11

Selected Episode Grouping Selected Episode Grouping IssuesIssues

Frederick Thomas, Ph.D.Frederick Thomas, Ph.D.Centers for Medicare & Medicaid Centers for Medicare & Medicaid

ServicesServices

22

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

33

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

44

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

55

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

66

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]

77

Severity AdjustmentSeverity Adjustment

Used to help identify Used to help identify complexity and resource use complexity and resource use

88

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

99

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

1010

Disease Staging ExampleDisease Staging Example

1111

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

1212

ETG Severity ScoreETG Severity Score

1313

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

21

1414

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

1515

Comparing Grouper Logic Comparing Grouper Logic

1616

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

1717

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

1818

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

1919

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

2020

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”

2121

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

2222

Philosophical Issue Philosophical Issue Example Example

Bundling physician claims Bundling physician claims with an inpatient staywith an inpatient stay

2323

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

2424

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

2525

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?