System and method for grouping claim records associated with a procedure
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. A computer-implemented method of grouping health-related claim records, comprising:
storing in at least one electronic database:
a plurality of health-related claim records for at least one patient; and
a plurality of predefined anchor categories, each predefined anchor category including a plurality of clinically related procedures and at least one anchor procedure having an associated time window that is divided into a first sub-window portion and a second sub-window portion different from the first sub-window portion, wherein the first sub-window portion has an associated first claim analysis process and the second sub-window portion has an associated second claim analysis process; and
using a computer processor to:
identify an anchor procedure from the stored claim records having the associated time window;
identify claim records falling within the associated time window using the date of service associated with each claim record;
assess the identified claim records falling within the first sub-window portion of the time window using the first claim analysis process to determine whether the identified claim records have a first level of relationship with the anchor procedure in which the claim records generally relate to the predefined anchor category associated with the identified anchor procedure;
assess the identified claim records falling within the second sub-window portion of the time window using the second claim analysis process to determine whether the identified claim records have a second level of relationship with the anchor procedure in which the claim records generally relate to the predefined anchor category associated with the identified anchor procedure, and in which the second claim analysis process further analyzes the claim records to confirm their relationship to the predefined anchor category;
group the identified claim records respectively having the first and second level of relationship with the anchor procedure into a procedure episode group; and
store the procedure episode group of claim records in the electronic database.
2. The method of claim 1 , wherein the first sub-window portion of the associated time window for the anchor record is defined to be in temporally closer proximity to the anchor procedure than the second sub-window portion of the time window for the anchor record.
3. The method of claim 2 , wherein determining the first level of relationship using the first claim analysis process comprises analyzing the claims in the first sub-window portion to determine whether the claim records are associated with ETG data having a predefined relationship to the anchor category.
4. The method of claim 3 , wherein determining the second level of relationship using the second claim analysis process comprises further analyzing the claims in the second sub-window portion to determine whether the claim records are associated with procedure codes having a predefined relationship to the anchor category such that the second level of relationship requires a higher degree of relationship between the identified claim record and the anchor procedure than does the first level of relationship.
5. A computer-implemented system for grouping health-related claim records associated with a medical procedure, comprising:
a database configured for storing:
a plurality of health-related claim records for at least one patient; and
a plurality of predefined anchor categories, each predefined anchor category including a plurality of clinically related procedures and at least one anchor procedure having an associated time window that is divided into a first sub-window portion and a second sub-window portion different from the first sub-window portion, wherein the first sub-window portion has an associated first claim analysis process and the second sub-window portion has an associated second claim analysis process;
a processor configured for:
identifying an anchor procedure from the stored claim records having the associated time window;
identifying claim records falling within the associated time window using the date of service associated with each claim record;
assessing the identified claim records falling within the first sub-window portion of the time window using the first claim analysis process to determine whether the identified claim records have a first level of relationship with the anchor procedure in which the claim records generally relate to the predefined anchor category associated with the identified anchor procedure;
assessing the identified claim records falling within the second sub-window portion of the time window using the second claim analysis process to determine whether the identified claim records have a second level of relationship with the anchor procedure in which the claim records generally relate to the predefined anchor category associated with the identified anchor procedure, and in which the second claim analysis process further analyzes the claim records to confirm their relationship to the predefined anchor category;
grouping the identified claim records respectively having the first and second level of relationship with the anchor procedure into a procedure episode group; and
storing the procedure episode group of claim records in the electronic database.
6. The system of claim 5 , wherein the first sub-window portion of the associated time window for the anchor record is defined to be in temporally closer proximity to the anchor procedure than the second sub-window portion of the time window for the anchor record.
7. The system of claim 6 , wherein determining the first level of relationship using the first claim analysis process comprises analyzing the claims in the first sub-window portion to determine whether the claim records are associated with ETG data having a predefined relationship to the anchor category.
8. The system of claim 7 , wherein determining the second level of relationship using the second claim analysis process comprises further analyzing the claims in the second sub-window portion to determine whether the claim records are associated with procedure codes having a predefined relationship to the anchor category such that the second level of relationship requires a higher degree of relationship between the identified claim record and the anchor procedure than does the first level of relationship.