Outpatient Diagnostic measures
The following tables list all the measures currently available in Clinical Analytics for Outpatient Diagnostic Encounters (OP Diagnostic).
In these tables, the following appear:
-
Short Description of the measure (what the measure is called in Clinical Analytics)
-
Long Description (to help you understand what the measure is for)
-
Polarity (if high or low values are preferred)
-
If All Payer and/or MedPar benchmarks are currently available for the measure
-
Benchmark calculation level (that is, if the benchmark values are based on the DRG grouping of the encounter, or if they are facility-level).
Click here to download this measure list as a PDF: Outpatient Diagnostic measures (December 2019)
Click here to download all measure lists as a single PDF: Comprehensive Clinical Analytics Measure list
OP Diagnostic Comorbidity measures
These measures help identify patients with additional health factors; encounters are flagged by the AHRQ grouper software. All comorbidity measures have undeterminable polarity.
|
Measure name |
Description |
Polarity |
All Payer benchmarks? |
Medicare benchmarks? |
Benchmark detail level |
|---|---|---|---|---|---|
|
Heart Attack Case |
Number of cases with at least one secondary diagnosis for a heart attack |
N/A |
Yes |
Yes |
Provider |
|
Heart Failure Case |
Number of cases with at least one secondary diagnosis for heart failure |
N/A |
Yes |
Yes |
Provider |
|
Pneumonia Case |
Number of cases with at least one Secondary Diagnosis for pneumonia |
N/A |
Yes |
Yes |
Provider |
|
Septicemia Case |
Number of cases with at least one Secondary Diagnosis for septicemia |
N/A |
Yes |
Yes |
Provider |
|
Stroke Case |
Number of cases with at least one Secondary Diagnosis for a stroke |
N/A |
Yes |
Yes |
Provider |
|
VTE Case |
Number of cases with at least one Secondary Diagnosis for a venous thromboembolism |
N/A |
No |
Yes |
APC |
OP Diagnostic Knowledge measures
These measures help monitor the usage levels of certain services. Low values are desirable for all Knowledge measures.
|
Measure name |
Description |
Polarity |
All Payer benchmarks? |
Medicare benchmarks? |
Benchmark detail level |
|---|---|---|---|---|---|
|
Usage - Blood Use |
Percent of patients with Blood Use Revenue codes: 0380-0387, 0389-0391, 0399 |
Low |
No |
Yes |
APC |
|
Usage - CT Use |
Percent of patients with CT Use Revenue codes: 035X |
Low |
No |
Yes |
APC |
|
Usage - MRI Use |
Percent of patients with MRI Use Revenue codes: 0610-0612, 0614-0616, 0618, 0619 |
Low |
No |
Yes |
APC |
|
Usage - Occupational Therapy Use |
Percent of patients with Occupational Therapy charges Revenue codes: 0430-0434, 0439 |
Low | No | No | APR-DRG/SOI or MS-DRG |
|
Usage - Physical Therapy Use |
Percent of patients with Physical Therapy charges Revenue codes: 0420-0424, 0429 |
Low | No | No | APR-DRG/SOI or MS-DRG |
|
Usage - Respiratory Therapy Use |
Percent of patients with Respiratory Therapy charges Revenue codes: 0410, 0412, 0413, 0419 |
Low | No | No | APR-DRG/SOI or MS-DRG |
|
Usage - Speech Therapy Use |
Percent of patients with Speech Therapy charges Revenue codes: 0440-0444, 0449, 0470-0472, 0479 |
Low | No | No | APR-DRG/SOI or MS-DRG |
|
Usage - PT, OT and Speech Therapy Use |
Percent of patients with at least one revenue code for Physical Therapy, Occupational Therapy, or Speech Therapy Revenue codes: 0420-0424, 0429-0434, 0439-0444, 0449 |
Low |
No |
Yes |
APC |
|
Usage - Radiology Use |
Percent of patients with Radiology Use Revenue codes: 0320-0324, 0329, 0330, 0339-0342, 0349-0352, 0359, 0400-0404, 0409 |
Low |
No |
Yes |
APC |
OP Diagnostic Quality measures
These measures help you track typical patient outcomes, such as readmissions and mortality, as well as core measures data from your third-party vendor.
|
Measure name |
Description |
Polarity |
All Payer benchmarks? |
Medicare benchmarks? |
Benchmark detail level |
|---|---|---|---|---|---|
|
Mortality Rate |
Number of deaths in-house divided by number of patients |
Low |
No |
No |
N/A |
|
Mortality without Palliative Rate |
Number of in-house deaths (excluding deaths of patients with palliative care) divided by number of patients |
Low |
No |
No |
N/A |
| Mortality Rate (with Exclusions) | Number of deaths in-house divided by number of patients; numerator and denominator also exclude patients transferred in (4, A), transferred out (2, 5, 43, 82), or discharged Against Medical Advice (AMA: 7). |
Low |
Yes |
Yes |
APR-DRG/ROM or MS-DRG |
| Mortality without Palliative Rate (with Exclusions) |
Number of in-house deaths (excluding deaths of patients with palliative care) divided by number of patients; numerator and denominator also exclude patients transferred in (4, A), transferred out (2, 5, 43, 82), or discharged Against Medical Advice (AMA: 7). |
Low |
Yes |
Yes |
APR-DRG/ROM or MS-DRG |
|
Patient Returns measures |
|||||
|
Hours to Return (Any Patient Type) |
Average number of hours from patient discharge date/time to subsequent admit date/time. Note that the return encounter can be for any patient type. |
High |
No |
No |
N/A |
|
Patient returns within 24 hours (Any Patient Type) |
Percent of patients who were re-admitted as any patient type within 24 hours of discharge. |
Low |
No |
No |
N/A |
|
Patient returns within 48 hours (Any Patient Type) |
Percent of patients who were re-admitted as any patient type within 48 hours of discharge. |
Low |
No |
No |
N/A |
|
Days to Return (Any Patient Type) - Decimal |
Average number of days from patient discharge date/time to subsequent admit date/time. Note that the return encounter can be for any patient type. |
High |
No |
No |
N/A |
|
Patient returns within 7 days (Any Patient Type) |
Percent of patients who were re-admitted as any patient type within 7 days of discharge. |
Low |
No |
No |
N/A |
|
Patient returns within 14 days (Any Patient Type) |
Percent of patients who were re-admitted as any patient type within 14 days of discharge. |
Low |
No |
No |
N/A |
|
Patient returns within 30 days (Any Patient Type) |
Percent of patients who were re-admitted as any patient type within 30 days of discharge. |
Low |
No |
No |
N/A |
|
Returns to ED measures |
|||||
|
Hours to Return to ED |
Average number of hours from patient discharge date/time to subsequent Emergency Department admit date/time. |
High |
No |
No |
N/A |
|
Patient returns to ED within 24 hours |
Percent of patients who were re-admitted to the Emergency Department within 24 hours of discharge. |
Low |
No |
No |
N/A |
|
Patient returns to ED within 48 hours |
Percent of patients who were re-admitted to the Emergency Department within 48 hours of discharge. |
Low |
No |
No |
N/A |
|
Days to Return to ED - Decimal |
Average number of days from patient discharge date/time to subsequent Emergency Department admit date/time. |
High |
No |
No |
N/A |
|
Patient returns to ED within 7 days |
Percent of patients who were re-admitted to the Emergency Department within 7 days of discharge. |
Low |
No |
No |
N/A |
|
Patient returns to ED within 14 days |
Percent of patients who were re-admitted to the Emergency Department within 14 days of discharge. |
Low |
No |
No |
N/A |
|
Patient returns to ED within 30 days |
Percent of patients who were re-admitted to the Emergency Department within 30 days of discharge. |
Low |
No |
No |
N/A |
|
Returns to Surgery measures |
|||||
|
Hours to Return to Surgery |
Average number of hours from patient discharge date/time to subsequent surgery encounter admit date/time. Note that the returns include inpatient encounters with a surgical MS-DRG and ASC (outpatient ambulatory surgery) encounters. |
High |
No |
No |
N/A |
|
Patient returns to Surgery within 24 hours |
Percent of patients who were re-admitted as a surgical patient within 24 hours of discharge. Note that the returns include inpatient encounters with a surgical MS-DRG and ASC (outpatient ambulatory surgery) encounters. |
Low |
No |
No |
N/A |
|
Patient returns to Surgery within 48 hours |
Percent of patients who were re-admitted as a surgical patient within 48 hours of discharge. Note that the returns include inpatient encounters with a surgical MS-DRG and ASC (outpatient ambulatory surgery) encounters. |
Low |
No |
No |
N/A |
|
Days to Return to Surgery - Decimal |
Average number of days from patient discharge date/time to subsequent surgery encounter admit date/time. Note that the returns include inpatient encounters with a surgical MS-DRG and ASC (outpatient ambulatory surgery) encounters. |
High |
No |
No |
N/A |
|
Patient returns to Surgery within 7 days |
Percent of patients who were re-admitted as a surgical patient within 7 days of discharge. Note that the returns include inpatient encounters with a surgical MS-DRG and ASC (outpatient ambulatory surgery) encounters. |
Low |
No |
No |
N/A |
|
Patient returns to Surgery within 14 days |
Percent of patients who were re-admitted as a surgical patient within 14 days of discharge. Note that the returns include inpatient encounters with a surgical MS-DRG and ASC (outpatient ambulatory surgery) encounters. |
Low |
No |
No |
N/A |
|
Patient returns to Surgery within 30 days |
Percent of patients who were re-admitted as a surgical patient within 30 days of discharge. Note that the returns include inpatient encounters with a surgical MS-DRG and ASC (outpatient ambulatory surgery) encounters. |
Low |
No |
No |
N/A |
OP Diagnostic Systems measures
These measures are summary statistics of your patient populations, like gender and admission source.
|
Measure name |
Description |
Polarity |
All Payer benchmarks? |
Medicare benchmarks? |
Benchmark detail level |
|---|---|---|---|---|---|
|
Volume |
Count of inpatient discharges |
High |
No |
No |
N/A |
|
Gender - Female |
Number of female patients divided by the total number of discharges |
N/A |
No |
No |
N/A |
|
Gender - Male |
Number of male patients divided by the total number of discharges |
N/A |
No |
No |
N/A |
|
Discharge Disposition measures |
|||||
|
% Admitted As an Inpatient to This Hospital |
Percent of outpatient encounters admitted as an inpatient to this hospital: Number of encounters with Discharge Disposition=9 divided by the total number of discharges |
N/A |
Yes |
Yes |
APR-DRG/SOI or MS-DRG |
|
% Discharged To Home / Self Care (Routine Discharge) |
Percent of patients discharged to home or self-care (routine discharge): Number of encounters with Discharge Disposition=1 divided by the total number of discharges |
N/A |
Yes |
Yes |
APR-DRG/SOI or MS-DRG |
|
% Discharged / Transferred / Referred To another Institution for Outpatient Services |
Percent of patients discharged, transferred, or referred to another institution for outpatient services: Number of encounters with Discharge Disposition=71 divided by the total number of discharges |
N/A |
Yes |
Yes |
APR-DRG/SOI or MS-DRG |
|
% Discharged / Transferred / Referred To This Institution for Outpatient Services |
Percent of patients discharged, transferred, or referred to this institution for outpatient services: Number of encounters with Discharge Disposition=72 divided by the total number of discharges |
N/A |
Yes |
Yes |
APR-DRG/SOI or MS-DRG |
|
% Discharged / Transferred To Home Care |
Percent of patients discharged or transferred to Home Care: Number of encounters with Discharge Disposition=6 divided by the total number of discharges |
N/A |
Yes |
Yes |
APR-DRG/SOI or MS-DRG |
|
% Discharged / Transferred To a Long Term Care |
Percent of patients discharged or transferred to a long-term care facility: Number of encounters with Discharge Disposition=63 divided by the total number of discharges |
N/A |
Yes |
Yes |
APR-DRG/SOI or MS-DRG |
|
% Discharged / Transferred To a Nursing Facility |
Percent of patients discharged or transferred to a nursing facility: Number of encounters with Discharge Disposition=64 divided by the total number of discharges |
N/A |
Yes |
Yes |
APR-DRG/SOI or MS-DRG |
|
% Discharged / Transferred To an Inpatient Rehabilitation Facility |
Percent of patients discharged or transferred to an inpatient rehabilitation facility: Number of encounters with Discharge Disposition=62 divided by the total number of discharges |
N/A |
Yes |
Yes |
APR-DRG/SOI or MS-DRG |
|
% Discharged / Transferred To another Type of Institution for Inpatient Care |
Percent of patients discharged or transferred to another type of institution for inpatient care: Number of encounters with Discharge Disposition=5 divided by the total number of discharges |
N/A |
Yes |
Yes |
APR-DRG/SOI or MS-DRG |
|
% Discharged / Transferred To Home under Care of a Home IV Drug Therapy Provider |
Percent of patients discharged or transferred to home under care of a home iv drug therapy provider: Number of encounters with Discharge Disposition=8 divided by the total number of discharges |
N/A |
Yes |
Yes |
APR-DRG/SOI or MS-DRG |
|
% Discharged / Transferred To Intermediate Care Facility |
Percent of patients discharged or transferred to intermediate care facility: Number of encounters with Discharge Disposition=4 divided by the total number of discharges |
N/A |
Yes |
Yes |
APR-DRG/SOI or MS-DRG |
|
% Discharged / Transferred To Other Short Term General Hospital for Inpatient Care |
Percent of patients discharged or transferred to other short-term general hospital for inpatient care: Number of encounters with Discharge Disposition=2 divided by the total number of discharges |
N/A |
Yes |
Yes |
APR-DRG/SOI or MS-DRG |
|
% Discharged / Transferred To Skilled Nursing Facility (SNF) |
Percent of patients discharged or transferred to skilled nursing facility (SNF): Number of encounters with Discharge Disposition=3 divided by the total number of discharges |
N/A |
Yes |
Yes |
APR-DRG/SOI or MS-DRG |
|
% Discharged / Transferred Within This Institution to a Hospital-Based Medicare Approved Swing Bed |
Percent of patients discharged or transferred within this institution to a hospital-based Medicare-approved swing bed: Number of encounters with Discharge Disposition=61 divided by the total number of discharges |
N/A |
Yes |
Yes |
APR-DRG/SOI or MS-DRG |
|
% Discharged/transferred to a Critical Access Hospital (CAH) |
Percent of patients discharged or transferred to a critical access hospital (CAH): Number of encounters with Discharge Disposition=66 divided by the total number of discharges |
N/A |
Yes |
Yes |
APR-DRG/SOI or MS-DRG |
|
% Discharged/transferred to a federal hospital |
Percent of patients discharged or transferred to a federal hospital: Number of encounters with Discharge Disposition=43 divided by the total number of discharges |
N/A |
Yes |
Yes |
APR-DRG/SOI or MS-DRG |
|
% Discharged/Transferred to a psychiatric hospital or psychiatric distinct unit of a hospital |
Percent of patients discharged or transferred to a psychiatric hospital or psychiatric distinct unit of a hospital: Number of encounters with Discharge Disposition=65 divided by the total number of discharges |
N/A |
Yes |
Yes |
APR-DRG/SOI or MS-DRG |
|
% Expired - At Home (Hospice Claims Only) |
Percent of patients discharged expired - at home (hospice claims only): Number of encounters with Discharge Disposition=40 divided by the total number of discharges |
N/A |
Yes |
Yes |
APR-DRG/SOI or MS-DRG |
|
% Expired - Did Not Recover (Christian Science Patient) |
Percent of patients discharged expired (or "did not recover" for Christian Science patients): Number of encounters with Discharge Disposition=20 divided by the total number of discharges |
N/A |
Yes |
Yes |
APR-DRG/SOI or MS-DRG |
|
% Expired - In a Medical Facility Such as Hospital, SNF, ICF, or Freestanding Hospice |
Percent of patients discharged expired from a medical facility such as hospital, SNF, ICF, or freestanding hospice: Number of encounters with Discharge Disposition=41 divided by the total number of discharges |
N/A |
Yes |
Yes |
APR-DRG/SOI or MS-DRG |
|
% Expired - Place Unknown (Hospice Claims Only) |
Percent of patients discharged expired - place unknown (hospice claims only): Number of encounters with Discharge Disposition=42 divided by the total number of discharges |
N/A |
Yes |
Yes |
APR-DRG/SOI or MS-DRG |
|
% Hospice - Home |
Percent of patients discharged to hospice - home: Number of encounters with Discharge Disposition=50 divided by the total number of discharges |
N/A |
Yes |
Yes |
APR-DRG/SOI or MS-DRG |
|
% Hospice - Medical Facility |
Percent of patients discharged to hospice - medical facility: Number of encounters with Discharge Disposition=51 divided by the total number of discharges |
N/A |
Yes |
Yes |
APR-DRG/SOI or MS-DRG |
|
% Left Against Medical Advice or Discontinued Care |
Percent of patients who left against medical advice (AMA) or discontinued care: Number of encounters with Discharge Disposition=7 divided by the total number of discharges |
N/A |
Yes |
Yes |
APR-DRG/SOI or MS-DRG |
|
% Still Patient |
Percent of patients who are still a patient: Number of encounters with Discharge Disposition=30 divided by the total number of discharges |
N/A |
Yes |
Yes |
APR-DRG/SOI or MS-DRG |
OP Diagnostic Utilization measures
These measures help you analyze patient days, LOS, and costs/charges throughout your facility.
|
Measure name |
Description |
Polarity |
All Payer benchmarks? |
Medicare benchmarks? |
Benchmark detail level |
|---|---|---|---|---|---|
|
Observation Hours |
Average number of observation days per patient Revenue Codes: 0762, 0760 |
Low |
No |
No |
N/A |
|
Patient Stayed Two Midnights |
Flag of 0 or 1, where 1 indicates that a given encounter was discharged at least two midnights after admission |
Low |
No |
Yes |
APC |
|
Charges measures |
|||||
|
Charges - Total |
Sum of all charges divided by volume of cases |
Low |
No |
Yes |
APC |
|
Charges - Ambulance |
Sum of ambulance charges divided by volume of cases Revenue codes: 0540-0549 |
Low |
No |
Yes |
APC |
|
Charges - Anesthesiology |
Sum of anesthesiology charges divided by volume of cases Revenue codes: 0370-0372, 0374, 0379 |
Low |
No |
Yes |
APC |
|
Charges - Blood Administration |
Sum of blood administration charges divided by volume of cases Revenue codes: 0390, 0391, 0399 |
Low |
No |
Yes |
APC |
|
Charges - Blood Use |
Sum of blood use charges divided by volume of cases Revenue codes: 0380-0387, 0389 |
Low |
No |
Yes |
APC |
|
Charges - Cardiology |
Sum of cardiology charges divided by volume of cases Revenue codes: 0480-0483, 0489, 0730-0732, 0739 |
Low |
No |
Yes |
APC |
|
Charges - Clinic Visit |
Sum of clinic visit charges divided by volume of cases Revenue codes: 0510-0517, 0519 |
Low |
No |
Yes |
APC |
|
Charges - Durable Medical Equipment |
Sum of durable medical equipment charges divided by volume of cases Revenue codes: 0290-0292, 0294, 0299 |
Low |
No |
Yes |
APC |
|
Charges - Emergency Department |
Sum of emergency room department charges divided by volume of cases Revenue codes: 0450-0452, 0456, 0459 |
Low |
No |
Yes |
APC |
|
Charges - ESRD Revenue Setting |
Sum of ESRD revenue-setting charges divided by volume of cases Revenue codes: 0800-0804, 0809, 0820-0825, 0829-0835, 0839-0845, 0849-0855, 0859-0882, 0889 |
Low |
No |
Yes |
APC |
|
Charges - Labor and Delivery |
Sum of labor and delivery charges divided by volume of cases Revenue codes: 0720-0724, 0729 |
Low |
No |
Yes |
APC |
|
Charges - Laboratory and Pathology |
Sum of laboratory& pathology charges divided by volume of cases Revenue codes: 0300-0307, 0309-0312, 0314, 0319, 0740, 0749, 0750, 0759 |
Low |
No |
Yes |
APC |
|
Charges - Lithotripsy |
Sum of lithotripsy charges divided by volume of cases Revenue codes: 0790, 0799 |
Low |
No |
Yes |
APC |
|
Charges - Medical/Surgical Supplies |
Sum of medical/surgical supply charges divided by volume of cases Revenue codes: 0270-0279, 0620-0624 |
Low |
No |
Yes |
APC |
|
Charges - MRI |
Sum of MRI charges divided by volume of cases Revenue codes: 0610-0612, 0614-0616, 0618, 0619 |
Low |
No |
Yes |
APC |
|
Charges - Nuclear Medicine |
Sum of nuclear medicine charges divided by volume of cases Revenue codes: 340-342, 349 |
Low |
No |
Yes |
APC |
|
Charges - Nursery and NICU |
Sum of nursery and NICU Charges divided by volume of cases Revenue codes: 0230-0232, 0234, 0235, 0239, 0240, 0249 |
Low |
No |
Yes |
APC |
|
Charges - Occupation Therapy |
Sum of occupational therapy charges divided by volume of cases Revenue codes: 0430-0434, 0439 |
Low |
No |
Yes |
APC |
|
Charges - Oncology |
Sum of oncology charges divided by volume of cases Revenue codes: 0280, 0289, 0331-0333, 0335 |
Low |
No |
Yes |
APC |
|
Charges - Operating Room and Labor & Delivery |
Sum of operating room labor and delivery charges divided by volume of cases Revenue codes: 0360-0362, 0367, 0369, 0710, 0719, 0720-0724, 0729 |
Low |
No |
Yes |
APC |
|
Charges - Organ Acquisition |
Sum of organ acquisition charges divided by volume of cases Revenue codes: 0810-0814, 0819, 0890-0893, 0899 |
Low |
No |
Yes |
APC |
|
Charges - Other |
Sum of other charges divided by volume of cases Revenue codes: 0220-0224, 0229-0235, 0239, 0240, 0249, 0520-0523, 0526, 0529, 0530, 0531, 0539, 0550-0553, 0559-0562, 0569-0572, 0579-0583, 0589, 0590, 0599-0604, 0640-0652, 0655-0663, 0669-0672, 0679, 0681-0684, 0689, 0700, 0709, 0760-0762, 0769-0771, 0779, 0780, 0900, 0901-0907, 0909-0925, 0929, 0931, 0932, 0940-0947, 0949-0952, 0990-0999 |
Low |
No |
Yes |
APC |
|
Charges - Other Not Including Nursery and NICU and Psych |
Sum of other charges (without NICU or psych) divided by volume of cases Revenue codes: 0220-0224, 0229, 0520-0523, 0526, 0529-0531, 0539, 0550-0553, 0559-0562, 0569-0572, 0579-0583, 0589, 0590, 0599-0604, 0640-0652, 0655-0663, 0669-0672, 0679, 0681-0684, 0689, 0700, 0709, 0760-0762, 0769-0771, 0779, 0780, 0920-0925, 0929, 0931, 0932, 0940-0947, 0949-0952, 0990-0999 |
Low |
No |
Yes |
APC |
|
Charges - Outpatient Services |
Sum of outpatient services charges divided by volume of cases Revenue codes: 0490, 0499, 0500, 0509 |
Low |
No |
Yes |
APC |
|
Charges - Pathology |
Sum of pathology charges divided by volume of cases Revenue codes: 0310-0312, 0314, 0319 |
Low |
No |
Yes |
APC |
|
Charges - Pharmacy |
Sum of pharmacy charges divided by volume of cases Revenue codes: 0250-0263, 0264, 0269, 0630-0637 |
Low |
No |
Yes |
APC |
|
Charges - Physical Therapy |
Sum of physical therapy charges divided by volume of cases Revenue codes: 0420-0424, 0429 |
Low |
No |
Yes |
APC |
|
Charges - Professional Fee |
Sum of professional fees charges Revenue codes: 0960-0964, 0969, 0971-0979, 0981-0989 |
Low |
No |
Yes |
APC |
|
Charges - Psych Services |
Sum of psych charges divided by volume of cases Revenue codes: 0900-0907, 0909-0919 |
Low |
No |
Yes |
APC |
|
Charges - Radiology and CT Scan |
Sum of radiology and CT scan charges divided by volume of cases Revenue codes: 0320-0324, 0329, 0350-0352, 0359, 0400-0404, 0409 |
Low |
No |
Yes |
APC |
|
Charges - Radiology, CT, Oncology & Nuclear Med. |
Sum of radiology charges divided by volume of cases Revenue codes: 0280, 0289, 0320-0324, 0329-0333, 0335, 0339-0342, 0349-0352, 0359, 0400-0404, 0409 |
Low |
No |
Yes |
APC |
|
Charges - Respiratory Services |
Sum of respiratory services charges divided by volume of cases Revenue codes: 0410, 0412, 0413, 0419 |
Low |
No |
Yes |
APC |
|
Charges - Respiratory Therapy |
Sum of inhalation therapy charges divided by volume of cases Revenue codes: 0410, 0412, 0413, 0419 |
Low |
No |
Yes |
APC |
|
Charges - Speech Pathology |
Sum of speech pathology charges divided by volume of cases Revenue codes: 0440-0444, 0449, 0470-0472, 0479 |
Low |
No |
Yes |
APC |
|
Charges - Therapy: Physical, Occupational, Speech |
Sum of physical, occupational and speech therapy divided by volume of cases -Physical therapy revenue codes: 0420-0424, 0429 -Occupational therapy revenue codes: 0430-0434, 0439 -Speech pathology revenue codes: 0440-0444, 0449, 0470-0472, 0479 |
Low |
No |
Yes |
APC |
|
Charges - Used Durable Medical Equipment |
Sum of used durable medical equipment charges divided by volume of cases Revenue code: 0293 |
Low |
No |
Yes |
APC |
|
Cost measures |
|||||
|
Cost - Total |
Sum of all costs divided by volume of cases |
Low |
No |
Yes |
APC |
|
Cost - Ambulance |
Sum of ambulance costs divided by volume of cases Revenue codes: 0540-0549 |
Low |
No |
Yes |
APC |
|
Cost - Anesthesiology |
Sum of anesthesiology costs divided by volume of cases Revenue codes: 0370-0372, 0374, 0379 |
Low |
No |
Yes |
APC |
|
Cost - Blood Administration |
Sum of blood administration costs divided by volume of cases Revenue codes: 0390, 0391, 0399 |
Low |
No |
Yes |
APC |
|
Cost - Blood Use |
Sum of blood use costs divided by volume of cases Revenue codes: 0380-0387, 0389 |
Low |
No |
Yes |
APC |
|
Cost - Cardiology |
Sum of cardiology costs divided by volume of cases Revenue codes: 0480-0483, 0489, 0730-0732, 0739 |
Low |
No |
Yes |
APC |
|
Cost - Clinic Visit |
Sum of clinic visit costs divided by volume of cases Revenue codes: 0510-0517, 0519 |
Low |
No |
Yes |
APC |
|
Cost - Durable Medical Equipment |
Sum of durable medical equipment costs divided by volume of cases Revenue codes: 0290-0292, 0294, 0299 |
Low |
No |
Yes |
APC |
|
Cost - Emergency Department |
Sum of emergency room department costs divided by volume of cases Revenue codes: 0450-0452, 0456, 0459 |
Low |
No |
Yes |
APC |
|
Cost - ESRD Revenue Setting |
Sum of ESRD revenue-setting costs divided by volume of cases Revenue codes: 0800-0804, 0809, 0820-0825, 0829-0835, 0839-0845, 0849-0855, 0859-0882, 0889 |
Low |
No |
Yes |
APC |
|
Cost - Intermediate ICU/CCU |
Sum of intermediate ICU/ CCU costs (Revenue codes 206 and 214) divided by volume of cases Revenue codes: 206, 214 |
Low |
No |
Yes |
APC |
|
Cost - Labor and Delivery |
Sum of labor and delivery costs divided by volume of cases Revenue codes: 0720-0724, 0729 |
Low |
No |
Yes |
APC |
|
Cost - Laboratory and Pathology |
Sum of laboratory& pathology costs divided by volume of cases Revenue codes: 0300-0307, 0309-0312, 0314, 0319, 0740, 0749, 0750, 0759 |
Low |
No |
Yes |
APC |
|
Cost - Lithotripsy |
Sum of lithotripsy costs divided by volume of cases Revenue codes: 0790, 0799 |
Low |
No |
Yes |
APC |
|
Cost - Medical/Surgical Supplies |
Sum of medical/surgical supplies divided by volume of cases Revenue codes: 0270-0279, 0620-0624 |
Low |
No |
Yes |
APC |
|
Cost - MRI |
Sum of MRI costs divided by volume of cases Revenue codes: 0610-0612, 0614-0616, 0618, 0619 |
Low |
No |
Yes |
APC |
|
Cost - Nuclear Medicine |
Sum of nuclear medicine costs divided by volume of cases Revenue codes: 340-342, and 349 |
Low |
No |
Yes |
APC |
|
Cost - Nursery and NICU |
Sum of nursery and NICU costs divided by volume of cases Revenue codes: 0230-0232, 0234, 0235, 0239, 0240, 0249 |
Low |
No |
Yes |
APC |
|
Cost - Occupation Therapy |
Sum of occupational therapy costs divided by volume of cases Revenue codes: 0430-0434, 0439 |
Low |
No |
Yes |
APC |
|
Cost - Oncology |
Sum of oncology costs divided by volume of cases Revenue codes: 0280, 0289, 0331-0333, 0335 |
Low |
No |
Yes |
APC |
|
Cost - Operating Room and Labor & Delivery |
Sum of operating room labor and delivery costs divided by volume of cases Revenue codes: 0360- 0362, 0367, 0369, 0710, 0719, 0720-0724, 0729 |
Low |
No |
Yes |
APC |
|
Cost - Organ Acquisition |
Sum of organ acquisition costs divided by volume of cases Revenue codes: 0810-0814, 0819, 0890-0893, 0899 |
Low |
No |
Yes |
APC |
|
Cost - Other |
Sum of other costs divided by volume of cases Revenue codes: 0220-0224, 0229-0235, 0239, 0240, 0249, 0520-0523, 0526, 0529-0531, 0539, 0550-0553, 0559-0562, 0569-0572, 0579-0583, 0589, 0590, 0599-0604, 0640-0652, 0655-0663, 0669-0672, 0679, 0681-0684, 0689, 0700, 0709, 0760-0762, 0769-0771, 0779, 0780, 0900-0907, 0909, 0910-0925, 0929, 0931, 0932, 0940-0947, 0949-0952, 0990-0999 |
Low |
No |
Yes |
APC |
|
Cost - Other Not Including Nursery and NICU and Psych |
Sum of other costs (without NICU or psych) divided by volume of cases Revenue codes: 0220-0224, 0229, 0520-0523, 0526, 0529-0531, 0539, 0550-0553, 0559-0562, 0569-0572, 0579-0583, 0589, 0590, 0599-0604, 0640-0652, 0655-0663, 0669-0672, 0679, 0681-0684, 0689, 0700, 0709, 0760-0762, 0769-0771, 0779, 0780, 0920-0925, 0929, 0931, 0932, 0940-0947, 0949-0952, 0990-0999 |
Low |
No |
Yes |
APC |
|
Cost - Outpatient Services |
Sum of outpatient services costs divided by volume of cases Revenue codes: 0490, 0499, 0500, 0509. |
Low |
No |
Yes |
APC |
|
Cost - Pathology |
Sum of pathology costs divided by volume of cases Revenue codes: 0310-0312, 0314, 0319. |
Low |
No |
Yes |
APC |
|
Cost - Pharmacy |
Sum of pharmacy costs divided by volume of cases Revenue codes: 0250-0264, 0269, 0630-0637. |
Low |
No |
Yes |
APC |
|
Cost - Physical Therapy |
Sum of physical therapy costs divided by volume of cases Revenue codes: 0420-0424, 0429. |
Low |
No |
Yes |
APC |
|
Cost - Professional Fee |
Sum of professional fees costs Revenue codes: 0960-0964, 0969, 0971-0979, 0981-0989 |
Low |
No |
Yes |
APC |
|
Cost - Psych Services |
Sum of psych costs divided by volume of cases Revenue codes: 0900-0907, 0909-0919 |
Low |
No |
Yes |
APC |
|
Cost - Radiology and CT Scan |
Sum of radiology and CT scan costs divided by volume of cases Revenue codes: 0320-0324, 0329, 0350-0352, 0359, 0400-0404, 0409 |
Low |
No |
Yes |
APC |
|
Cost - Radiology, CT, Oncology & Nuclear Med. |
Sum of radiology costs divided by volume of cases Revenue codes: 0280, 0289, 0320-0324, 0329-0333, 0335, 0339-0342, 0349-0352, 0359, 0400-0404, 0409 |
Low |
No |
Yes |
APC |
|
Cost - Respiratory Services |
Sum of respiratory services costs divided by volume of cases Revenue codes: 0410, 0412, 0413, 0419 |
Low |
No |
Yes |
APC |
|
Cost - Respiratory Therapy |
Sum of inhalation therapy costs divided by volume of cases Revenue codes: 0410, 0412, 0413, 0419 |
Low |
No |
Yes |
APC |
|
Cost - Speech Pathology |
Sum of speech pathology costs divided by volume of cases Revenue codes: 0440-0444, 0449, 0470-0472, 0479 |
Low |
No |
Yes |
APC |
|
Cost - Therapy: Physical, Occupational, Speech |
Sum of physical, occupational, and speech therapy divided by volume of cases -Physical therapy revenue codes: 0420-0424, 0429 -Occupational therapy revenue codes: 0430-0434, 0439 -Speech pathology revenue codes: 0440-0444, 0449, 0470-0472, 0479 |
Low |
No |
Yes |
APC |
|
Cost - Used Durable Medical Equipment |
Sum of used durable medical equipment costs divided by volume of cases Revenue code: 0293 |
Low |
No |
Yes |
APC |
|
Total Indirect Costs |
Total indirect costs as defined in client’s cost accounting system. |
Low |
No |
Yes |
APC |
|
Total Direct Costs |
Total direct costs as defined in client’s cost accounting system. |
Low |
No |
Yes |
APC |
|
Total Variable Costs |
Total variable costs as defined in client’s cost accounting system. |
Low |
No |
No |
N/A |
|
Total Fixed Costs |
Total fixed costs as defined in client’s cost accounting system. |
Low |
No |
No |
N/A |
|
Other Utilization measures |
|||||
|
Contractual Allowance and Adjustments |
Contractual allowance and adjustments equals charges minus total actual payment |
Low |
No |
No |
N/A |
|
LOS (hours) |
Average length of stay, in hours, for all patients |
Low |
No |
Yes |
APC |
|
Number of Consultants |
Number of consultant physicians utilized for this encounter |
Low |
No |
Yes |
APC |
|
Expected Payment |
Total expected payment as defined in client’s cost accounting system. |
Low |
No |
No |
N/A |
|
Total Actual Payment |
Total actual payment as defined in client’s cost accounting system. |
Low |
No |
No |
N/A |
|
Expected Net Income |
Expected total actual payment minus total costs |
High |
No |
No |
N/A |
|
Net Income |
Net Income equals total actual payment minus total costs |
High |
No |
No |
N/A |
|
Expected Contribution Margin |
Expected Total Actual Payment minus Total Variable Costs |
High |
No |
No |
N/A |
|
Contribution Margin |
Total Actual Payment minus Total Variable Costs |
High |
No |
No |
N/A |
|
Medicare Contribution Margin |
Total Actual Medicare Payment minus Total Variable Costs |
High |
No |
No |
N/A |
|
Medicare Net Income |
Total actual Medicare payment minus total costs |
High |
No |
No |
N/A |
|
Medicare Reimbursement |
Total actual Medicare payment |
High |
No |
No |
N/A |
OP Diagnostic Payments & Adjustments measures
These measures are based on the Transaction Type specified in your billing data.
|
Measure name |
Description |
Polarity |
All Payer benchmarks? |
Medicare benchmarks? |
Benchmark detail level |
|---|---|---|---|---|---|
|
Final Billed |
A flag indicating if the account has been Final Billed |
High |
No |
No |
N/A |
|
Patient Payment at POS |
Amount of patient payment made on the date(s) of service |
High |
No |
No |
N/A |
|
Patient Pay Write-Off |
Sum of all charge amounts written off by the provider because the patient did not pay them |
Low |
No |
No |
N/A |
|
Charity Care |
Sum of all charges discounted by the facility as free or reduced-cost care for patient in financial hardship |
Low |
No |
No |
N/A |
|
Other Adjustments |
Sum of all other adjustments made to the Open Balance |
Low |
No |
No |
N/A |
|
Payments - Patient |
Sum of all payments made to an account by the patient (classified "Self") |
Low |
No |
No |
N/A |
|
Payments - Insurance |
Sum of all payments made to an account by an insurance provider; this includes Blue Cross/Blue Shield, Champus/Tricare/VA, CHP, Medicaid, Medicare, Other Govt, Private Ins, Workers Compensation and possibly others. |
Low |
No |
No |
N/A |
|
Payments - Total |
Sum of all Patient and Insurance payments made to an account |
Low |
No |
No |
N/A |
|
Contractual Allowance |
Sum of all Contractual Allowance adjustments made to an account; contractual allowance refers to the amount an insurance company does not pay to an account because of previous agreements with the facility as to the charges for a service. |
Low |
No |
No |
N/A |
|
Denials |
Sum of all charge amounts denied by insurance |
Low |
No |
No |
N/A |
|
Payments - Other |
Sum of all payments made to a patient account not classified as "Insurance" or "Patient Pay"; this can include Charity, Other, Unknown, and missing values. |
Low |
No |
No |
N/A |
|
Employee Discount |
Sum of all Employee Discount adjustments made to an account |
Low |
No |
No |
N/A |
|
Self-Pay Discount |
Sum of all Self-Pay Discount adjustments made to an account |
Low |
No |
No |
N/A |
|
Not Covered by Insurance |
Sum of all charges on an account not paid by insurance because they are not covered |
Low |
No |
No |
N/A |
OP Diagnostic Revenue Cycle measures
These measures are based on billing data sent to Clinical Analytics.
|
Measure name |
Description |
Polarity |
All Payer benchmarks? |
Medicare benchmarks? |
Benchmark detail level |
|---|---|---|---|---|---|
|
Aging Category (366+) |
Account was paid in full (Open Balance = $0) over 365 days of the patient discharge date |
N/A |
No |
No |
N/A |
|
Aging Category (181-365) |
Account was paid in full (Open Balance = $0) within 181-365 days of the patient discharge date |
N/A |
No |
No |
N/A |
|
Aging Category (151-180) |
Account was paid in full (Open Balance = $0) within 151-180 days of the patient discharge date |
N/A |
No |
No |
N/A |
|
Aging Category (121-150) |
Account was paid in full (Open Balance = $0) within 121-150 days of the patient discharge date |
N/A |
No |
No |
N/A |
|
Aging Category (91-120) |
Account was paid in full (Open Balance = $0) within 91-120 days of the patient discharge date |
N/A |
No |
No |
N/A |
|
Aging Category (61-90) |
Account was paid in full (Open Balance = $0) within 61-90 days of the patient discharge date |
N/A |
No |
No |
N/A |
|
Aging Category (31-60) |
Account was paid in full (Open Balance = $0) within 31-60 days of the patient discharge date |
N/A |
No |
No |
N/A |
|
Aging Category (0-30) |
Account was paid in full (Open Balance = $0) within 30 days of the patient discharge date |
N/A |
No |
No |
N/A |
|
Aging Category - Closed to Zero Balance |
A letter designating the aging category of the account based on the Zero Balance Age. Category assignments are as follows: A represents 0-30 days; B represents 31-60 days; C represents 61-90 days; D represents 91-120 days; E represents 121-150 days; F represents 151-180 days; G represents 181-365 days; and H represents 366+ days |
N/A |
No |
No |
N/A |
|
Zero Balance Age (in Days) |
Number of days from the patient discharge date to the date when Open Balance is equal to $0 |
Low |
No |
No |
N/A |
|
Open Balance |
Total open balance on the account |
Low |
No |
No |
N/A |
|
Credit Balance |
Amount of overpayment on the account; this amount shows $0 if the Open Balance is greater than or equal to $0 |
Low |
No |
No |
N/A |
