US5970463A
Expired / Lapsed
US
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Medical claims integration and data analysis system
Assignee: Practice Patterns Science Inc
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Filing: 1996-05-01
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Granted: 1999-10-19
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Expires: 2016-05-01
Abstract
Abstract A medical claims analysis system and method categorizes medical claims into episodes of care having predetermined diagnostic cluster types. The system analyzes medical claim items, some of which have principal diagnosis codes, and some of which have non-principal, missing, or incorrect diagnosis codes. Patient treatment episodes (PTEs) are formed from the principal diagnosis codes, each PTE being of a particular diagnostic cluster type. The system categorizes non-principal-diagnosis claim items into the PTEs on the basis of temporal, physiological or clinical relationships between the claim items and the PTEs. A drug lookup table enables drug claims to be properly categorized in the PTEs. A diagnostic cluster lookup table enables claim items to be categorized into PTEs with ongoing treatment windows for which the diagnosis code of the claim item is in the diagnostic cluster lookup table. The system merges PTEs of the same diagnostic cluster type when the treatment windows of the PTEs overlap. The system attempts to recategorize medical claims into merged PTEs. The system analyzes each PTE to determine the presence of required diagnoses and eliminates any PTE without a required diagnosis. The system also identifies and merges PTEs that are clinically related or clinically similar. In a system for integrating medical claims data, medical claim items that are in different data formats and/or use different coding systems are analyzed, and related claim items are categorized in a common coding system.
Inventors
- 👤 Douglas G. Cave
- 👤 Bradley Munson
Bibliographic Details
Application Number
—
Jurisdiction
US
Data Source
google_patents
Last Synchronized
2026-11-09 19:21
CPC Classifications
G; G16; G16H; G16H10/00; G16H10/60; G06; G06Q; G06Q10/00; G06Q10/10; G16H10/65; G16H15/00; G16H70/00; G16H70/40; Y; Y02; Y02A; Y02A90/00; Y02A90/10
Claims Analysis
Total Claims: 41
Claim 1
Independent Claim
137 words
A system for integrating medical claim/encounter records for comparative analysis, the system comprising: A) data storage means for storing medical claims data from one or more data sources, the medical claims data comprising medical claim items, at least a first portion of the medical claim items comprising principal diagnosis codes, and at least a second portion of the medical claim items comprising non-principal diagnosis codes, no diagnosis codes, or incorrect diagnosis codes; and B) data processing means comprising i) means for forming patient treatment episodes (PTEs) from the principal diagnosis codes, each PTE being of a diagnostic cluster type; and ii) means for assigning at least some of the claim items of the second portion of the medical claims to the PTEs on the basis of a relationship between the second portion claim items and the PTEs.
Claim 2
Dependent Claim
35 words
The system according to claim 1 wherein the means for assigning at least some of the claim items performs the assignment on the basis of a temporal relationship between the claim items and the PTEs.
Claim 3
Dependent Claim
35 words
The system according to claim 1 wherein the means for assigning at least some of the claim items performs the assignment on the basis of a physiological relationship between the claim items and the PTEs.
Claim 4
Dependent Claim
85 words
The system according to claim 1 wherein the second portion of the claims comprises drug claims, the system further comprising a drug lookup table for relating drugs to associated diagnostic cluster types, and wherein the means for assigning at least some of the claim items comprises: means for identifying drug claims from the second portion of the medical claims; and drug logic for identifying misassigned drug claims using the drug lookup table and for reassigning at least some of the drug claims to different PTEs.
Claim 5
Dependent Claim
58 words
The system according to claim 4 wherein the drug lookup table further relates drugs to associated diagnostic cluster types in more than one degree of preference, the drug logic further comprising means using the drug lookup table for reassigning at least some of the drug claims to PTEs of diagnostic cluster types having a greater degree of preference.
Claim 6
Dependent Claim
108 words
The system according to claim 1 wherein each claim item has an associated treatment date, and each PTE has a predetermined treatment window associated with the diagnostic cluster type for the PTE, the system further comprising a diagnostic cluster lookup table which associates each diagnostic cluster type with associated diagnosis codes, the means for assigning at least some of the claim items assigning each such claim item to a PTE with an ongoing treatment window on the treatment date for that claim item for which the diagnosis code of the claim item is associated with the diagnostic cluster type of the PTE in the diagnostic cluster lookup table.
Claim 7
Dependent Claim
99 words
The system according to claim 6 wherein at least some of the diagnostic cluster types are preference ranked with respect to diagnosis codes that are associated with more than one type of diagnostic cluster, and wherein the means for assigning at least some of the claim items assigns each such claim item to a PTE with an ongoing treatment window on the treatment date for that claim item, wherein the PTE is of the diagnostic cluster type having the highest preference rank with respect to the diagnosis code of the claim relative to other PTEs with ongoing treatment windows.
Claim 8
Dependent Claim
66 words
The system according to claim 2 wherein a claim item comprising a non-principal diagnosis code, no diagnosis code, or incorrect diagnosis code is assigned the diagnosis code of and assigned to the PTE associated with a claim item with a specific diagnosis code occurring within a predetermined period of time of the claim item comprising a non-principal diagnosis code, no diagnosis code, or incorrect diagnosis code.
Claim 9
Dependent Claim
72 words
The system according to claim 8 wherein each diagnostic cluster type has an associated ranking, and wherein a claim item comprising a non-principal diagnosis code, no diagnosis code, or incorrect diagnosis code is assigned the diagnosis code of and assigned to the PTE of the claim item with a specific diagnosis code occurring within the predetermined period of time that is associated with the PTE of the highest ranking diagnostic cluster type.
Claim 10
Dependent Claim
69 words
The system according to claim 1 wherein each diagnostic cluster type has an associated ranking and treatment window, and each claim item has an associated treatment date, and wherein a claim item comprising a non-principal diagnosis code, no diagnosis code, or incorrect diagnosis code is assigned the diagnosis code of and assigned to the PTE with an ongoing treatment window with the highest ranking diagnostic cluster type associated therewith.
Claim 11
Dependent Claim
107 words
The system according to claim 1 wherein each diagnostic cluster type has an associated treatment window, the treatment window for each PTE of each diagnostic cluster type extending from a last treatment in that PTE, and wherein each claim item has an associated treatment date, the system further comprising means for merging PTEs of the same diagnostic cluster type when the treatment windows of the PTEs of the same diagnostic cluster type overlap for forming a merged PTE of the same diagnostic cluster type as the overlapping PTEs, the treatment window of the merged PTE extending from the date of a last treatment in the merged PTE.
Claim 12
Dependent Claim
42 words
The system according to claim 11 further comprising means for attempting to reassign at least some of the claim items of the second portion of the medical claims to the PTEs on the basis of the treatment window of the merged PTE.
Claim 13
Dependent Claim
102 words
The system according to claim 1 wherein the second portion of the claims comprises claims having CPT codes associated therewith, the system further comprising a CPT lookup table for relating CPT codes to associated diagnostic cluster types, and wherein the means for assigning at least some of the claim items comprises: means for identifying CPT claims from the second portion of the medical claims, the CPT claims comprising CPT codes and missing or non-specific diagnosis codes; and CPT logic for identifying misassigned CPT claims using the CPT lookup table and for reassigning at least some of the CPT claims into different PTEs.
Claim 14
Dependent Claim
53 words
The system according to claim 1 wherein a diagnostic cluster type comprises a required diagnosis associated therewith, the system further comprising means for analyzing each PTE to determine the presence of the required diagnosis for the diagnostic cluster type associated with that PTE, and means for eliminating any PTE without the required diagnosis.
Claim 15
Dependent Claim
30 words
The system according to claim 1 further comprising means for identifying PTEs that are clinically related or clinically similar; and means for merging such clinically related or clinically similar PTEs.
Claim 16
Dependent Claim
20 words
The system according to claim 15 further comprising a clinical relationship lookup table identifying clinically related or clinically similar PTEs.
Claim 17
Dependent Claim
76 words
The system according to claim 1 wherein each diagnostic cluster type comprises a predetermined severity of illness relationship which relates a severity of illness associated with a PTE of each diagnostic cluster type to the claim items associated with such PTE, and wherein the system further comprises means for varying the severity of illness associated with each PTE on the basis of the claim items in that PTE in accordance with the severity of illness relationship.
Claim 18
Dependent Claim
39 words
The system according to claim 1 further comprising means for identifying PTEs related to treatment of a common underlying condition; and means for merging such related PTEs into the most severe or most resource intensive of such related PTEs.
Claim 19
Dependent Claim
80 words
The system according to claim 18 further comprising: means for determining whether the most severe or most resource intensive episode of such related PTEs is larger than the other such related PTEs by a predetermined threshold; and means for merging the most severe or resource intensive PTE into one of the other such related PTEs in the event that the most severe or most resource intensive episode is not larger than the other such related PTEs by the predetermined threshold.
Claim 20
Dependent Claim
39 words
The system according to claim 1 further comprising means for identifying combinations of PTEs that when combined are of a different diagnostic cluster type; and means for combining such PTEs into a single PTE of the different diagnostic cluster.
Claim 21
Dependent Claim
39 words
The system according to claim 1 wherein a first PTE relates to a second PTE as a complicating factor, a comorbid condition, or an adverse effect of the second PTE; and means for linking the first and second PTEs.
Claim 22
Dependent Claim
17 words
The system according to claim 1 further comprising means for identifying inpatient, outpatient, and ambulatory claims items.
Claim 23
Independent Claim
126 words
A method of integrating medical claim/encounter records for comparative analysis, the method comprising the steps of: A) storing medical claims data from one or more data sources, the medical claims data comprising medical claim items, at least a first portion of the medical claim items comprising principal diagnosis codes, and at least a second portion of the medical claim items comprising non-principal diagnosis codes, no diagnosis codes, or incorrect diagnosis codes; B) forming patient treatment episodes (PTEs) from the principal diagnosis codes, each PTE being of a diagnostic cluster type; and C) assigning at least some of the claim items of the second portion of the medical claims to the PTEs on the basis of a relationship between the second portion claim items and the PTEs.
Claim 24
Dependent Claim
36 words
The method according to claim 23 wherein the step of assigning at least some of the claim items comprises performing the assignment on the basis of a temporal relationship between the claim items and the PTEs.
Claim 25
Dependent Claim
36 words
The method according to claim 23 wherein the step of assigning at least some of the claim items comprises performing the assignment on the basis of a physiological relationship between the claim items and the PTEs.
Claim 26
Dependent Claim
80 words
The method according to claim 23 wherein the second portion of the claims comprises drug claims, the method further comprising providing a drug lookup table which relates drugs to associated diagnostic cluster types, and wherein the step of assigning at least some of the claim items comprises: identifying drug claims from the second portion of the medical claims; and identifying misassigned drug claims using the drug lookup table and reassigning at least some of the drug claims into different PTEs.
Claim 27
Dependent Claim
59 words
The method according to claim 26 wherein the drug lookup table further relates drugs to associated diagnostic cluster types in more than one degree of preference, the method further comprising the step of using the drug lookup table to reassign at least some of the drug claims into PTEs of diagnostic cluster types having a greater degree of preference.
Claim 28
Dependent Claim
111 words
The method according to claim 23 wherein each claim item has an associated treatment date, and each PTE has a predetermined treatment window associated with the diagnostic cluster type for the PTE, the method further comprising providing a diagnostic cluster lookup table which associates each diagnostic cluster type with associated diagnosis codes, the step of assigning at least some of the claim items further comprising assigning each such claim item to a PTE with an ongoing treatment window on the treatment date for that claim item for which the diagnosis code of the claim item is associated with the diagnostic cluster type of the PTE in the diagnostic cluster lookup table.
Claim 29
Dependent Claim
100 words
The method according to claim 28 wherein at least some of the diagnostic cluster types are preference ranked with respect to diagnosis codes that are associated with more than one type of diagnostic cluster, and wherein the step of assigning at least some of the claim items comprises assigning each such claim item to a PTE with an ongoing treatment window on the treatment date for that claim item, wherein the PTE is of the diagnostic cluster type having the highest preference rank with respect to the diagnosis code of the claim relative to other PTEs with ongoing treatment windows.
Claim 30
Dependent Claim
58 words
The method according to claim 24 wherein a claim item comprising a non-principal diagnosis code, no diagnosis code, or incorrect diagnosis code is assigned the diagnosis code of and assigned to the PTE associated with a claim item with a specific diagnosis code occurring within a predetermined period of time of the claim item without a diagnosis code.
Claim 31
Dependent Claim
72 words
The method according to claim 30 wherein each diagnostic cluster type has an associated ranking, and wherein a claim item comprising a non-principal diagnosis code, no diagnosis code, or incorrect diagnosis code is assigned the diagnosis code of and assigned to the PTE of the claim item with a specific diagnosis code occurring within the predetermined period of time that is associated with the PTE of the highest ranking diagnostic cluster type.
Claim 32
Dependent Claim
69 words
The method according to claim 23 wherein each diagnostic cluster type has an associated ranking and treatment window, and each claim item has an associated treatment date, and wherein a claim item comprising a non-principal diagnosis code, no diagnosis code, or incorrect diagnosis code is assigned the diagnosis code of and assigned to the PTE with an ongoing treatment window with the highest ranking diagnostic cluster type associated therewith.
Claim 33
Dependent Claim
108 words
The method according to claim 23 wherein each diagnostic cluster type has an associated treatment window, the treatment window for each PTE of each diagnostic cluster type extending from a last treatment in that PTE, and wherein each claim item has an associated treatment date, the method further comprising the steps of merging PTEs of the same diagnostic cluster type when the treatment windows of the PTEs of the same diagnostic cluster type overlap and forming a merged PTE of the same diagnostic cluster type as the overlapping PTEs, the treatment window of the merged PTE extending from the date of a last treatment in the merged PTE.
Claim 34
Dependent Claim
43 words
The method according to claim 33 further comprising the step of attempting to reassign at least some of the claim items of the second portion of the medical claims to the PTEs on the basis of the treatment window of the merged PTE.
Claim 35
Dependent Claim
97 words
The method according to claim 23 wherein the second portion of the claims comprises claims having CPT codes associated therewith, the method further comprising providing a CPT lookup table which relates CPT codes to associated diagnostic cluster types, and wherein the step of assigning at least some of the claim items comprises: identifying CPT claims from the second portion of the medical claims, the CPT claims comprising CPT codes and missing or non-specific diagnosis codes; and identifying misassigned CPT claims using the CPT lookup table and reassigning at least some of the CPT claims into different PTEs.
Claim 36
Dependent Claim
52 words
The method according to claim 23 wherein a diagnostic cluster type comprises a required diagnosis associated therewith, the method further comprising the steps of analyzing each PTE to determine the presence of the required diagnosis for the diagnostic cluster type associated with that PTE, and eliminating any PTE without the required diagnosis.
Claim 37
Dependent Claim
29 words
The method according to claim 23 further comprising the step of identifying PTEs that are clinically related or clinically similar; and merging such clinically related or clinically similar PTEs.
Claim 38
Dependent Claim
24 words
The method according to claim 37 further comprising the step of providing a clinical relationship lookup table identifying clinically related or clinically similar PTEs.
Claim 39
Dependent Claim
77 words
The method according to claim 23 wherein each diagnostic cluster type comprises a predetermined severity of illness relationship which relates a severity of illness associated with a PTE of each diagnostic cluster type to the claim items associated with such PTE, and wherein the method further comprises the step of varying the severity of illness associated with each PTE on the basis of the claim items in that PTE in accordance with the severity of illness relationship.
Claim 40
Independent Claim
194 words
A system for integrating medical claim/encounter records which comprises: A) data storage means for storing medical claims data, the medical claims data comprising medical claim items, each claim item having an associated treatment date, a first portion of the medical claim items comprising principal diagnosis codes; B) means for forming initial patient treatment episodes (PTEs) from the principal diagnosis codes, each PTE comprising a predetermined treatment window extending from a last treatment in the PTE; C) means for assigning at least some of a second portion of the claim items into respective PTEs on the basis of a temporal overlap between the second portion claim items and the treatment windows of the PTEs and extending the treatment window for each respective PTE from the date of treatment of the second portion claim item assigned thereto provided that such date of treatment is later than the prior last treatment in the PTE; and D) means for reanalyzing at least some of the second portion claim items and assigning such claim items to respective PTEs on the basis of a temporal overlap between the second portion claim items and the extended treatment windows of the PTEs.
Claim 41
Independent Claim
149 words
A system for assigning medical claims to a physician which comprises: A) data storage means for storing medical claims data, the medical claims data comprising medical claim items for treatment of a condition by the physician, and other medical claim items related to treatment of the condition, each medical claim item having a charge; B) means for forming patient treatment episodes (PTEs) from the medical claim items, a PTE for the condition including claim items for treatment by the physician and other claim items related to treatment of the condition; C) means for determining whether the charges by the physician in the PTE for the condition exceed a predetermined threshold; and D) means for assigning all of the charges in the PTE for the condition to the physician in the event that the charges by the physician in the PTE for treatment of the condition exceed the predetermined threshold.
References Cited (Backward Citations)
US4489387A
Cited
US4491725A
Cited
US4667292A
Cited
US4858121A
Cited
US5018067A
Cited
US5070452A
Cited
US4937743A
Cited
US4878175A
Cited
US5253164A
Cited
US5072383A
Cited
US5001630A
Cited
US4987538A
Cited
US5099424A
Cited
US5065315A
Cited
US5235702A
Cited
US5724379A
Cited
US5519607A
Cited
US5301105A
Cited
US5404292A
Cited
US5359509A
Cited
US5307262A
Cited
US5325293A
Cited
US5319543A
Cited
US5583758A
Cited
US5392209A
Cited
US5471382A
Cited
US5467268A
Cited
US5483443A
Cited
US5486999A
Cited
US5557514A
Cited
US5664207A
Cited
US5835897A
Cited
US5835897C1
Cited
USPTO Annuity & Maintenance Windows
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| 3.5 Years (Year 4) | 2002-10-18 | 2003-04-19 | 2003-10-19 | $2000.00 | Window Closed / Lapsed |
| 7.5 Years (Year 8) | 2006-10-18 | 2007-04-19 | 2007-10-19 | $3760.00 | Window Closed / Lapsed |
| 11.5 Years (Year 12) | 2010-10-18 | 2011-04-19 | 2011-10-19 | $7700.00 | Window Closed / Lapsed |