dx on Physician and Inpatient Facility Claims and Inpatient Facility Claims
• The hospital stay (facility claim) is usually The hospital stay (facility claim) is usually grouped by the grouped by the principalprincipal Dx, even though Dx, even though multiple conditions may be involvedmultiple conditions may be involved
• About 55% of physician claims Dx differ from About 55% of physician claims Dx differ from the Dx on the inpatient claimthe Dx on the inpatient claim
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Episode with IP Stay: MEG 525 Neoplasm, Malignant Other Respiratory System
Internal medicine . CHF NOS . CHFDiagnostic radiology. RESPIRATORY ABNORM NEC.Diagnostic radiology. OTHER GENERAL SYMPTOMS. UngroupedInternal medicine . NAUSEA ALONE .Neurology . AC CEREBROVASC INSUF NOS. Cerebrovascular Dis, Chronic MaintenanceCrna, anesthesia asst. NAUSEA WITH VOMITING .Anesthesiology . NAUSEA WITH VOMITING .Internal medicine . ACUTE PANCREATITIS . PancreatitisNeurology . AC CEREBROVASC INSUF NOS. Cerebrovascular Dis, Chronic Maintenance
Claim DxPhysician Specialty MEG Assign
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Philosophical Question:Philosophical Question:
• Group all inpatient physician claims Group all inpatient physician claims with the principal inpatient stay Dx, with the principal inpatient stay Dx, regardless of physician Dx? Orregardless of physician Dx? Or
• Group each physician claim by its Dx Group each physician claim by its Dx into multiple episodes, that may not into multiple episodes, that may not include the inpatient stay?include the inpatient stay?