REFERENCE TO RELATED APPLICATIONS 
       [0001]    This patent application is a divisional application of U.S. patent application Ser. No. 09/188,986 filed Nov. 9, 1998, which is a continuation patent application of U.S. patent application Ser. No. 08/493,728, filed on Jun. 22, 1995, issued as U.S. Pat. No. 5,835,897 on Nov. 10, 1998. 
     
    
     FIELD OF THE INVENTION 
       [0002]    The present invention relates generally to computer-implemented methods for processing medical claims information. More particularly, the present invention relates to a computer-implemented method for receiving input data relating to a person&#39;s medical claim, establishing a management record for the person, establishing episode treatment groups to define groupings of medical episodes of related etiology, correlating subsequent medical claims events to an episode treatment group and manipulating episode treatment groups based upon time windows for each medical condition and co-morbidities. 
       BACKGROUND OF THE INVENTION 
       [0003]    Due to an increase in health care costs and inefficiency in the health care system, health care providers and service management organizations need health care maintenance systems which receive input medical claim data, correlate the medical claim data and provide a means for quantitatively and qualitatively analyzing provider performance. Because of the complex nature of medical care service data, many clinicians and administrators are not able to efficiently utilize the data. A need exists for a computer program that transforms inpatient and out patient claim data to actionable information, which is logically understood by clinicians and administrators. 
         [0004]    Performance is quickly becoming the standard by which health care purchasers and informed consumers select their health care providers. Those responsible for the development and maintenance of provider networks search for an objective means to measure and quantify the health care services provided to their clients. Qualitative and quantitative analysis of medical provider performance is a key element for managing and improving a health care network. Operating a successful health care network requires the ability to monitor and quantify medical care costs and care quality. Oftentimes, success depends on the providers&#39; ability to identify and correct problems in their health care system. A need exists, therefore, for an analytical tool for identifying real costs in a given health care management system. 
         [0005]    To operate a more efficient health care system, health care providers need to optimize health care services and expenditures. Many providers practice outside established utilization and cost norms. Systems that detect inappropriate coding, eliminate potentially inappropriate services or conduct encounter-based payment methodology are insufficient for correcting the inconsistencies of the health care system. When a complication or comorbidity is encountered during the course of treatment, many systems do not reclassify the treatment profile. Existing systems do not adjust for casemix, concurrent conditions or recurrent conditions. A system that compensates for casemix should identify the types of illnesses treated in a given population, determine the extent of resource application to specific types of illnesses, measure and compare the treatment patterns among individual and groups of health care providers and educate providers to more effectively manage risk. When profiling claims, existing systems establish classifications that do not contain a manageable number of groupings, are not clinically homogeneous or are not statistically stable. A need exists, therefore, for a patient classification system that accounts for differences in patient severity and establishes a clearly defined unit of analysis. 
         [0006]    For many years, computer-implemented programs for increasing health care efficiency have been available for purchase. Included within the current patent literature and competitive information are many programs that are directed to the basic concept of health care systems. 
         [0007]    The Mohlenbrock, et al. patent, U.S. Pat. No. 4,667,292, issued in 1987, discloses a medical reimbursement computer system which generates a list identifying the most appropriate diagnostic-related group (DRG) and related categories applicable to a given patient for inpatient claims only. The list is limited by a combination of the characteristics of the patient and an initial principal diagnosis. A physician can choose a new designation from a list of related categories while the patient is still being treated. The manually determined ICD-9 numbers can be applied to an available grouper computer program to compare the working DRG to the government&#39;s DRG. 
         [0008]    The Mohlenbrock, et al. patent, U.S. Pat. No. 5,018,067, issued in 1991, discloses an apparatus and method for improved estimation of health resource consumption through the use of diagnostic and/or procedure grouping and severity of illness indicators. This system is a computer-implemented program that calculates the amount of payment to the health provider by extracting the same input data as that identified in the Mohlenbrock &#39;292 Patent teaching the DRG System. The system calculates the severity of the patient&#39;s illness then classifies each patient into sub-categories of resource consumption within a designated DRG. A computer combines the input data according to a formula consisting of constants and variables. The variables are known for each patient and relate to the number of ICD codes and the government weighing of the codes. The software program determines a set of constants for use in the formula for a given DRG that minimizes variances between the actual known outcomes and those estimated by use of the formula. Because it is based upon various levels of illness severity within each diagnosis, the results of this system provide a much more homogenous grouping of patients than is provided by the DRGs. Providers can be compared to identify those providers whose practice patterns are of the highest quality and most cost efficient. A set of actual costs incurred can be compared with the estimated costs. After the initial diagnosis, the system determines the expected costs of treating a patient. 
         [0009]    The Schneiderman patent, U.S. Pat. No. 5,099,424, issued in 1992, discloses a model user application system for clinical data processing that tracks and monitors a simulated outpatient medical practice using database management software. The system allows for a database of patients and the entry of EKG and/or chest x-ray (CXR) test results into separate EKG/CXR records as distinct logical entities. This system requires entry of test results that are not part of the medical claim itself. If not already present, the entry creates a separate lab record that may be holding blood work from the same lab test request. Portions of the information are transferred to the lab record for all request situations. Although the lab record data routine is limited to blood work, each time the routine is run, historical parameter data are sent to a companion lab record along with other data linking both record types. The system also includes a revision of the system&#39;s specialist record and the general recommendation from an earlier work for more explicit use in information management. 
         [0010]    The Tawil patent, U.S. Pat. No. 5,225,976, issued in 1993, discloses an automated health benefit processing system. This system minimizes health care costs by informing the purchasers of medical services about market conditions of those medical services. A database includes, for each covered medical procedure in a specific geographic area, a list of capable providers and their charges. A first processor identifies the insured then generates a treatment plan and the required medical procedures. Next, the first processor retrieves information related to the medical procedures and appends the information to the treatment plan. A second processor generates an actual treatment record including the actual charges. A third processor compares the plan and the actual records to determine the amounts payable to the insured and the provider. 
         [0011]    The Ertel patent, U.S. Pat. No. 5,307,262, issued in 1994, discloses a patient data quality review method and system. The system performs data quality checks and generates documents to ensure the best description of a case. The system provides file security and tracks the cases through the entire review process. Patient data and system performance data are aggregated into a common database that interfaces with existing data systems. Data profiles categorize data quality problems by type and source. Problems are classified as to potential consequences. The system stores data, processes it to determine misreporting, classifies the case and displays the case-specific patient data and aggregate patient data. 
         [0012]    The Holloway, et al. patent, U.S. Pat. No. 5,253,164, issued in 1993, discloses a system and method for detecting fraudulent medical claims via examination of service codes. This system interprets medical claims and associated representation according to specific rules and against a predetermined CPT-4 code database. A knowledge base interpreter applies the knowledge base using the rules specified. The database can be updated as new methods of inappropriate coding are discovered. The system recommends appropriate CPT codes or recommends pending the claims until additional information is received. The recommendations are based on the decision rules that physician reviewers have already used on a manual basis. 
         [0013]    The Cummings patent, U.S. Pat. No. 5,301,105, issued in 1994, discloses an all care health management system. The patient-based system includes an integrated interconnection and interaction of essential health care participants to provide patients with complete support. The system includes interactive participation with the patients employers and banks. The system also integrates all aspects of the optimization of health-inducing diet and life style factors and makes customized recommendations for health-enhancing practices. By pre-certifying patients and procedures, the system enhances health care efficiency and reduces overhead costs. 
         [0014]    The Dome patent, U.S. Pat. No. 5,325,293, issued in 1994, discloses a system and method for correlating medical procedures and medical billing codes. After an examination, the system automatically determines raw codes directly associated with all of the medical procedures performed or, planned to be performed with a particular patient. The system allows the physician to modify the procedures after performing the examination. By manipulating the raw codes, the system generates intermediate and billing codes without altering the raw codes. 
         [0015]    The Kessler, et al. patent, U.S. Pat. No. 5,324,077, issued in 1994, discloses a negotiable medical data draft for tracking and evaluating medical treatment. This system gathers medical data from ambulatory visits using a medical data draft completed by the provider to obtain payment for services, to permit quality review by medical insurers. In exchange for immediate partial payment of services, providers are required to enter data summarizing the patient&#39;s visit on negotiable medical drafts. The partial payments are incentives to providers for participating in the system. 
         [0016]    The Torma, et al. patent, U.S. Pat. No. 5,365,425, issued in 1994, discloses a method and system for measuring management effectiveness. Quality, cost and access are integrated to provide a holistic description of the effectiveness of care. The system compares general medical treatment databases and surveyed patient perceptions of care. Adjustments based on severity of illness, case weight and military costs are made to the data to ensure that all medical facilities are considered fairly. 
         [0017]    Health Chex&#39;s PEER-A-MED computer program is a physician practice profiling system that provides case-mix adjusted physician analysis based on a clinical severity concept. The system employs a multivariate linear regression analysis to appropriately adjust for case-mix. After adjusting for the complexity of the physician&#39;s caseload, the system compares the relative performance of a physician to the performance of the peer group as a whole. The system also compares physician utilization performance for uncomplicated, commonly seen diagnosis. Because the full spectrum of clinical care that is rendered to a patient is not represented in its databases, the system is primarily used as an economic performance measurement tool. This system categorizes the claims into general codes including acute, chronic, mental health and pregnancy. Comorbidity and CPT-4 codes adjust for acuity level. The codes are subcategorized into twenty cluster groups based upon the level of severity. The system buckets the codes for the year and contains no apparent episode building methodology. While the PEER-A-MED system contains clinically heterogeneous groupings, the groupings are not episode-based and recurrent episodes cannot be accounted. 
         [0018]    Ambulatory Care Groups (ACG) provides a patient-based system that uses the patient and the analysis unit. Patients are assigned to an diagnosis group and an entire year&#39;s claims are bucketed into thirty-one diagnosis groups. By pre-defining the diagnosis groups, this is a bucketing-type system and claim management by medical episode does not occur. The system determines if a claim is in one of the buckets. Because different diseases could be categorized into the same ACG, this system is not clinically homogeneous. An additional problem with ACGs is that too many diagnosis groups are in each ACG. 
         [0019]    Ambulatory Patient Groups (APGs) are a patient classification system designed to explain the amount and type of resources used in an ambulatory visit. Patients in each APG have similar clinical characteristics and similar resource use and cost. Patient characteristics should relate to a common organ system or etiology. The resources used are constant and predictable across the patients within each APG. This system is an encounter-based system because it looks at only one of the patient&#39;s encounters with the health care system. This system mainly analyzes outpatient hospital visits and does not address inpatient services. 
         [0020]    The GMIS system uses a bucketing procedure that profiles by clumps of diagnosis codes including 460 diagnostic episode clusters (DECs). The database is client specific and contains a flexible number and type of analytic data files. This system is episode-based, but it does not account for recurrent episodes, so a patient&#39;s complete data history within a one-year period is analyzed as one pseudo-episode. Signs and symptoms do not cluster to the actual disease state, e.g. abdominal pain and appendicitis are grouped in different clusters. This system does not use CPT-4 codes and does not shift the DEC to account for acuity changes during the treatment of a patient. 
         [0021]    Value Health Sciences offers a value profiling system, under the trademark VALUE PROFILER, which utilizes a DB2 mainframe relational database with 1,800 groups. The system uses ICD9 and CPT-4 codes, which are bucket codes. Based on quality and cost-effectiveness of care, the system evaluates all claims data to produce case-mix-adjusted profiles of networks, specialties, providers and episodes of illness. The pseudo-episode building methodology contains clinically pre-defined time periods during which claims for a patient are associated with a particular condition and designated provider. The automated practice review system analyzes health care claims to identify and correct aberrant claims in a pre-payment mode (Value Coder) and to profile practice patterns in a post-payment mode (Value Profiler). This system does not link signs and symptoms and the diagnoses are non-comprehensive because the profiling is based on the exclusion of services. No apparent shifting of episodes occurs and the episodes can only exist for a preset time because the windows are not recurrent. 
         [0022]    The medical claim profiling programs described in foregoing patents and non-patent literature demonstrate that, while conventional computer-implemented health care systems exist, they each suffer from the principal disadvantage of not identifying and grouping medical claims on an episodic basis or shifting episodic groupings based upon complications or co-morbidities. The present computer-implemented health care system contains important improvements and advances upon conventional health care systems by identifying concurrent and recurrent episodes, flagging records, creating new groupings, shifting groupings for changed clinical conditions, selecting the most recent claims, resetting windows, making a determination if the provider is an independent lab and continuing to collect information until an absence of treatment is detected. 
       SUMMARY OF THE INVENTION 
       [0023]    Accordingly, it is a broad aspect of the present invention to provide a computer-implemented medical claims profiling system. 
         [0024]    It is a further object of the present invention to provide a medical claims profiling system that allows an objective means for measuring and quantifying health care services. 
         [0025]    It is a further object of the present invention to provide a medical claims profiling system that includes a patient classification system based upon episode treatment groups. 
         [0026]    It is a further object of the present invention to provide a medical claims profiling system that groups claims to clinically homogeneous and statistically stable episode treatment groups. 
         [0027]    It is a further object of the present invention to provide a medical claims profiling system that includes claims grouping utilizing service or segment-level claim data as input data. 
         [0028]    It is a further object of the present invention to provide a medical claims profiling system that assigns each claim to an appropriate episode. 
         [0029]    It is a further object of the present invention to provide a medical claims profiling system that identifies concurrent and recurrent episodes. 
         [0030]    It is a further object of the present invention to provide a medical claims profiling system that shifts groupings for changed clinical conditions. 
         [0031]    It is a further object of the present invention to provide a medical claims profiling system that employs a decisional tree to assign claims to the most relevant episode treatment group. 
         [0032]    It is a further object of the present invention to provide a medical claims profiling system that resets windows of time based upon complications, co-morbidities or increased severity of clinical conditions. 
         [0033]    It is a further object of the present invention to provide a health care system that continues to collect claim information and assign claim information to an episode treatment group until an absence of treatment is detected. 
         [0034]    It is a further object of the present invention to provide a health care system that creates orphan records. 
         [0035]    It is a further object of the present invention to provide a health care system that creates phantom records. 
         [0036]    The foregoing objectives are met by the present system that allows an objective means for measuring and quantifying health care services based upon episode treatment groups (ETGs). An episode treatment group (ETG) is a clinically homogenous and statistically stable group of similar illness etiology and therapeutic treatment. ETG grouper method uses service or segment-level claim data as input data and assigns each service to the appropriate episode. 
         [0037]    ETGs gather all in-patient, ambulatory and ancillary claims into mutually exclusive treatment episodes, regardless of treatment duration, then use clinical algorithms to identify both concurrent and recurrent episodes. ETG grouper method continues to collect information until an absence of treatment is detected for a predetermined period of time commensurate with the episode. For example, a bronchitis episode will have a sixty-day window, while a myocardial infarction may have a one-year window. Subsequent records of the same nature within the window reset the window for an additional period of time until the patient is asymptomatic for the pre-determined time period. 
         [0038]    ETGs can identify a change in the patient&#39;s condition and shift the patient&#39;s episode from the initially defined ETG to the ETG that includes the change in condition. ETGs identify all providers treating a single illness episode, allowing the user to uncover specific treatment patterns. After adjusting for case-mix, ETGs measure and compare the financial and clinical performance of individual providers or entire networks. 
         [0039]    Medical claim data is input as data records by data entry into a computer storage device, such as a hard disk drive. The inventive medical claims profiling system may reside in any of a number of computer system architectures, i.e., it may be run from a stand-alone computer or exist in a client-server system, for example a local area network (LAN) or wide area network (WAN). 
         [0040]    Once relevant medical claim data is input, claims data is processed by loading the computer program into the computer system memory. During set-up of the program onto the computer system, the computer program will have previously set pointers to the physical location of the data files and look-up tables written to the computer storage device. Upon initialization of the inventive computer program, the user is prompted to enter an identifier for a first patient. The program then checks for open episodes for the identified patient, sets flags to identify the open episodes and closes any episodes based upon a predetermined time duration from date of episode to current date. After all open episodes for a patient are identified, the new claims data records are read to memory and validated for type of provider, CPT code and ICD-9 (dx) code, then identified as a management, surgery, facility, ancillary, drug or other record. 
         [0041]    As used herein, “Management records” are defined as claims that represent a service by a provider engaging in the direct evaluation, management or treatment or a patient. Examples of management records include office visits and therapeutic services. Management records serve as anchor records because they represent focal points in the patient treatment as well as for related ancillary services. 
         [0042]    “Ancillary records” are claims which represent services which are incidental to the direct evaluation, management and treatment of the patient. Examples of ancillary records include X-ray and laboratory tests. 
         [0043]    “Surgery records” are specific surgical claims. Surgery records also serve as anchor records. 
         [0044]    “Facility records” are claims for medical care facility usage. Examples of facility records include hospital room charges or outpatient surgical room charges. 
         [0045]    “Drug records” are specific for pharmaceutical prescription claims. 
         [0046]    “Other records” are those medical claim records which are not management, surgery, ancillary, facility or drug records. 
         [0047]    Invalid records are flagged and logged to an error output file for the user. Valid records are then processed by an ETG Assignor Sub-routine and, based upon diagnosis code, is either matched to existing open episodes for the patient or serve to create new episodes. 
         [0048]    Management and surgery records serve as “anchor records.” An “anchor record” is a record which originates a diagnosis or a definitive treatment for a given medical condition. Management and surgery records serve as base reference records for facility, ancillary and drug claim records relating to the diagnosis or treatment which is the subject of the management or surgery record. Only management and surgery records can serve to start a given episode. 
         [0049]    If the record is a management record or a surgery record, the diagnosis code in the claim record is compared with prior related open episodes in an existing look-up table for a possible ETG match. If more than one open episode exists, the program selects the most recent open episode. A positive match signifies that the current episode is related to an existing open episode. After the match is determined, the time window is reset for an additional period of time corresponding to the episode. A loop shifts the originally assigned ETG based on the additional or subsequent diagnoses. If any of the additional or subsequent diagnoses is a defined co-morbidity diagnosis, the patient&#39;s co-morbidity file updated. If no match between the first diagnosis code and an open episode is found, a new episode is created. 
         [0050]    Grouping prescription drug records requires two tables, a NDC (National Drug Code) by GDC (Generic Drug Code) table and a GDC by ETG table. Because the NDC table has approximately 200,000 entries, it has been found impracticable to directly construct an NDC by ETG table. For this reason the NDC by GDC table serves as a translation table to translate NDCs to GDCs and construct a smaller table based upon GDCs. Reading, then from these tables, the NDC code in the claim data record is read and translated to a GDC code. The program then identifies all valid ETGs for the GDC codes in the claim data record then matches those valid ETGs with active episodes. 
         [0051]    These and other objects, features and advantages of the present invention will become more apparent to those skilled in the art from the following more detailed description of the non-limiting preferred embodiment of the invention taken with reference to the accompanying Figures. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0052]    Briefly summarized, a preferred embodiment of the invention is described in conjunction with the illustrative disclosure thereof in the accompanying drawings, in which: 
           [0053]      FIG. 1  is a diagrammatic representation of a computer system used with the computer-implemented method for analyzing medical claims data in accordance with the present invention. 
           [0054]      FIG. 2  is a flow diagram illustrating the general functional steps of the computer implemented method for analyzing medical claims data in accordance with the present invention. 
           [0055]      FIG. 3  is a flow diagram illustrating an Eligible Record Check routine which validates and sorts patient claim data records. 
           [0056]      FIGS. 4A to 4F  are flow diagrams illustrating the Management Record Grouping Sub-routine of the ETG Assignor Routine in accordance with the computer-implemented method of the present invention. 
           [0057]      FIGS. 5A-5D  are flow diagrams illustrating a Surgery Record Grouping Sub-routine of the ETG Assignor Routine in accordance with the computer-implemented method of the present invention. 
           [0058]      FIGS. 6A-6E  are flow diagrams illustrating a Facility Record Grouping Sub-routine of the ETG Assignor Routine in accordance with the computer-implemented method of the present invention. 
           [0059]      FIGS. 7A-B  are flow diagrams illustrating an Ancillary Record Grouping Sub-routine of the ETG Assignor Routine in accordance with the computer-implemented method of the present invention. 
           [0060]      FIGS. 8A-8C  are flow diagrams illustrating a Drug Record Grouping Sub-routine of the ETG Assignor Routine in accordance with the computer-implemented method of the present invention. 
           [0061]      FIG. 9  is a flow diagram illustrating the Episode Definer Routine in accordance with the computer-implemented method of the present invention. 
           [0062]      FIG. 10  is diagrammatic timeline illustrating a hypothetical patient diagnosis and medical claims history during a one year period and grouping of claim records as management records and ancillary records with cluster groupings. 
           [0063]      FIG. 11  is a diagrammatic representation of a I-9 Diagnosis Code (dx) X ETG table illustrating predetermined table values called by the Episode Definer Routine of the present invention. 
           [0064]      FIG. 12  is a diagrammatic representation of an I-9 Diagnosis Code 9 (dx) X CPT Code table illustrating predetermined table values called by the Episode Definer Routine of the present invention. 
           [0065]      FIG. 13  is a diagrammatic representation of a National Drug Code (NDC) to Generic Drug Code (GDC) conversion table illustrating predetermined Generic Drug Code values called by the Drug Record Grouping Sub-routine of the Episode Definer Routine of the present invention. 
           [0066]      FIG. 14  is a diagrammatic representation of a Generic Drug Code (GDC) to Episode Treatment Group (ETG) table illustrating predetermined table values called by the Drug Record Grouping Sub-routine of the Episode Definer Routine of the present invention. 
       
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT 
       [0067]    Referring particularly to the accompanying drawings, the basic structural elements of a health care management system of the present invention are shown. Health care management system consists generally of a computer system  10 . Computer system  10  is capable of running a computer program  12  that incorporates the inventive method is shown in  FIG. 1 . The computer system  10  includes a central processing unit (CPU)  14  connected to a keyboard  16  which allows the user to input commands and data into the CPU  14 . It will be understood by those skilled in the art that CPU  14  includes a microprocessor, random access memory (RAM), video display controller boards and at least one storage means, such as a hard disk drive or CD-ROM. The computer system  10  also contains a video display  18  which displays video images to a person using the computer system  10 . The video display screen  18  is capable of displaying video output in the form of text or other video images. 
         [0068]    Episode Treatment Groups (ETGs) are used to define the basic analytical unit in the computer-implemented method of the present invention. ETGs are episode based and conceptually similar to Diagnostic Related Groups (DRGs), with a principal difference being that DRGs are inpatient only. ETGs encompass both inpatient and outpatient treatment. 
         [0069]    Using ETGs as the basic episodic definer permits the present invention to track concurrently and recurrently occurring illnesses and correctly identify and assign each service event to the appropriate episode. Additionally, ETGs account for changes in a patient&#39;s condition during a course of treatment by shifting from the initially defined ETG to one which includes the changed condition once the changed condition is identified. 
         [0070]    The inventive medical claims profiling system defines Episode Treatment Groups (ETGs). The number of ETGs may vary, depending upon the definitional specificity the health care management organization desires. Presently, the inventive system defines 558 ETGs, which are assigned ETG Numbers 1-900 distributed across the following medical areas: Infectious Diseases, Endocrinology, Hematology, Psychiatry, Chemical Dependency, Neurology, Ophthalmology, Cardiology, Otolaryngology, Pulmonology, Gastroenterology, Hepatology, Nephrology, Obstetrics, Gynecology, Dermatology, Orthopedics and Rheumatology, Neonatology, Preventative and Administrative and Signs and Isolated Signs, Symptoms and Non-Specific Diagnoses or Conditions. Under the presently existing system, ETG 900 is reserved to “Isolated Signs, Symptoms and Non-Specific Diagnoses or Conditions,” and is an ETG designation used where the diagnosis code is incapable of being assigned to another ETG. A listing of exemplary ETGs for typical episodes is found at Table 1, below. Those skilled in the art will understand, however, that the number of ETGs may change, the ETG numbering system is variable, the ETG classifications may be defined with relatively broader or narrower degrees of specificity and the range of medical specialties may be greater or fewer, as required may be require by the management organization in their medical claims data analysis protocols. 
         [0071]    An episode may be considered a low outlier or high outlier. Low outliers are episodes with dollar values below the minimum amount which is specific to each ETG. Examples of low outliers include patients which drop from a plan during mid-episode and patients who use out-of-network providers and do not submit claims. High outliers are those episodes with high dollar values greater than the 75th percentile plus 2.5 times the interquartile range, based upon a predefined database. The low and high outlier points are pre-determined and hard-coded into the inventive system and will vary across analysis periods. 
         [0072]    If no ICD-9 (diagnosis code) on a given record matches the CPT-4 code, i.e., a diagnosis of bronchitis and a CPT of knee x-ray, an invalid code segment results. The inventive system outputs invalid records and discontinues the processing of these records. An invalid ICD-9 code is assigned to ETG 997, an invalid CPT-4 code is assigned to ETG 996 and an invalid provider type is assigned to ETG 995. A sequential anchor count and a sequential episode count are incremented after each ETG assignment. Active open and closed ETG files include ETG number, sequential episode number, most recent anchor from date of service and most recent sequential anchor record count. An alternative embodiment creates a single record for each individual episode containing ETG number, patient age, patient sex, episode number, total charges, total payments, earlier anchor record, last anchor record, whether the episode was closed (“clean finish”), number of days between database start date and earliest anchor record, whether a number of days between database start date and earliest anchor record exceeds the ETG&#39;s days interval, patient identification, physician identification, management charges, management paid, surgery charges, surgery paid, ancillary charges and ancillary paid. 
         [0073]    The inventive system uses clinical algorithms to identify both concurrent and recurrent episodes. Subsequent episodes of the same nature within a window reset the window for an additional period of time until the patient is asymptomatic for a pre-determined time period. If an ETG matches a prior ETG, a recurrent ETG is created and the window is reset. The most recent claim is selected if more than one matched claim exists. If the ETG does not match an active ETG, a new concurrent ETG is created. 
         [0074]    Comorbidities, complications or a defining surgery could require an update of the patient&#39;s condition to an ETG requiring a more aggressive treatment profile. ETG&#39;s changes in the patient&#39;s clinical condition and shift the patient&#39;s episode from the initially defined ETG to an ETG which includes the change in clinical condition. 
         [0075]    If the claim is an ancillary record and it does not match an active ETG it is designated an “orphan” ancillary record. 
         [0076]    Termination of an episode is detected by an absence of treatment for a period of time commensurate with the episode. 
         [0077]    If the claim is a prescription drug record, two pre-defined tables written to the computer data storage medium, are read. The first of the tables is a National Drug Code (NDC) by Generic Drug Code (GDC) table. The GDC code is equivalent to the Generic Drug Code table known in the art. This table acts as a translator table to translate a large number of NDCs to a smaller set of GCNs. A second pre-defined table is employed and is constructed as a GDC by ETG table. The GDC by ETG table is used, in conjunction with the NDC by GDC translator table, to identify all valid ETGs for a particular NDC code in the claim record. 
         [0078]    To determine specific treatment patterns and performance contributions, the computer-implemented method identifies all providers treating a single illness episode. If a network of providers contains Primary Care Physicians (PCP), the ETGs clearly identify each treatment episode by PCP. Financial and clinical performance of individual providers or entire networks may be monitored and analyzed. To monitor health care cost management abilities of providers, components of a provider&#39;s treatment plan may be analyzed by uncovering casemix-adjusted differences in direct patient management, the use of surgery and the prescribing of ancillary services. By identifying excessive utilization and cost areas, continuous quality improvement protocols are readily engineered based on internally or externally derived benchmarks. After adjusting for location and using geographically derived normative charge information, ETG-based analysis compares the cost performance of providers or entire networks. By using geographically derived utilization norms, the present invention forms the methodology base for measuring both prevalence and incidence rates among a given population by quantifying health care demand in one population and comparing it to external utilization norms. This comparison helps to identify health care providers who practice outside established utilization or cost norms. 
         [0079]    Turning now to  FIG. 2 , there is illustrated the general operation of the computer-implemented method of the present invention. Those skilled in the art will understand that the present invention is first read from a removable, transportable recordable medium, such as a floppy disk, magnetic tape or a CD-ROM onto a recordable, read-write medium, such as a hard disk drive, resident in the CPU  14 . Upon a user&#39;s entry of appropriate initialization commands entered via the keyboard  16 , or other input device, such as a mouse or trackball device, computer object code is read from the hard disk drive into the memory of the CPU  14  and the computer-implemented method is initiated. The computer-implemented method prompts the user by displaying appropriate prompts on display  18 , for data input by the user. 
         [0080]    Those familiar with medical claims information processing will understand that medical claims information is typically received by a management service organization on paper forms. If this is the case, a user first manually sorts claim records by patient, then input patient data through interfacing with the CPU  14  through the keyboard  16  or other input device. 
         [0081]    Prior to being submitted to the grouping algorithm, records must be sorted by patient by chronological date of service. An Eligible Record Check routine  48  to verify the validity and completeness of the input data. As each record is read by the software, it first checks the date of service on the record and compares it to the last service date of all active episodes to evaluate which episodes have expired in terms of an absence of treatment. These episodes are closed at step  50 . Next the record is identified as either a management  52 , surgery  54 , facility  56 , ancillary  58  or drug  60  record. These types of records are categorized as follows: 
         [0082]    “Management records” are defined as claims which represent a service by a provider engaging in the direct evaluation, management or treatment or a patient. Examples of management records include office visits, surgeries and therapeutic services. Management records serve as anchor records because they represent focal points in the patient treatment as well as for related ancillary services. 
         [0083]    “Ancillary records” are claims which represent services which are incidental to the direct evaluation, management and treatment of the patient. Examples of ancillary records include X-ray and laboratory tests. 
         [0084]    “Surgery records” represent surgical procedures performed by physicians and other like medical allied personnel. Like management records, surgery records also serve as anchor records. 
         [0085]    “Facility records” are claims for medical care facility usage. Examples of facility records include hospital room charges or ambulatory surgery room charges. 
         [0086]    “Drug records” are specific for pharmaceutical prescription claims. 
         [0087]    A “cluster” is a grouping of one, and only one, anchor record, management or surgery, and possibly ancillary, facility and/or drug records. A cluster represents a group of services in which the focal point, and therefore the responsible medical personnel, is the anchor record. An episode is made up of one or more clusters. 
         [0088]    After the management, surgery, facility, ancillary and drug records are identified at steps  52 ,  54 ,  56 ,  58  and  60 , respectively, an ETG Assignor Sub-routine is executed at step  62 . The ETG Assignor Sub-routine  62  assigns patient medical claims to ETGs based one or more cluster of services related to the same episode, and provides for ETG shifting upon encountering a diagnosis code or CPT code which alters the relationship between the diagnosis or treatment coded in the claim record and an existing ETG assignment. For example, ETG&#39;s may be shifted to account for changes in clinical severity, for a more aggressive ETG treatment profile if a complication or comorbidity is encountered during the course of treatment for a given ETG or where a defining surgery is encountered during the course of treatment for a given ETG. 
         [0089]    When the last claim data record for a given patient is processed by the ETG Assignor Routine  62 , the Episode Definer Routine is executed at step  64 . Episode Definer Routine  64  identifies all open and closed ETG episodes for the patient and appropriately shifts any episodes to a different ETG if such ETG is defined by age and/or the presence or absence of a co-morbidity. The patient records are then output to a file with each record containing the ETG number, a sequential episode number, and a sequential cluster number. Upon input of an identifier for the next patient, the processing of medical claims for the next patient is initiated at step  66  by looping back to check for eligible records for the new patient at step  48 . 
         [0090]    Operation of the Eligible Record Check routine  100  is illustrated in  FIG. 3 . The patient records input by the user are read from the recordable read-write data storage medium into the CPU  14  memory in step  102 . From the patient records read to memory in step  102 , a record validation step  104  is carried out to check provider type, treatment code and diagnosis code against pre-determined CPT code and diagnosis code look up tables. The diagnosis code is preferably the industry standard ICD-9 code and the treatment code is preferably the industry standard CPT-4 code. All valid patient records are assigned as one of a) management record, b) ancillary record, c) surgery record, d) facility record, e) drug record or f) other record, and coded as follows:
       m=management record;   a=ancillary record;   s=surgery record;   f=facility record;   d=drug record; or   o=other record.       
 
         [0097]    A sort of valid records  106  and invalid records  108  from step  104  is made. For valid records  106  in step  110 , patient age is then read to memory from the first patient record from step  106 . All valid records are then sorted by record type in step  112 , i.e., record type m, a, s, f, d or o by a date of service from date (DOS-from). A sort index of all record-type sorted records from step  116  is generated and written to the hard disk, and the ETG Assignor routine  120  is initialized. 
         [0098]    For invalid records  108  identified at step  104 , the records are assigned ETG designations reserved for records having invalid provider data, invalid treatment code, or invalid diagnosis code, e.g., ETG 995 , 996 and 997, respectively, at step  111 . An error log file is output identifying the invalid records by reserved ETG and written to disk or displayed for the user and processing of the invalid records terminates at step  113 . 
         [0099]    The computer-implemented method of the present invention then initializes an Episode Assignor Routine  200 , the operation of which is illustrated in  FIGS. 4A-8C . Episode Assignor Routine  200  consists generally of five Sub-routine modules for processing management records, surgery records, facility records, ancillary records and drug records and assigning claims to proper ETGs.  FIGS. 4A-4F  illustrate initial identification of records as management, surgery, facility ancillary and drug records and the Management Record Grouping Sub-Routine.  FIGS. 5A-5E  illustrate operation of the Surgery Record Grouping routine  400  for matching surgery claim records to proper ETGs.  FIGS. 6A-6E  illustrate operation of the Facility Record Grouping routine  500  for matching facilities records to proper ETGs.  FIGS. 7A-7  illustrate operation of the Ancillary Record Grouping routine  600  for matching ancillary records to proper ETGs. Finally,  FIGS. 8A-8C  illustrate operation of the Drug Records Grouping routine  700  for matching drug records to proper ETGs. 
       Management Records 
       [0100]    The Episode Assignor routine begins by executing a Management Records Grouping Sub-routine  200 , illustrated in  FIGS. 4A-4F , first reads the input claim record for a given patient in step  202 . The first processing of the input claim record entails categorizing the record as a management, surgery, facility, ancillary or drug record at step  204 . A series of logical operands  208 ,  210 ,  212  and  214 , read the record and determine whether the record is a management record at step  204 , a surgery record at step  208 , a facility record at step  210 , an ancillary record at step  212  or a drug record at step  214 . If an affirmative response is returned in response to logical operand  204 , grouping of the management record to an ETG is initialized and processing of the management record proceeds to step  215 . If however, a negative response is returned in response to the logical operand  206 , logical operand  208  is executed to determine whether the record is a surgery record. If an affirmative response is returned from logical operand  208 , the Surgery Record Grouping routine  400  is initialized. If, however, a negative response to logical operand  208  is returned, logical operand  210  is executed to determine whether the record is a facility record. If an affirmative response is returned in response to logical operand  210 , the Facility Record Grouping Sub-routine  500  is executed. If, however, a negative response is returned in response to the logical operand  210 , logical operand  212  is executed to determine whether the record is an ancillary record. If an affirmative response is returned from logical operand  212 , the Ancillary Record Grouping Sub-routine  600  is executed. If, however, a negative response to logical operand  212  is returned, logical operand  214  is executed to determine whether the record is a facility record. At this point all records except drug records have been selected. Thus, all the remaining records are drug records and the Drug Record Grouping Sub-routine  700  is executed. 
         [0101]    Returning now to the initialization of the Management Record Grouping routine  200 , and in particular to step  215 . Once the record has been categorized as a management record in step  206 , the DOS-to value is compared to active episodes for the patient to determine if any active episodes should be closed. Closed episodes are moved to an archive created on the storage means, such as a hard disk or CD-ROM. 
         [0102]    The management record is examined and the first diagnosis code on record is read, a diagnosis code (dx) by ETG table  201  is read from the storage means and all valid ETGs for the first diagnosis code on record are identified at step  216 . The dx by ETG table  201  consists of a table matrix having diagnosis codes on a first table axis and ETG numbers on a second table axis. At intersection cells of the dx by ETG table are provided table values which serve as operational flags for the inventive method. In accordance with the preferred embodiment of the invention, dx by ETG table values are assigned as follows: 
         [0103]    P=primary, with only one P value existing per ETG; 
         [0104]    S=shift; 
         [0105]    I=incidental; 
         [0106]    A=shift to ETG with C value; and 
         [0107]    C=P, where P′ is a shiftable primary value. 
         [0000]    An illustrative example of a section of a dx by ETG table is found at  FIG. 11 . 
         [0108]    ETG validation in step  216  occurs where for a given diagnosis code on record, the code has either a P, S, I, A or C dx-ETG table value. The ETGs identified as valid for the first diagnosis code on record in step  216 , are then matched with active open ETGs in step  217  by comparing the valid ETGs with the open ETGs identified in step  215 . A logical operand is then executed at step  218  to determine whether a match exists between the valid ETG from the management record and any open ETGs. A negative response at step  218  causes execution of another logical operand at step  220  to determine whether for the first diagnosis code is the P value in the dx-ETG table equal to the ETG for non-specific diagnosis, i.e., ETG 900. If an affirmative response is returned at step  216 , ETG identifiers for the second to the fourth diagnosis codes in the management record are established from the dx-ETG table and the ETG identifier value is matched to active specific ETGs in step  222  and execution of the program continues as represented by designator AA  236  bridging to  FIG. 5B . If, however, a negative response is returned from logical operand  220 , a value of one is added to the management record or anchor count and to the episode count and the ETG with a P value on the dx-ETG table is selected and a new episode is initialized. Further processing of the new episode by the program continues as represented by designator F  236  bridging to  FIG. 5C . 
         [0109]    If an affirmative response is returned at logical operand step  218 , the matched active ETG with the most recent DOS-to are selected at step  230 . If a tie is found based upon most recent DOS-to values, then the most recent DOS-from value is selected for matching with active ETGs. If a tie is found at most recent DOS-from values is found, the first encountered ETG is selected and matched. A value of one is then added to the management record or anchor record counter at step  232  and further processing continues as represented by designator G  238  bridging to  FIG. 5C . 
         [0110]    Turning now to  FIG. 4B , which is a continuation from designator AA  236  of  FIG. 4A , identifier ETGs for the second to fourth diagnoses in the management record are matched to active ETGs in logical operand  237 . If an affirmative response is returned in response to logical operand  237 , the matched active ETG with the most recent DOS-to is selected in step  240 . If there is a tie between two or more ETGs with the most recent DOS-to value, the most recent DOS-from ETG is selected. If, however, there is a tie between two or more active ETGs with the most recent DOS-from value, then the first encountered ETG is selected in step  240 . A value of one is then added to the sequential anchor record counter in step  241  and operation of the computer-implemented method continues as indicated by designator G  243  bridging to  FIG. 5C . 
         [0111]    From logical step  237 , if a negative response is returned, the ETG with the second diagnosis value of P is selected at step  242 , then a logical query is made to determine whether the selected ETG is a non-specific ETG, i.e., ETG 900 at step  244 . A negative response to logical query  244  causes a value of one to be added to the sequential anchor count and to the sequential episode count at step  254 . If an affirmative response to logical query  244  is returned, logical queries  246  and  248  are sequentially executed to select ETGs with the third and fourth diagnosis values of P from the dx-ETG table written on the storage means, respectively, and logical query  244  is executed to determine whether the selected ETG is the non-specific ETG, i.e., ETG 900. If a negative response is returned to logical query  244  for the ETG selected in step  248 , a value of one is added to the sequential anchor count and to the sequential episode count in step  254 . If an affirmative response is returned from logical query  244 , a value of one is added to the sequential anchor count and the sequential episode count at step  250 . 
         [0112]    From step  250 , the non-specific ETG, i.e., ETG 900 is selected and a new episode is started in the active ETG file. The updated sequential episode number, the updated sequential anchor count, the DOS-from and the DOS-to from the record are written to the new episode in the active ETG file in step  252 . 
         [0113]    From step  254 , the ETG with a dx-ETG table value of P is selected and a new episode is started in the active ETG file. The updated sequential episode number, the updated sequential anchor count, the DOS-from and the DOS-to from the record are written to the new episode in the active ETG file in step  256 . A comorbidity file written on the storage means is then updated with all the dx codes in the management record in step  258 . 
         [0114]    From each of steps  252  and steps  258  a check is made to determine whether the processed management record is the last record for the patient at logical step  260 . An affirmative response returned to logical step  260  prompts the program operation to the Episode Definer Sub-routine  264 , bridging to  FIG. 9  with identifier GG, while a negative response to logical step  260  returns program operation to the beginning of the ETG Assignor routine  200  and the next patient record is read at step  262 . 
         [0115]    Turning now to  FIG. 4C , the bridge reference G  238  is continued from  FIG. 4A . For those records having a match with an open ETG, a query is made at step  270  of the dx-ETG table  201  to determine the table value of the dx code for the selected ETG. Again, valid table values are one of P, S, I, A, or C. If the table value returned from step  270  is A, the selected ETG in the active file is changed at step  272  to the ETG number having an equivalent table value of C for the diagnosis on record. If the table value returned from step  270  is S, the selected ETG in the active file is shifted at step  274  to an ETG value having a table value of P for the diagnosis code on record. If the table value is one of P, I or C, the ETG remains the same and the selected active ETG&#39;s most recent DOS-to is updated by writing the record date to the ETG DOS-to field, and the sequential anchor count in the selected active ETG is updated to reflect writing of the record to the ETG at step  276 . 
         [0116]    At step  278 , the record is then written with a sequential episode number and the sequential anchor count of the selected ETG from the selected active ETG. In this manner, the record is identified with the ETG and the specific episode. The patient&#39;s co-morbidity file is flagged with the output read from bridge designator F at step  234 . A patient&#39;s co-morbidity file is a predefined list of diagnoses which have been identified as comorbidities. If during the course of grouping a patient&#39;s records, a management record is encountered which is a comorbidity diagnosis, the ETG for that diagnosis is flagged or “turned on” in the comorbidity file. Then, during the execution of the Episode Definer Routine, all the patient&#39;s episodes with an ETG which can shift based on the presence of a comorbidity and which are “turned on” are appropriately shifted to the ETG “with comorbidity”. 
         [0117]    A loop beginning at step  282  is then executed to determine whether the ETG assigned by the first diagnosis code should be shifted to another ETG based upon the second, third and fourth diagnoses on record. At step  282 , the second diagnosis is read from the patient&#39;s claim record and all valid ETGs for the second diagnosis are read from the dx-ETG table  201 . A logical operand  284  is executed to determine whether one of the valid ETGs for the second diagnosis matches the primary diagnosis ETG. If a negative response is returned to logical operand  284 , a loop back at step  285  is executed to step  282  for the next sequential diagnosis code on record, i.e., the third and forth diagnosis codes on record. If an affirmative response is returned to the logical operand  284 , the a logical operand  286  queries the table value of the matched ETG to determine if a value of A is returned from the dx-ETG table. If a negative response is returned, the loop back step  285  is initialized. If an affirmative response is returned, the first dx ETG is flagged for change to a second dx ETG having an equivalent table value of C for the second diagnosis code on record at step  288  and all valid ETGs for the current diagnosis code on record are identified at step  290  from the dx-ETG table. The identified C-value ETG is then matched with any open active ETGs at step  292 . Program operation then continues at bridge H  292  to  FIG. 4D . 
         [0118]    At  FIG. 4D  the continued operation of the Management Grouping Sub-routine from bridge H  292  of  FIG. 4C . Logical operand  296  queries the open active ETGs to determine whether a valid match with the identified C-value ETG exists. If a negative response is returned to logical operand  296 , a value of 1 is added to the sequential episode count at step  297  and a new episode having a P value ETG is started in the patient&#39;s master active ETG file at step  299 . The new episode is written with a sequential episode number, DOS-from and DOS-to values and forms a phantom management record. A phantom record is an anchor record, management or surgery, with more than one diagnosis, which is assigned to one episode and its corresponding ETG based on one diagnosis, but can start a new episode(s) or update the most recent date of another active episode(s) based on other diagnoses on the record. 
         [0119]    If an affirmative response is returned from logical operand  296 , the matched active ETG with the most recent DOS-to value is selected at step  298 . If a tie is found based upon most recent DOS-to values, then the most recent DOS-from value is selected for matching with active ETGs. If a tie is found at most recent DOS-from values is found, the first encountered ETG is selected and matched. The selected ETG&#39;s most recent DOS-to and sequential anchor count are updated in the patient&#39;s master active ETG file in step  300 . 
         [0120]    For either the new episode created at step  299  or the updated ETG from step  300 , the patient&#39;s co-morbidity file is then updated with the second diagnosis code on-record at step  302 . Processing then continues to identify all valid ETGs for a third diagnosis code on record at step  304  and the identified valid ETGs from step  304  are compared to the active ETGs in the patient&#39;s master active ETG file in step  306 . 
         [0121]    Bridge I  308  continues to  FIG. 4E , and a logical operand  310  is executed to query the patient&#39;s master active ETG file to determine whether a match exists between the valid ETGs identified in step  304  with any active ETG from the patients master active ETG file. If a negative response is returned to logical operand  310 , a value of 1 is added to the sequential episode count at step  311  and a new episode having a P value ETG is started in the patient&#39;s master active ETG file at step  313 . The new episode is written with a sequential episode number, DOS-from and DOS-to values and forms a phantom management record. 
         [0122]    If an affirmative response is returned from logical operand  310 , the matched active ETG with the most recent DOS-to value is selected at step  312 . Again a decisional hierarchy is executed. If a tie is found based upon most recent DOS-to values, then the most recent DOS-from value is selected for matching with active ETGs. If a tie is found at most recent DOS-from values is found, the first encountered ETG is selected and matched. The selected ETG&#39;s most recent DOS-to and sequential anchor count are updated in the patient&#39;s master active ETG file in step  314 . 
         [0123]    For either the new episode created at step  311  or the updated ETG from step  314 , the patient&#39;s co-morbidity file is then updated with the third diagnosis code on-record at step  316 . Processing then continues to identify all valid ETGs for a fourth diagnosis code on record at step  318  and the identified valid ETGs from step  3318  are compared to the active ETGs in the patient&#39;s master active ETG file in step  320 . Bridge reference  1322 , bridges to  FIG. 4F . 
         [0124]    Turning to  FIG. 4F , a logical operand  324  is executed to query the patient&#39;s master active ETG file to determine whether a match exists between the valid ETGs identified in step  320  with any active ETG from the patients master active ETG file. If a negative response is returned to logical operand  324 , a value of 1 is added to the sequential episode count at step  325  and a new episode having a P value ETG is started in the patient&#39;s master active ETG file at step  337 . The new episode is written with a sequential episode number, DOS-from and DOS-to values and forms a phantom management record. 
         [0125]    If an affirmative response is returned from logical operand  324 , the matched active ETG with the most recent DOS-to value is selected at step  326 . Again a decisional hierarchy is executed. If a tie is found based upon most recent DOS-to values, then the most recent DOS-from value is selected for matching with active ETGs. If a tie is found at most recent DOS-from values is found, the first encountered ETG is selected and matched. The selected ETG&#39;s most recent DOS-to and sequential anchor count are updated in the patient&#39;s master active ETG file in step  328 . 
         [0126]    For either the new episode created at step  337  or the updated ETG from step  324 , the patient&#39;s co-morbidity file is then updated with the fourth diagnosis code on-record at step  330 . A check is then made to determine whether the processed record is the last record for the patient by execution of logical operand  332  and reading the input claim records from the storage means. If logical operand  332  returns an affirmative value, the ETG Definer Sub-routine is called at step  334 , as represented by bridge reference GG. If, however, a negative response is returned to logical operand  332 , program execution returns to the step  204  of the Episode Assignor routine  200  and the next patient claim record is read from the storage means. 
       Surgery Records 
       [0127]    Grouping of Surgery Records to ETGs is governed by the Surgery Record Grouping Sub-routine  400 , the operation of which is illustrated in  FIGS. 5A-5D . 
         [0128]    For those patient claim records identified as Surgery Records at step  208 , the DOS-from value on-record is compared with the DOS-to value read from the patient master active ETG file at step  402 . This identifies and flags those active ETGs which are to be closed, the flagged ETGs are then moved to the patient master closed ETG file. The first diagnosis code on-record is then read and compared to the dx-ETG table  201  to identify all possible valid ETGs for the first diagnosis code on-record in step  404 . 
         [0129]    Surgery records are coded with treatment codes (CPT codes). Each surgery record has a single CPT code value. The CPT code on-record is then read, and compared to a CPT by ETG table  401  previously written to the storage means. The CPT-ETG table will have pre-determined table values. For example, in accordance with the preferred embodiment of the invention, the CPT-ETG table  401  has table values of R, W and X, where R is a value shiftable to W and X is a validator value. All valid ETGs for the on-record CPT code are identified by this comparison at step  406 . A logical operand  408  is then executed to determine whether there is a match of valid ETGs returned from the dx-ETG table  201  and the CPT-ETG table  401 . If an affirmative response is returned to logical operand  408 , a second logical operand  410  is executed to determine whether a match of valid specific ETGs exists. Again, if an affirmative response is returned from second logical operand  410 , the valid specific ETGs matched in step  410  are then compared at step  414  with the open active ETGs for the patient read from the patient&#39;s master active ETG file at step  412 . If an affirmative response is returned from step  414 , the matched ETG with the most recent DOS-to is selected at step  416  and a value of 1 is added to the sequential anchor count in the selected ETG at step  418 . In step  416 , if a tie is found based upon most recent DOS-to values, then a decisional hierarchy is followed to select the most recent DOS-from value for matching with active ETGs. If a tie is found at most recent DOS-from values is found, the first encountered ETG is selected and matched. 
         [0130]    If a negative response is returned to any of logical operands  408 ,  410  or  414 , second, third and fourth dx codes on-record are read and all possible valid ETGs are read in step  411  from the dx-ETG table  201 . Further processing of the valid ETGs output from step  411  is continued at  FIG. 5B  identified by bridge reference P,  413 . 
         [0131]    Turning to  FIG. 5B , a logical operand  415  compares the valid ETGs for the second, third and fourth dx codes with the valid ETGs for the CPT code on-record in step  411 . If a negative response is returned from logical operand  415 , the patient claim record is assigned to an ETG reserved for match errors between dx code and CPT code, e.g., ETG 998, and further processing of the match error ETG bridges at reference R,  431 , to  FIG. 5D . 
         [0132]    If an affirmative response is returned from logical operand  415 , the matched ETGs are compared with active ETGs read from the patient master active ETG file at step  417  and logical operand  419  is executed at step  419  to determine whether any valid matches between matched ETGs and active ETGs. If a negative response is returned to logical operand  419 , a value of 1 is added to the sequential anchor count and to the sequential episode count at step  425  and a new episode is started at step  437  with the first dx code on-record having a P value for a specific ETG in the dx-ETG table  201 . If no specific ETG has a P value, a non-specific ETG having a P value for the dx code on record is used to start the new episode. The new episode is started by writing the sequential episode number, the sequential anchor count, the DOS-from and the DOS-to values on the record. 
         [0133]    If an affirmative response is returned from logical operand  419 , the matched specific ETG with the most recent DOS-to is selected at step  421 . If a tie is found based upon most recent DOS-to values, then the most recent DOS-from value is selected for matching with active ETGs. If a tie is found at most recent DOS-from values is found, the first encountered ETG is selected and matched. A value of 1 is added to the sequential anchor count at step  423 . Processing the new episode started at step  427  or of the selected matched specific ETG at step  421  continues to bridge Q,  420 , continued at  FIG. 5C . 
         [0134]    Turning to  FIG. 5C , bridged from reference Q,  420 , logical operand  422  is executed which reads the CPT-ETG table  401  and determines the table value of the selected ETG from step  421  and step  427  based on the CPT value on-record. If a table value of R is returned from the read of the CPT-ETG table  401  at step  422 , the matched ETG in the master active ETG file is shifted at step  424  to the ETG with an equivalent value of W for the CPT code on-record. If a table value of X or W is returned from step  422  or from step  242 , the dx-ETG table  201  is read at step  426  and the dx code for the selected matched ETG from the CPT-ETG table  401  or the shifted ETG from step  424  is read. From the dx-ETG table  201 , if a value of S is returned, the matched ETG in the patient master active ETG file is shifted at step  428  to the ETG with a table value of P for the dx code on-record. If a table value of A is returned, the matched ETG in the patient master active ETG file is changed in step  430  to an equivalent value of C for the dx code on-record. If a table value of P, I or C is returned either from logical operand  426 , or from the ETG change step  428  or the ETG shift step  430 , the DOS-to and the sequential anchor count of the ETG in the patient master active ETG file are updated in step  432 . The patient claim record is then assigned and written with the sequential episode number and the sequential anchor count of the selected ETG at step  434 . The patient co-morbidity file is then updated with all diagnosis codes on-record at step  436 . 
         [0135]      FIG. 5D  bridges from  FIG. 5C  with bridge reference BB,  438 . In  FIG. 5D , the diagnosis codes on-record which were not used in the ETG selection described above, are then read from the patient claim record to identify all possible valid ETGs in the dx-ETG table  201 . The identified possible valid ETGs are then matched against the patient master active ETG file in step  442  and logical operand  444  is executed to validate the matches. If an affirmative response is returned to logical operand  444 , for each matched dx code on-record, the matched active ETG with the most recent DOS-to is selected at step  446 . If a tie is found based upon most recent DOS-to values, then the most recent DOS-from value is selected for matching with active ETGs. If a tie is found at most recent DOS-from values is found, the first encountered ETG is selected and matched. The selected ETG&#39;s most recent DOS-to value is updated to the date of the patient medical claim, and the sequential anchor count in the active ETG is updated in step  448 . 
         [0136]    If a negative response is returned to logical operand  444 , a value of 1 is added to sequential episode count at step  456  and a new episode having a P value ETG is started in the patient&#39;s master active ETG file at step  458 . The new episode is written with a sequential episode number, DOS-from and DOS-to value&#39;s and forms a phantom surgery record. If an affirmative response is returned to logical operand  444 , the matched active ETG for each diagnosis code is selected at step  446  on the basis of the most recent DOS-to value. If a tie is found based upon most recent DOS-to values, then the most recent DOS-from value is selected for matching with active ETGs. If a tie is found at most recent DOS-from values is found, the first encountered ETG is selected and matched. The DOS-to field of the selected ETG from step  446  is updated in step  448  to the date of service on-record and the sequential anchor count in the active ETG file is updated. From either step  458  or from step  448 , the patient co-morbidity file is updated to reference the selected ETG and a check is made to determine whether the patient claim record processed in step  429 , which assigned an invalid dx-CPT code match to the record, or from step  450 , which updated the co-morbidity file, is the last record for the patient at logical operand  462 . If an affirmative response is returned to logical operand  462 , record processing proceeds to the Episode Definer Sub-routine at step  464 , bridged by reference GG, to  FIG. 9 . If, however, a negative response is returned to logical operand  462 , a loop back  468  to the beginning of the ETG Assigner routine  200  is executed and the next patient claim record is read. 
       Facility Records 
       [0137]    The Facility Record Grouping Sub-routine  500  assigns facility records to ETGs on the basis of diagnosis codes on-record. The patient claim record is read and the first diagnosis code on-record is read to the dx-ETG table  201  to identify all valid ETGs for the first dx code at step  502 . The identified valid ETGs are then compared to the open active ETGs in the patient master active ETG file in step  504 . Logical operand  506  executes to determine whether any valid matches exist between identified ETGs for the dx code and the active ETGs for the patient. If a negative response is returned to step  506 , a value of 1 is added to the sequential episode count at step  507  and a new episode is started in step  509  in the patient active ETG file with the ETG corresponding to the dx-ETG table value of P. If logical operand  507  returns an affirmative response, a query of the matched ETG value is made at step  508  to determine whether the matched ETG has a table value of P, C, A or S. If a negative response is returned to step  508 , the matched active ETG with the most recent DOS-from value is selected at step  511 . If a tie is found based upon most recent DOS-to values, then the most recent DOS-from value is selected for matching with active ETGs. If a tie is found at most recent DOS-from values is found, the first encountered ETG is selected and matched. If an affirmative response is returned at step  508 , the table value of the matched ETG table value is identified at step  510 . If the table value for the matched ETG in the dx-ETG table  201  is S, the matched ETG is shifted at step  514  to the ETG having a table value of P for the dx code. If the table value for the matched ETG returns a value of A, the matched ETG in the patient master active ETG file is changed at step  512  to an ETG having an equivalent table value of C for the dx code. If a table value of either P or C is returned at step  510 , the most recent DOS-to is updated at step  516  in the ETG to the on-record claim date. Further processing of the claim record from steps  509 ,  511  and  516  bridges at reference  1 ,  520 , to  FIG. 6B . 
         [0138]    Turning to  FIG. 6B , bridged from reference  1 ,  520 , in  FIG. 6A , the patient&#39;s co-morbidity file is updated with the first dx code at step  522 . A loop beginning at step  524  is then executed to determine whether the ETG assigned by the first diagnosis code should be shifted to another ETG based upon the second, third and fourth diagnoses on record. At step  524 , the second diagnosis is read from the patient&#39;s claim record and all valid ETGs for the second diagnosis are read from the dx-ETG table  201 . A logical operand  526  is executed to determine whether one of the valid ETGs for the second diagnosis matches the primary diagnosis ETG. If a negative response is returned to logical operand  526 , a loop back at step  527  is executed to step  524  for the next sequential diagnosis code on record, i.e., the third and forth diagnosis codes on record. If an affirmative response is returned to the logical operand  524 , the logical operand  528  queries the table value of the matched ETG to determine if a value of A is returned from the dx-ETG table. If a negative response is returned, the loop back step  527  is initialized. If an affirmative response is returned, the first dx ETG is flagged for change to a second dx ETG having an equivalent table value of C for the second diagnosis code on record at step  530 . All valid ETGs for the second diagnosis code on record are identified at step  532  from the dx-ETG table. The identified ETGs are then matched with any open active ETGs at step  532 . Program operation then continues at bridge  2 ,  536  to  FIG. 6C . 
         [0139]    At  FIG. 6C  the continued operation of the Facility Record Grouping Sub-routine  500  from bridge  2  of  FIG. 6   b  is illustrated. Logical operand  538  queries the open active ETGs to determine whether a valid match with the identified ETGs exists. If a negative response is returned to logical operand  538 , the patient co-morbidity file is updated with the second diagnosis code at step  544 . If an affirmative response is returned from logical operand  538 , the matched active ETG with the most recent DOS-to value is selected at step  540 . If a tie is found based upon most recent DOS-to values, then the most recent DOS-from value is selected for matching with active ETGs. If a tie is found at most recent DOS-from values is found, the first encountered ETG is selected and matched. The selected ETG&#39;s most recent DOS-to and sequential anchor count are updated in the patient&#39;s master active ETG file in step  542 . 
         [0140]    Processing then continues to identify all valid ETGs for a third diagnosis code on record at step  546  and the identified valid ETGs from step  546  are compared to the active ETGs in the patient&#39;s master active ETG file in step  548 . 
         [0141]    Bridge  3 ,  550 , continues to  FIG. 6D , and a logical operand  552  is executed to query the patient&#39;s master active ETG file to determine whether a match exists between the valid ETGs identified in step  548  with any active ETG from the patients master active ETG file. If a negative response is returned to logical operand  538 , the patient&#39;s comorbidity file is updated with the third diagnosis code at  558 . 
         [0142]    If an affirmative response is returned from logical operand  552 , the matched active ETG with the most recent DOS-to value is selected at step  554 . Again a decisional hierarchy is executed. If a tie is found based upon most recent DOS-to values, then the most recent DOS-from value is selected for matching with active ETGs. If a tie is found at most recent DOS-from values is found, the first encountered ETG is selected and matched. 
         [0143]    The patient&#39;s co-morbidity file is then updated with the third diagnosis code on-record at step  558 . Processing then continues to identify all valid ETGs for a fourth diagnosis code on record at step  560  and the identified valid ETGs from step  3318  are compared to the active ETGs in the patient&#39;s master active ETG file in step  562 . Bridge reference  4 ,  564 , bridges to  FIG. 6D . 
         [0144]    Turning to  FIG. 6D , a logical operand  566  is executed to query the patient&#39;s master active ETG file to determine whether a match exists between the valid ETGs identified in step  562  with any active ETG from the patients master active ETG file. If a negative response is returned to logical operand  566 , the patient&#39;s comorbidity file is updated with the fourth diagnosis code. 
         [0145]    If an affirmative response is returned from logical operand  566 , the matched active ETG with the most recent DOS-to value is selected at step  568 . In the event of a tie, a decisional hierarchy is executed. If a tie is found based upon most recent DOS-to values, then the most recent DOS-from value is selected for matching with active ETGs. If a tie is found at most recent DOS-from values is found, the first encountered ETG is selected and matched. The selected ETG&#39;s most recent DOS-to are updated in the patient&#39;s master active ETG file in step  570  and the patient&#39;s co-morbidity file is then updated with the fourth diagnosis code on-record at step  572 . A check is then made to determine whether the processed record is the last record for the patient by execution of logical operand  574  and reading the input claim records from the storage means. If logical operand  574  returns an affirmative value, the ETG Definer Sub-routine is called at step  576 , as represented by bridge reference GG. If, however, a negative response is returned to logical operand  574 , program execution returns to the step  204  of the Episode Assignor routine  200  and the next patient claim record is read from the storage means at step  578 . 
       Ancillary Records 
       [0146]    Operation of the Ancillary Record Grouping Sub-routine  600  is illustrated in  FIGS. 7A-7B . Like surgery records, ancillary records are grouped to ETGs on the basis of both dx codes and CPT code on record. First all valid ETGs for the treatment or CPT code on-record are identified in step  602  from the CPT-ETG table  401 . Then all valid ETGs for the first dx code on record are identified in step  604  from the dx-ETG table  201 . The ETGs from the CPT-ETG table  401  are then compared at step  606  to the ETGs from the dx-ETG table  201  and a logical operand  608  determines whether there is an ETG match. An affirmative response returned from logical operand  608  continues record processing at bridge D,  610 , which continues on  FIG. 7B . A negative response returned from logical operand  608  prompts a look up on the dx-ETG table to determine all valid ETGs for the second diagnosis code on record in step  611 . Step  613  again compares the valid ETGs for the CPT code on record and with the valid ETGs for the second dx code on record and a logical operand  614  is executed to match the second dx code ETG with the CPT code ETG. Again, an affirmative response returned from logical operand  614  continues record processing at bridge D,  610 , which continues on  FIG. 7B . If a negative response is returned to logical operand  614 , a look up on the dx-ETG table occurs to determine all valid ETGs for the third diagnosis code on record in step  615 . Step  616  again compares the valid ETGs for the CPT code on record and with the valid ETGs for the third dx code on-record, which bridges E,  619 , to  FIG. 7B  for identification of all valid ETGs for the fourth dx code on-record at step  625 . 
         [0147]    Step  627  then compares the valid ETGs for the CPT code on record and with the valid ETGs for the fourth dx code on record and a logical operand  629  is executed to match the fourth dx code ETG with the CPT code ETG. An affirmative response returned from logical operand  629  continues to step  616  which compares the matched ETGs with the ETGs in the patient master active ETG file and a query is made at logical operand  618  to determine whether any valid matches exist. If a negative response is returned to logical operand  629 , the record is output to the ETG reserved for a CPT code-dx code mismatch at step  631  and a check is made at step  635  to determine whether the record is the last record for the patient. 
         [0148]    If a match is found between the matched ETGs from the dx code-CPT code comparison in step  616 . The matched active ETG with the most recent DOS-to value is selected. In the event of a tie, a decisional hierarchy is executed. If a tie is found based upon most recent DOS-to values, then the most recent DOS-from value is selected for matching with active ETGs. If a tie is found at most recent DOS-from values is found, the first encountered ETG is selected. The sequential episode number of the selected ETG is assigned to the record and the most recent sequential anchor count of the episode from the active ETG file is assigned to the record at step  622 . 
         [0149]    If the response to logical operand  618  is negative, the record is assigned to an orphan record ETG at step  633  and maintained in the claims records until subsequent record processing either matches the record to an ETG or the orphan record DOS-from exceeds a one-year time period, at which time the record is output to an error log file. 
         [0150]    A check is then made to determine whether this record is the last record for the patient at step  635 . If logical operand  635  returns an affirmative value, the ETG Definer Sub-routine is called at step  642 , as represented by bridge reference GG. If, however, a negative response is returned to logical operand  635 , program execution returns to the step  204  of the Episode Assignor routine  200  and the next patient claim record is read from the storage means at step  644 . 
       Prescription Drug Records 
       [0151]      FIGS. 8A-8C  illustrate the operation of the Drug Record Grouping Sub-routine  700 . Drug Record Grouping Sub-routine  700  references two predetermined tables previously written to the storage means. The first of the tables is a National Drug Code (NDC) by Generic Drug Code (GDC) table  800 . This table acts as a translator table to translate a large number of NDCs to a smaller set of GDCs. A second pre-defined table is employed and is constructed as a GDC by ETG table  900 . The GDC by ETG table is used, in conjunction with the NDC by GDC translator table, to identify all valid ETGs for a particular NDC code in the claim record. 
         [0152]    Once identified as a drug record in the initial operation of the Episode Assignor Routine  200 , the drug record is read from storage to memory in step  702 . The NDC code on-record is converted to a GDC code by reading from the NDC-GDC table  800  in step  704 . Using the GDC number so identified, all possible valid ETGs for the GDC code are identified in step  706 . The possible valid ETGs for the GDC code are then compared to the patient master active ETG file in step  708 . Following bridge LL,  710 , to  FIG. 8B , a logical operand is executed in step  712  based upon the comparison executed in step  708 , to determine whether a match occurs having a table value of P, A, C or S. 
         [0153]    If a negative response is returned to logical operand  712 , a check is made to determine whether a match having table value I in the GDC-ETG table  900  exists in step  713 . If another negative response is returned to logical operand  713 , the record is flagged an orphan drug record and assigned to an orphan drug record ETG in step  715 . If an affirmative response is returned to logical operand  713 , the ETG with the highest second value is selected in step  718  (e.g. I 1 , I 2 , I 3  and so on). If more than one ETG having the highest second value exists, the ETG having the most recent DOS-from value is selected. If a tie is again encountered, the first encountered ETG is selected. A sequential episode number and the most recent sequential anchor count of the episode from the patient master active ETG file is assigned to the drug record for the selected ETG in step  720 . 
         [0154]    If an affirmative response is returned to logical operand  712 , the ETG having the highest second value, in order of P, S, A, C is selected in step  714  (e.g. P 1 , then P 2  . . . then S 1 , then S 2  . . . and so on). The record is then assigned a sequential episode number of the selected ETG and the most recent sequential anchor count of the episode from the patient master active ETG file in step  716 . 
         [0155]    Further processing of the drug record continues from steps  716 ,  715  and  720  through bridge MM,  724  and is described with reference to  FIG. 8C . A check is made in step  726  to determine whether the drug record is the last drug record for the patient on the record date. If a negative response is returned, a loop back to the top of the Drug Record Grouping Sub-routine  700  is executed. If an affirmative response is returned at step  726 , a check is made to determine whether the drug record is the last record for the patient in step  728 . If logical operand  728  returns an affirmative value, the ETG Definer Sub-routine is called at step  732 , as represented by bridge reference GG. If, however, a negative response is returned to logical operand  728 , program execution returns to the step  204  of the Episode Assignor routine  200  and the next patient claim record is read from the storage means at step  730 . 
         [0156]    The Episode Definer Sub-routine is illustrated with reference to  FIG. 9 . Episode Definer Routine  118  is employed to assign all non-specific claims records, i.e., those initially assigned to ETG 900, to specific more appropriate ETGs. Episode Definer routine  750 . Once all episodes have been grouped to ETGs, all ETG episodes in both active and closed ETGs are then identified in step  752  by patient age and presence or absence of a comorbidity. The ETG number for each episode is then shifted and re-written to an ETG appropriate for the patient age and/or presence or absence of a comorbidity in step  754 . All patient records are then output in step  756  to the display, to a file or to a printer, along with their shifted ETG number, sequential episode number of the record and in patient master active and closed ETG file for the patient. The Episode Definer routine  750  then writes a single record at step  758  for each episode containing key analytical information, for example: the ETG number, patient age, patient sex, the sequential episode number, the total sum charges, the total sum paid, the earliest anchor record DOS-from value, the last anchor record DOS-to value, patient identification, physician identification, management charges, management charges paid, surgery charges, surgery charges paid, ancillary charges, and ancillary charges paid. 
         [0157]    After the single record for each episode is written in step  758  for the patient, processing for the next patient begins by initialization of the next patient master active and closed ETG file, the next patient co-morbidity file, and the patient age file in step  760  and the Eligible Record Check Routine is re-initiated for processing claims records for the next patient at step  762 . 
       Example 
       [0158]      FIG. 10  provides an example of Management and Ancillary record clustering over a hypothetical time line for a single patient over a one year period from January, 1995 to December, 1995.  FIG. 10  depicts time frames of occurrences for claims classified as management records, i.e., office visit  84 , hospital or emergency room visit  85 , and surgery and surgical follow-up  86  and for claims records classified as ancillary records, i.e., laboratory tests  87 , X-ray and laboratory tests  88  and x-ray  89 . Two time lines are provided. A first timeline  71  includes the diagnosis and the time duration of the diagnosed clinical condition. A second timeline  72  includes the claim events which gave rise to the medical claims. Where claim events occur more than once, an alphabetic designator is added to the reference numeral to denote chronological order of the event. For example, the first office visit is denoted  84   a , the second office visit is denoted  84   b , the third denoted  84   c , etc. Vertical broken lines denote the beginning and end of each Episode Treatment Group  90 , and facilitate correlation of the episode event, e.g., office visit, with the resulting diagnosis, e.g., bronchitis. 
         [0159]    A first office visit  84   a  resulted in a diagnosis of bronchitis  76 . Office visit  84   a  started an episode  90   a  for this patient based upon the bronchitis diagnosis  76 . A second office visit  84   b  occurred concurrently with the bronchitis episode  90   a , but resulted in a diagnosis of eye infection  77 . Because the eye infection  77  is unrelated to the open bronchitis episode ETG  90   a , a new eye infection episode ETG  90   b  is started. An X-ray and lab test  88  was taken during the time frame of each of the bronchitis episode  90   a  and the eye infection  90   b . Based upon the CPT-ETG table, discussed above, the X-ray and lab test  88  is assigned to the eye infection episode  90   b . A third office visit  84   c  and x-ray  89   a  occurred and related to the bronchitis episode  90   a  rather than the eye infection episode  90   b.    
         [0160]    A fourth office visit  84   d  occurred and resulted in a diagnosis of major infection  78  unrelated to the bronchitis diagnosis  76 . Because the major infection  78  is unrelated to the bronchitis, the fourth office visit  84   d  opened a new ETG  90   c . Two subsequent lab tests  87   a  and  87   b  were both assigned to the only open episode, i.e., ETG  90   c.    
         [0161]    A fifth office visit  84   e  resulted in a diagnosis of benign breast neoplasm  79 , which is unrelated to the major infection ETG  90   c . A fifth office visit  84   e  opened a new ETG  90   d  because the benign breast neoplasm is unrelated to either the bronchitis episode ETG  90   a , the eye infection episode ETG  90   b , or the major infection episode  90   c . Sixth office visit  84   f  was assigned then to the only open episode, i.e., ETG  90   d . Similarly, the surgery and follow-up records  86   a  and  86   b  related to the benign neoplasm ETG  90   d  and are grouped to that ETG. 
         [0162]    Some months later, the patient has a seventh office visit  84   g  which resulted in a diagnosis of bronchitis  80 . However, because the time period between the prior bronchitis episode  76  and the current bronchitis episode  80  exceeds a pre-determined period of time in which there was an absence of treatment for bronchitis, the bronchitis episode  90   a  is closed and the bronchitis episode  90   e  is opened. A hospital record  85  occurs as a result of an eye trauma and eye trauma  81  is the resulting diagnosis. Because the eye trauma  85  is unrelated to the bronchitis  80 , a new eye trauma ETG  90   f  is started which is open concurrently with the bronchitis ETG  90   e . An eighth office visity  84   h  occurs during the time when both ETG  90   e  and ETG  90   f  are open. Eighth office visity  84   h  is, therefore, grouped to the ETG most relevant to the office visity  84   h , i.e., ETG  90   e . A subsequent x-ray record  89   b  occurs and is related to the eye trauma diagnosis and is, therefore, grouped to ETG  90   f . Because and absence of treatment has occurred for the bronchitis ETG  90   e , that ETG  90   e  is closed. 
         [0163]    Finally, while the eye trauma ETG  90   f  is open, the patient has a routine office visit  84   h  which is unrelated to the open ETG  90   f  for the eye trauma diagnosis  91 . Because it is unrelated to the open ETG  90   f , the routine office visity  84   i  starts and groups to a new episode  90   g  which contains only one management record  84   i . An x-ray record  89   c  occurs after and is unrelated to the routine office visity  84   i . The only open episode is the eye trauma episode  90   f  and the x-ray record  89   c  is, therefore, grouped to the eye trauma episode  90   f . At the end of the year, all open episodes, i.e., the eye trauma ETG  90   f  are closed. 
         [0164]    It will be apparent to those skilled in the art, that the foregoing detailed description of the preferred embodiment of the present invention is representative of a type of health care system within the scope and spirit of the present invention. Further, those skilled in the art will recognize that various changes and modifications may be made without departing from the true spirit and scope of the present invention. Those skilled in the art will recognize that the invention is not limited to the specifics as shown here, but is claimed in any form or modification falling within the scope of the appended claims. For that reason, the scope of the present invention is set forth in the following claims. 
         [0000]    
       
         
               
               
             
               
               
             
           
               
                 TABLE 1 
               
               
                   
               
               
                 ETG 
                 DESCRIPTION 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                 1 
                 AIDS with major infectious complication 
               
               
                 2 
                 AIDS with minor infectious complication 
               
               
                 3 
                 AIDS with inflammatory complication 
               
               
                 4 
                 AIDS with neoplastic complication, with surgery 
               
               
                 5 
                 AIDS with neoplastic complication, w/o surgery 
               
               
                 6 
                 HIV sero-positive without AIDS 
               
               
                 7 
                 Major infectious disease except HIV, with comorbidity 
               
               
                 8 
                 Septicemia, w/o comorbidity 
               
               
                 9 
                 Major infectious disease except HIV and septicemia, w/o 
               
               
                   
                 comorbidity 
               
               
                 10 
                 Minor infectious disease 
               
               
                 11 
                 Infectious disease signs &amp; symptoms 
               
               
                 20 
                 Diseases of the thyroid gland, with surgery 
               
               
                 21 
                 Hyper-functioning thyroid gland 
               
               
                 22 
                 Hypo-functioning thyroid gland 
               
               
                 23 
                 Non-toxic goiter 
               
               
                 24 
                 Malignant neoplasm of the thyroid gland 
               
               
                 25 
                 Benign neoplasm of the thyroid gland 
               
               
                 26 
                 Other diseases of the thyroid gland 
               
               
                 27 
                 Insulin dependent diabetes, with comorbidity 
               
               
                 28 
                 Insulin dependent diabetes, w/o comorbidity 
               
               
                 29 
                 Non-insulin dependent diabetes, with comorbidity 
               
               
                 30 
                 Non-insulin dependent diabetes, w/o comorbidity 
               
               
                 31 
                 Malignant neoplasm of the pancreatic gland 
               
               
                 32 
                 Benign endocrine disorders of the pancreas 
               
               
                 33 
                 Malignant neoplasm of the pituitary gland 
               
               
                 34 
                 Benign neoplasm of the pituitary gland 
               
               
                 35 
                 Hyper-functioning adrenal gland 
               
               
                 36 
                 Hypo-functioning adrenal gland 
               
               
                 37 
                 Malignant neoplasm of the adrenal gland 
               
               
                 38 
                 Benign neoplasm of the adrenal gland 
               
               
                 39 
                 Hyper-functioning parathyroid gland 
               
               
                 40 
                 Hypo-functioning parathyroid gland 
               
               
                 41 
                 Malignant neoplasm of the parathyroid gland 
               
               
                 42 
                 Benign neoplasm of the parathyroid gland 
               
               
                 43 
                 Female sex gland disorders 
               
               
                 44 
                 Male sex gland disorders 
               
               
                 45 
                 Nutritional deficiency 
               
               
                 46 
                 Gout 
               
               
                 47 
                 Metabolic deficiency except gout 
               
               
                 48 
                 Other diseases of the endocrine glands or metabolic disorders, 
               
               
                   
                 with surgery 
               
               
                 49 
                 Other diseases of the endocrine glands or metabolic disorders, 
               
               
                   
                 w/o surgery 
               
               
                 50 
                 Endocrine disease signs &amp; symptoms 
               
               
                 70 
                 Leukemia with bone marrow transplant 
               
               
                 71 
                 Leukemia with splenectomy 
               
               
                 72 
                 Leukemia w/o splenectomy 
               
               
                 73 
                 Neoplastic disease of blood and lymphatic system except leukemia 
               
               
                 74 
                 Non-neoplastic blood disease with splenectomy 
               
               
                 75 
                 Non-neoplastic blood disease, major 
               
               
                 76 
                 Non-neoplastic blood disease, minor 
               
               
                 77 
                 Hematology signs &amp; symptoms 
               
               
                 90 
                 Senile or pre-senile mental condition 
               
               
                 91 
                 Organic drug or metabolic disorders 
               
               
                 92 
                 Autism and childhood psychosis 
               
               
                 93 
                 Inorganic psychoses except infantile autism 
               
               
                 94 
                 Neuropsychological &amp; behavioral disorders 
               
               
                 95 
                 Personality disorder 
               
               
                 96 
                 Mental disease signs &amp; symptoms 
               
               
                 110 
                 Cocaine or amphetamine dependence with complications age less 
               
               
                   
                 than 16 
               
               
                 111 
                 Cocaine or amphetamine dependence with complications age 16+ 
               
               
                 112 
                 Cocaine or amphetamine dependence w/o complications age less 
               
               
                   
                 than 16 
               
               
                 113 
                 Cocaine or amphetamine dependence w/o complications age 16+ 
               
               
                 114 
                 Alcohol dependence with complications, age less than 16 
               
               
                 115 
                 Alcohol dependence with complications, age 16+ 
               
               
                 116 
                 Alcohol dependence w/o complications, age less than 16 
               
               
                 117 
                 Alcohol dependence w/o complications, age 16+ 
               
               
                 118 
                 Opioid and/or barbiturate dependence, age less than 16 
               
               
                 119 
                 Opioid and/or barbiturate dependence, age 16+ 
               
               
                 120 
                 Other drug dependence, age less than 16 
               
               
                 121 
                 Other drug dependence, age 16+ 
               
               
                 140 
                 Viral meningitis 
               
               
                 141 
                 Bacterial and fungal meningitis 
               
               
                 142 
                 Viral encephalitis 
               
               
                 143 
                 Non-viral encephalitis 
               
               
                 144 
                 Parasitic encephalitis 
               
               
                 145 
                 Toxic encephalitis 
               
               
                 146 
                 Brain abscess, with surgery 
               
               
                 147 
                 Brain abscess, w/o surgery 
               
               
                 148 
                 Spinal abscess 
               
               
                 149 
                 Inflammation of the central nervous system, with surgery 
               
               
                 150 
                 Inflammation of the central nervous system, w/o surgery 
               
               
                 151 
                 Epilepsy, with surgery 
               
               
                 152 
                 Epilepsy, w/o surgery 
               
               
                 153 
                 Malignant neoplasm of the central nervous system, with surgery 
               
               
                 154 
                 Malignant neoplasm of the central nervous system, w/o surgery 
               
               
                 155 
                 Benign neoplasm of the central nervous system, with surgery 
               
               
                 156 
                 Benign neoplasm of the central nervous system, w/o surgery 
               
               
                 157 
                 Cerebral vascular accident, hemorrhagic, with surgery 
               
               
                 158 
                 Cerebral vascular accident, hemorrhagic, w/o surgery 
               
               
                 159 
                 Cerebral vascular accident, non-hemorrhagic, with surgery 
               
               
                 160 
                 Cerebral vascular accident, non-hemorrhagic, w/o surgery 
               
               
                 161 
                 Major brain trauma, with surgery 
               
               
                 162 
                 Major brain trauma, w/o surgery 
               
               
                 163 
                 Minor brain trauma 
               
               
                 164 
                 Spinal trauma, with surgery 
               
               
                 165 
                 Spinal trauma, w/o surgery 
               
               
                 166 
                 Hereditary and degenerative diseases of the central nervous system, 
               
               
                   
                 with surgery 
               
               
                 167 
                 Hereditary and degenerative diseases of the central nervous system, 
               
               
                   
                 w/o surgery 
               
               
                 168 
                 Migraine headache, non-intractable 
               
               
                 169 
                 Migraine headache, intractable 
               
               
                 170 
                 Congenital and other disorders of the central nervous system, 
               
               
                   
                 with surgery 
               
               
                 171 
                 Congenital and other disorders of the central nervous system, 
               
               
                   
                 w/o surgery 
               
               
                 172 
                 Inflammation of the cranial nerves, with surgery 
               
               
                 173 
                 Inflammation of the cranial nerves, w/o surgery 
               
               
                 174 
                 Carpal tunnel syndrome, with surgery 
               
               
                 175 
                 Carpal tunnel syndrome, w/o surgery 
               
               
                 176 
                 Inflammation of the non-cranial nerves, except carpal tunnel, 
               
               
                   
                 with surgery 
               
               
                 177 
                 Inflammation of the non-cranial nerves, except carpal tunnel, 
               
               
                   
                 w/o surgery 
               
               
                 178 
                 Peripheral nerve neoplasm, with surgery 
               
               
                 179 
                 Peripheral nerve neoplasm, w/o surgery 
               
               
                 180 
                 Traumatic disorder of the cranial nerves, with surgery 
               
               
                 181 
                 Traumatic disorder of the cranial nerves, w/o surgery 
               
               
                 182 
                 Traumatic disorder of the non-cranial nerves, with surgery 
               
               
                 183 
                 Traumatic disorder of the non-cranial nerves, w/o surgery 
               
               
                 184 
                 Congenital disorders of the peripheral nerves 
               
               
                 185 
                 Neurological disease signs &amp; symptoms 
               
               
                 200 
                 Internal eye infection with surgery 
               
               
                 201 
                 Internal eye infection w/o surgery 
               
               
                 202 
                 External eye infection, with surgery 
               
               
                 203 
                 External eye infection, except conjunctivitis, w/o surgery 
               
               
                 204 
                 Conjunctivitis 
               
               
                 205 
                 Inflammatory eye disease, with surgery 
               
               
                 206 
                 Inflammatory eye disease, w/o surgery 
               
               
                 207 
                 Malignant neoplasm of the eye, internal, with surgery 
               
               
                 208 
                 Malignant neoplasm of the eye, internal, w/o surgery 
               
               
                 209 
                 Malignant neoplasm of the eye, external 
               
               
                 210 
                 Benign neoplasm of the eye, internal 
               
               
                 211 
                 Benign neoplasm of the eye, external 
               
               
                 212 
                 Glaucoma, closed angle with surgery 
               
               
                 213 
                 Glaucoma, closed angle w/o surgery 
               
               
                 214 
                 Glaucoma, open angle, with surgery 
               
               
                 215 
                 Glaucoma, open angle, w/o surgery 
               
               
                 216 
                 Cataract, with surgery 
               
               
                 217 
                 Cataract, w/o surgery 
               
               
                 218 
                 Trauma of the eye, with surgery 
               
               
                 219 
                 Trauma of the eye, w/o surgery 
               
               
                 220 
                 Congenital anomaly of the eye, with surgery 
               
               
                 221 
                 Congenital anomaly of the eye, w/o surgery 
               
               
                 222 
                 Diabetic retinopathy, with surgery 
               
               
                 223 
                 Diabetic retinopathy, w/o surgery with comorbidity 
               
               
                 224 
                 Diabetic retinopathy, w/o surgery w/o comorbidity 
               
               
                 225 
                 Non-diabetic vascular retinopathy, with surgery 
               
               
                 226 
                 Non-diabetic vascular retinopathy, w/o surgery 
               
               
                 227 
                 Other vascular disorders of the eye except retinopathies, 
               
               
                   
                 with surgery 
               
               
                 228 
                 Other vascular disorders of the eye except retinopathies, 
               
               
                   
                 w/o surgery 
               
               
                 229 
                 Macular degeneration, with surgery 
               
               
                 230 
                 Macular degeneration, w/o surgery 
               
               
                 231 
                 Non-macular degeneration, with surgery 
               
               
                 232 
                 Non-macular degeneration, w/o surgery 
               
               
                 233 
                 Major visual disturbances, with surgery 
               
               
                 234 
                 Major visual disturbances, w/o surgery 
               
               
                 235 
                 Minor visual disturbances, with surgery 
               
               
                 236 
                 Minor visual disturbances, w/o surgery 
               
               
                 237 
                 Other diseases and disorders of the eye and adnexa 
               
               
                 250 
                 Heart transplant 
               
               
                 251 
                 AMI, with coronary artery bypass graft 
               
               
                 252 
                 AMI or acquired defect, with valvular procedure 
               
               
                 253 
                 AMI, with angioplasty 
               
               
                 254 
                 AMI with arrhythmia, with pacemaker implant 
               
               
                 255 
                 AMI, with cardiac catheterization 
               
               
                 256 
                 AMI, anterior wall with complication 
               
               
                 257 
                 AMI, anterior wall w/o complication 
               
               
                 258 
                 AMI, inferior wall with complication 
               
               
                 259 
                 AMI, inferior wall w/o complication 
               
               
                 260 
                 Ischemic heart disease, w/o AMI, with coronary artery bypass graft 
               
               
                 261 
                 Ischemic heart disease, w/o AMI, with valvular procedure 
               
               
                 262 
                 Ischemic heart disease, w/o AMI, with angioplasty 
               
               
                 263 
                 Ischemic heart disease, w/o AMI, with arrhythmia, with pacemaker 
               
               
                   
                 implant 
               
               
                 264 
                 Ischemic heart disease, w/o AMI, with cardiac catheterization 
               
               
                 265 
                 Ischemic heart disease, w/o AMI 
               
               
                 266 
                 Pulmonary heart disease, w/o AMI 
               
               
                 267 
                 Aortic aneurysm, with surgery 
               
               
                 268 
                 Aortic aneurysm, w/o surgery 
               
               
                 269 
                 Cardiac infection, with surgery 
               
               
                 270 
                 Cardiac infection, w/o surgery 
               
               
                 271 
                 Valvular disorder, with complication 
               
               
                 272 
                 Valvular disorder, w/o complication 
               
               
                 273 
                 Major conduction disorder, with pacemaker/defibrillator implant 
               
               
                 274 
                 Major conduction disorder, w/o pacemaker/defibrillator implant 
               
               
                 275 
                 Minor conduction disorder 
               
               
                 276 
                 Malignant hypertension with comorbidity 
               
               
                 277 
                 Malignant hypertension w/o comorbidity 
               
               
                 278 
                 Benign hypertension with comorbidity 
               
               
                 279 
                 Benign hypertension w/o comorbidity 
               
               
                 280 
                 Cardiac congenital disorder, with surgery 
               
               
                 281 
                 Cardiac congenital disorder, w/o surgery 
               
               
                 282 
                 Major cardiac trauma, with surgery 
               
               
                 283 
                 Major cardiac trauma, w/o surgery 
               
               
                 284 
                 Minor cardiac trauma 
               
               
                 285 
                 Other cardiac diseases 
               
               
                 286 
                 Arterial inflammation, with surgery 
               
               
                 287 
                 Major arterial inflammation, w/o surgery 
               
               
                 288 
                 Minor arterial inflammation, w/o surgery 
               
               
                 289 
                 Major non-inflammatory arterial disease with surgery 
               
               
                 290 
                 Arterial embolism/thrombosis, w/o surgery 
               
               
                 291 
                 Major non-inflammatory arterial disease, except 
               
               
                   
                 embolism/thrombosis, w/o surgery 
               
               
                 292 
                 Atherosclerosis, with surgery 
               
               
                 293 
                 Atherosclerosis, w/o surgery 
               
               
                 294 
                 Arterial aneurysm, except aorta, with surgery 
               
               
                 295 
                 Arterial aneurysm, except aorta, w/o surgery 
               
               
                 296 
                 Other minor non-inflammatory arterial disease, with surgery 
               
               
                 297 
                 Other minor non-inflammatory arterial disease, w/o surgery 
               
               
                 298 
                 Arterial trauma, with surgery 
               
               
                 299 
                 Arterial trauma, w/o surgery 
               
               
                 300 
                 Vein inflammation, with surgery 
               
               
                 301 
                 Embolism and thrombosis of the veins 
               
               
                 302 
                 Disorder of the lymphatic channels 
               
               
                 303 
                 Phlebitis and thrombophlebitis of the veins 
               
               
                 304 
                 Varicose veins of the lower extremity 
               
               
                 305 
                 Other minor inflammatory disease of the veins 
               
               
                 306 
                 Venous trauma, with surgery 
               
               
                 307 
                 Venous trauma, w/o surgery 
               
               
                 308 
                 Other diseases of the veins 
               
               
                 309 
                 Cardiovascular disease signs &amp; symptoms 
               
               
                 320 
                 Infection of the oral cavity 
               
               
                 321 
                 Inflammation of the oral cavity, with surgery 
               
               
                 322 
                 Inflammation of the oral cavity, w/o surgery 
               
               
                 323 
                 Trauma of the oral cavity, with surgery 
               
               
                 324 
                 Trauma of the oral cavity, w/o surgery 
               
               
                 325 
                 Other diseases of the oral cavity, with surgery 
               
               
                 326 
                 Other diseases of the oral cavity, w/o surgery 
               
               
                 327 
                 Otitis media, with major surgery 
               
               
                 328 
                 Otitis media, with minor surgery 
               
               
                 329 
                 Otitis media, w/o surgery 
               
               
                 330 
                 Tonsillitis, adenoiditis or pharyngitis, with surgery 
               
               
                 331 
                 Tonsillitis, adenoiditis or pharyngitis, w/o surgery 
               
               
                 332 
                 Sinusitis and Rhinitis, with surgery 
               
               
                 333 
                 Sinusitis and Rhinitis, w/o surgery 
               
               
                 334 
                 Other ENT infection, with surgery 
               
               
                 335 
                 Other ENT infection, w/o surgery 
               
               
                 336 
                 Major ENT inflammatory conditions with surgery 
               
               
                 337 
                 Major ENT inflammatory conditions w/o surgery 
               
               
                 338 
                 Minor ENT inflammatory conditions with surgery 
               
               
                 339 
                 Minor ENT inflammatory conditions w/o surgery 
               
               
                 340 
                 ENT malignant neoplasm, with surgery 
               
               
                 341 
                 ENT malignant neoplasm, w/o surgery 
               
               
                 342 
                 ENT benign neoplasm, with surgery 
               
               
                 343 
                 ENT benign neoplasm, w/o surgery 
               
               
                 344 
                 ENT congenital anomalies, with surgery 
               
               
                 345 
                 ENT congenital anomalies, w/o surgery 
               
               
                 346 
                 Hearing disorders, with surgery 
               
               
                 347 
                 Hearing disorders, w/o surgery 
               
               
                 348 
                 ENT trauma, with surgery 
               
               
                 349 
                 ENT trauma, w/o surgery 
               
               
                 350 
                 Other ENT disorders, with surgery 
               
               
                 351 
                 Other ENT disorders, w/o surgery 
               
               
                 352 
                 Otolaryngology disease signs &amp; symptoms 
               
               
                 371 
                 Viral pneumonia, with comorbidity 
               
               
                 372 
                 Viral pneumonia, w/o comorbidity 
               
               
                 373 
                 Bacterial lung infections, with comorbidity 
               
               
                 374 
                 Bacterial lung infections, w/o comorbidity 
               
               
                 375 
                 Fungal and other pneumonia, with comorbidity 
               
               
                 376 
                 Fungal and other pneumonia, w/o comorbidity 
               
               
                 377 
                 Pulmonary TB with comorbidity 
               
               
                 378 
                 Pulmonary TB w/o comorbidity 
               
               
                 379 
                 Disseminated TB with comorbidity 
               
               
                 380 
                 Disseminated TB w/o comorbidity 
               
               
                 381 
                 Acute bronchitis, with comorbidity, age less than 5 
               
               
                 382 
                 Acute bronchitis, with comorbidity, age 5+ 
               
               
                 383 
                 Acute bronchitis, w/o comorbidity, age less than 5 
               
               
                 384 
                 Acute bronchitis, w/o comorbidity, age 5+ 
               
               
                 385 
                 Minor infectious pulmonary disease other than acute bronchitis 
               
               
                 386 
                 Asthma with comorbidity, age less than 18 
               
               
                 387 
                 Asthma with comorbidity, age 18+ 
               
               
                 388 
                 Asthma w/o comorbidity, age less than 18 
               
               
                 389 
                 Asthma w/o comorbidity, age 18+ 
               
               
                 390 
                 Chronic bronchitis, with complication with comorbidity 
               
               
                 391 
                 Chronic bronchitis with complication w/o comorbidity 
               
               
                 392 
                 Chronic bronchitis, w/o complication with comorbidity 
               
               
                 393 
                 Chronic bronchitis w/o complication w/o comorbidity 
               
               
                 394 
                 Emphysema, with comorbidity 
               
               
                 395 
                 Emphysema w/o comorbidity 
               
               
                 396 
                 Occupational and environmental pulmonary diseases, with 
               
               
                   
                 comorbidity 
               
               
                 397 
                 Occupational and environmental pulmonary diseases, w/o 
               
               
                   
                 comorbidity 
               
               
                 398 
                 Other inflammatory lung disease, with surgery 
               
               
                 399 
                 Other inflammatory lung disease, w/o surgery 
               
               
                 400 
                 Malignant pulmonary neoplasm, with surgery 
               
               
                 401 
                 Malignant pulmonary neoplasm, w/o surgery 
               
               
                 402 
                 Benign pulmonary neoplasm, with surgery 
               
               
                 403 
                 Benign pulmonary neoplasm, w/o surgery 
               
               
                 404 
                 Chest trauma, with surgery 
               
               
                 405 
                 Chest trauma, open, w/o surgery 
               
               
                 406 
                 Chest trauma, closed, w/o surgery 
               
               
                 407 
                 Pulmonary congenital anomalies, with surgery 
               
               
                 408 
                 Pulmonary congenital anomalies, w/o surgery 
               
               
                 409 
                 Other pulmonary disorders 
               
               
                 410 
                 Pulmonology disease signs &amp; symptoms 
               
               
                 430 
                 Infection of the stomach and esophagus with comorbidity 
               
               
                 431 
                 Infection of the stomach and esophagus w/o comorbidity 
               
               
                 432 
                 Inflammation of the esophagus, with surgery 
               
               
                 433 
                 Inflammation of the esophagus, w/o surgery 
               
               
                 434 
                 Gastritis and/or duodenitis, complicated 
               
               
                 435 
                 Gastritis and/or duodenitis, simple 
               
               
                 436 
                 Ulcer, complicated with surgery 
               
               
                 437 
                 Ulcer, complicated w/o surgery 
               
               
                 438 
                 Ulcer, simple 
               
               
                 439 
                 Malignant neoplasm of the stomach and esophagus, with surgery 
               
               
                 440 
                 Malignant neoplasm of the stomach and esophagus, w/o surgery 
               
               
                 441 
                 Benign neoplasm of the stomach and esophagus, with surgery 
               
               
                 442 
                 Benign neoplasm of the stomach and esophagus, w/o surgery 
               
               
                 443 
                 Trauma or anomaly of the stomach or esophagus, with surgery 
               
               
                 444 
                 Trauma of the stomach or esophagus, w/o surgery 
               
               
                 445 
                 Anomaly of the stomach or esophagus, w/o surgery 
               
               
                 446 
                 Appendicitis, with rupture 
               
               
                 447 
                 Appendicitis, w/o rupture 
               
               
                 448 
                 Diverticulitis, with surgery 
               
               
                 449 
                 Diverticulitis, w/o surgery 
               
               
                 450 
                 Other infectious diseases of the intestines and abdomen 
               
               
                 451 
                 Inflammation of the intestines and abdomen with surgery 
               
               
                 452 
                 Inflammation of the intestines and abdomen, w/o surgery 
               
               
                 453 
                 Malignant neoplasm of the intestines and abdomen, with surgery 
               
               
                 454 
                 Malignant neoplasm of the intestines and abdomen, w/o surgery 
               
               
                 455 
                 Benign neoplasm of the intestines and abdomen, with surgery 
               
               
                 456 
                 Benign neoplasm of the intestines and abdomen, w/o surgery 
               
               
                 457 
                 Trauma of the intestines and abdomen, with surgery 
               
               
                 458 
                 Trauma of the intestines and abdomen, w/o surgery 
               
               
                 459 
                 Congenital anomalies of the intestines and abdomen, with surgery 
               
               
                 460 
                 Congenital anomalies of the intestines and abdomen, w/o surgery 
               
               
                 461 
                 Vascular disease of the intestines and abdomen 
               
               
                 462 
                 Bowel obstruction with surgery 
               
               
                 463 
                 Bowel obstruction w/o surgery 
               
               
                 464 
                 Irritable bowel syndrome 
               
               
                 465 
                 Hernias, except hiatal, with surgery 
               
               
                 466 
                 Hernias, except hiatal, w/o surgery 
               
               
                 467 
                 Hiatal hernia, with surgery 
               
               
                 468 
                 Hiatal hernia, w/o surgery 
               
               
                 469 
                 Other diseases of the intestines and abdomen 
               
               
                 470 
                 Infection of the rectum or anus, with surgery 
               
               
                 471 
                 Infection of the rectum or anus, w/o surgery 
               
               
                 472 
                 Hemorrhoids, complicated, with surgery 
               
               
                 473 
                 Hemorrhoids, complicated, w/o surgery 
               
               
                 474 
                 Hemorrhoids, simple 
               
               
                 475 
                 Inflammation of the rectum or anus, with surgery 
               
               
                 476 
                 Inflammation of the rectum or anus, w/o surgery 
               
               
                 477 
                 Malignant neoplasm of the rectum or anus, with surgery 
               
               
                 478 
                 Malignant neoplasm of the rectum or anus, w/o surgery 
               
               
                 479 
                 Benign neoplasm of the rectum or anus, with surgery 
               
               
                 480 
                 Benign neoplasm of the rectum or anus. w/o surgery 
               
               
                 481 
                 Trauma of the rectum or anus, open, with surgery 
               
               
                 482 
                 Trauma of the rectum or anus, open, w/o surgery 
               
               
                 483 
                 Trauma of the rectum or anus, closed 
               
               
                 484 
                 Other diseases and disorders of the rectum and anus, with surgery 
               
               
                 485 
                 Other diseases and disorders of the rectum and anus, w/o surgery 
               
               
                 486 
                 Gastroenterology disease signs &amp; symptoms 
               
               
                 510 
                 Liver Transplant 
               
               
                 511 
                 Infectious hepatitis, high severity with comorbidity 
               
               
                 512 
                 Infectious hepatitis, high severity w/o comorbidity 
               
               
                 513 
                 Infectious hepatitis, low severity with comorbidity 
               
               
                 514 
                 Infectious hepatitis, low severity w/o comorbidity 
               
               
                 515 
                 Non-infectious hepatitis, with complications 
               
               
                 516 
                 Non-infectious hepatitis, w/o complications 
               
               
                 517 
                 Cirrhosis, with surgery 
               
               
                 518 
                 Cirrhosis, w/o surgery 
               
               
                 519 
                 Acute pancreatitis 
               
               
                 520 
                 Chronic pancreatitis 
               
               
                 521 
                 Cholelithiasis, complicated 
               
               
                 522 
                 Cholelithiasis, simple, with surgery 
               
               
                 523 
                 Cholelithiasis, simple, w/o surgery 
               
               
                 524 
                 Malignant neoplasm of the hepato-biliary system, with surgery 
               
               
                 525 
                 Malignant neoplasm of the hepato-biliary system, w/o surgery 
               
               
                 526 
                 Benign neoplasm of the hepato-biliary system, with surgery 
               
               
                 527 
                 Benign neoplasm of the hepato-biliary system, w/o surgery 
               
               
                 528 
                 Trauma of the hepato-biliary system, complicated, with surgery 
               
               
                 529 
                 Trauma of the hepato-biliary system, complicated, w/o surgery 
               
               
                 530 
                 Trauma of the hepato-biliary system, simple 
               
               
                 531 
                 Other diseases of the hepato-biliary system, with surgery 
               
               
                 532 
                 Other diseases of the hepato-biliary system, w/o surgery 
               
               
                 533 
                 Hepatology disease signs &amp; symptoms 
               
               
                 550 
                 Kidney Transplant 
               
               
                 551 
                 Acute renal failure, with comorbidity 
               
               
                 552 
                 Acute renal failure, w/o comorbidity 
               
               
                 553 
                 Chronic renal failure, with ESRD 
               
               
                 554 
                 Chronic renal failure, w/o ESRD 
               
               
                 555 
                 Acute renal inflammation, with comorbidity 
               
               
                 556 
                 Acute renal inflammation, w/o comorbidity 
               
               
                 557 
                 Chronic renal inflammation, with surgery 
               
               
                 558 
                 Chronic renal inflammation, w/o surgery 
               
               
                 559 
                 Nephrotic syndrome, minimal change 
               
               
                 560 
                 Nephrotic syndrome 
               
               
                 561 
                 Other renal conditions 
               
               
                 562 
                 Nephrology disease signs &amp; symptoms 
               
               
                 570 
                 Infection of the genitourinary system with surgery 
               
               
                 571 
                 Infection of the genitourinary system w/o surgery 
               
               
                 572 
                 Sexually transmitted infection of the lower genitourinary system 
               
               
                 573 
                 Infection of the lower genitourinary system, not sexually 
               
               
                   
                 transmitted 
               
               
                 574 
                 Kidney stones, with surgery with comorbidity 
               
               
                 575 
                 Kidney stones, with surgery w/o comorbidity 
               
               
                 576 
                 Kidney stones, w/o surgery with comorbidity 
               
               
                 577 
                 Kidney stones, w/o surgery w/o comorbidity 
               
               
                 578 
                 Inflammation of the genitourinary tract except kidney stones, 
               
               
                   
                 with surgery 
               
               
                 579 
                 Inflammation of the genitourinary tract except kidney stones, 
               
               
                   
                 w/o surgery 
               
               
                 580 
                 Malignant neoplasm of the prostate, with surgery 
               
               
                 581 
                 Malignant neoplasm of the prostate, w/o surgery 
               
               
                 582 
                 Benign neoplasm of the prostate, with surgery 
               
               
                 583 
                 Benign neoplasm of the prostate, w/o surgery 
               
               
                 584 
                 Malignant neoplasm of the genitourinary tract, except prostate, 
               
               
                   
                 with surgery 
               
               
                 585 
                 Malignant neoplasm of the genitourinary tract, except prostate, 
               
               
                   
                 w/o surgery 
               
               
                 586 
                 Benign neoplasm of the genitourinary tract, except prostate 
               
               
                   
                 with surgery 
               
               
                 587 
                 Benign neoplasm of the genitourinary tract, except prostate, 
               
               
                   
                 w/o surgery 
               
               
                 588 
                 Trauma to the genitourinary tract, with surgery 
               
               
                 589 
                 Trauma to the genitourinary tract, w/o surgery 
               
               
                 590 
                 Urinary incontinence, with surgery 
               
               
                 591 
                 Urinary incontinence, w/o surgery 
               
               
                 592 
                 Other diseases of the genitourinary tract, with surgery 
               
               
                 593 
                 Other diseases of the genitourinary tract, w/o surgery 
               
               
                 594 
                 Urological disease signs &amp; symptoms 
               
               
                 610 
                 Normal pregnancy, normal labor &amp; delivery, with cesarean section 
               
               
                 611 
                 Normal pregnancy, normal labor &amp; delivery, w/o cesarean section 
               
               
                 612 
                 Complicated pregnancy, with cesarean section 
               
               
                 613 
                 Complicated pregnancy, w/o cesarean section 
               
               
                 614 
                 Hemorrhage during pregnancy, with cesarean section 
               
               
                 615 
                 Hemorrhage during pregnancy, w/o cesarean section 
               
               
                 616 
                 Other condition during pregnancy, with cesarean section 
               
               
                 617 
                 Other condition during pregnancy, w/o cesarean section 
               
               
                 618 
                 Fetal problems during pregnancy, with cesarean section 
               
               
                 619 
                 Fetal problems during pregnancy, w/o cesarean section 
               
               
                 620 
                 Ectopic pregnancy, with surgery 
               
               
                 621 
                 Ectopic pregnancy, w/o surgery 
               
               
                 622 
                 Spontaneous abortion 
               
               
                 623 
                 Non-spontaneous abortion 
               
               
                 624 
                 Obstetric signs &amp; symptoms 
               
               
                 630 
                 Infection of the ovary and/or fallopian tube, with surgery 
               
               
                 631 
                 Infection of the ovary and/or fallopian tube, w/o surgery, with 
               
               
                   
                 comorbidity 
               
               
                 632 
                 Infection of the ovary and/or fallopian tube, w/o surgery, w/o 
               
               
                   
                 comorbidity 
               
               
                 633 
                 Infection of the uterus, with surgery 
               
               
                 634 
                 Infection of the uterus, w/o surgery, with comorbidity 
               
               
                 635 
                 Infection of the uterus, w/o surgery, w/o comorbidity 
               
               
                 636 
                 Infection of the cervix, with surgery 
               
               
                 637 
                 Infection of the cervix, w/o surgery 
               
               
                 638 
                 Vaginal infection, with surgery 
               
               
                 639 
                 Monilial infection of the vagina (yeast) 
               
               
                 640 
                 Infection of the vagina except monilial 
               
               
                 641 
                 Inflammation of the female genital system, with surgery 
               
               
                 642 
                 Endometriosis, w/o surgery 
               
               
                 643 
                 Inflammatory condition of the female genital tract except 
               
               
                   
                 endometriosis, w/o surgery 
               
               
                 644 
                 Malignant neoplasm of the female genital tract, with surgery 
               
               
                 645 
                 Malignant neoplasm of the female genital tract, w/o surgery 
               
               
                 646 
                 Benign neoplasm of the female genital tract, with surgery 
               
               
                 647 
                 Benign neoplasm of the female genital tract, w/o surgery 
               
               
                 648 
                 Conditions associated with menstruation, with surgery 
               
               
                 649 
                 Conditions associated with menstruation, w/o surgery 
               
               
                 650 
                 Conditions associated with female infertility, with surgery 
               
               
                 651 
                 Conditions associated with female infertility, w/o surgery 
               
               
                 652 
                 Other diseases of the female genital tract, with surgery 
               
               
                 653 
                 Other diseases of the female genital tract, w/o surgery 
               
               
                 654 
                 Malignant neoplasm of the breast, with surgery 
               
               
                 655 
                 Malignant neoplasm of the breast, w/o surgery 
               
               
                 656 
                 Benign neoplasm of the breast, with surgery 
               
               
                 657 
                 Benign neoplasm of the breast, w/o surgery 
               
               
                 658 
                 Other disorders of the breast, with surgery 
               
               
                 659 
                 Other disorders of the breast, w/o surgery 
               
               
                 660 
                 Gynecological signs &amp; symptoms 
               
               
                 670 
                 Major bacterial infection of the skin, with surgery 
               
               
                 671 
                 Major bacterial infection of the skin, w/o surgery 
               
               
                 672 
                 Minor bacterial infection of the skin 
               
               
                 673 
                 Viral skin infection 
               
               
                 674 
                 Fungal skin infection, with surgery 
               
               
                 675 
                 Fungal skin infection, w/o surgery 
               
               
                 676 
                 Parasitic skin infection 
               
               
                 677 
                 Major inflammation of skin &amp; subcutaneous tissue 
               
               
                 678 
                 Minor inflammation of skin &amp; subcutaneous tissue 
               
               
                 679 
                 Malignant neoplasm of the skin, major, with surgery 
               
               
                 680 
                 Malignant neoplasm of the skin, major, w/o surgery 
               
               
                 681 
                 Malignant neoplasm of the skin, minor 
               
               
                 682 
                 Benign neoplasm of the skin 
               
               
                 683 
                 Major burns, with surgery 
               
               
                 684 
                 Major burns, w/o surgery 
               
               
                 685 
                 Major skin trauma, except burns, with surgery 
               
               
                 686 
                 Major skin trauma, except burns, w/o surgery 
               
               
                 687 
                 Minor burn 
               
               
                 688 
                 Minor trauma of the skin except burn, with surgery 
               
               
                 689 
                 Open wound of the skin, w/o surgery 
               
               
                 690 
                 Minor trauma of the skin except burn and open wound, w/o surgery 
               
               
                 691 
                 Other skin disorders 
               
               
                 692 
                 Dermatological signs &amp; symptoms 
               
               
                 710 
                 Infection of the large joints with comorbidity 
               
               
                 711 
                 Infection of the large joints w/o comorbidity 
               
               
                 712 
                 Infection of the small joints with comorbidity 
               
               
                 713 
                 Infection of the small joints w/o comorbidity 
               
               
                 714 
                 Degenerative orthopedic diseases with hip or spine surgery 
               
               
                 715 
                 Degenerative orthopedic diseases with large joint surgery 
               
               
                 716 
                 Degenerative orthopedic diseases with hand or foot surgery 
               
               
                 717 
                 Juvenile rheumatoid arthritis with complication with comorbidity 
               
               
                 718 
                 Juvenile rheumatoid arthritis with complication w/o comorbidity 
               
               
                 719 
                 Juvenile rheumatoid arthritis w/o complication with comorbidity 
               
               
                 720 
                 Juvenile rheumatoid arthritis w/o complication w/o comorbidity 
               
               
                 721 
                 Adult rheumatoid arthritis with complication with comorbidity 
               
               
                 722 
                 Adult rheumatoid arthritis with complication w/o comorbidity 
               
               
                 723 
                 Adult rheumatoid arthritis w/o complication with comorbidity 
               
               
                 724 
                 Adult rheumatoid arthritis w/o complication w/o comorbidity 
               
               
                 725 
                 Lupus, with complication 
               
               
                 726 
                 Lupus, w/o complication 
               
               
                 727 
                 Autoimmune rheumatologic disease except lupus 
               
               
                 728 
                 Inflammation of the joints other than rheumatoid arthritis, 
               
               
                   
                 with comorbidity 
               
               
                 729 
                 Inflammation of the joints other than rheumatoid arthritis, 
               
               
                   
                 w/o comorbidity 
               
               
                 730 
                 Degenerative joint disease, generalized 
               
               
                 731 
                 Degenerative joint disease, localized with comorbidity 
               
               
                 732 
                 Degenerative joint disease, localized w/o comorbidity 
               
               
                 733 
                 Infections of bone, with surgery 
               
               
                 734 
                 Infections of bone, w/o surgery 
               
               
                 735 
                 Maxillofacial fracture or dislocation, with surgery 
               
               
                 736 
                 Maxillofacial fracture or dislocation, w/o surgery 
               
               
                 737 
                 Pelvis fracture or dislocation, with surgery 
               
               
                 738 
                 Pelvis fracture or dislocation, w/o surgery 
               
               
                 739 
                 Hip and/or femur fracture or dislocation, with surgery 
               
               
                 740 
                 Hip and/or femur fracture or dislocation, open, w/o surgery 
               
               
                 741 
                 Hip and/or femur fracture or dislocation, closed, w/o surgery 
               
               
                 742 
                 Upper extremity fracture or dislocation, with surgery 
               
               
                 743 
                 Upper extremity fracture or dislocation, open, w/o surgery 
               
               
                 744 
                 Upper extremity fracture or dislocation, closed, w/o surgery 
               
               
                 745 
                 Lower extremity fracture or dislocation, with surgery 
               
               
                 746 
                 Lower extremity fracture or dislocation, open, w/o surgery 
               
               
                 747 
                 Lower extremity fracture or dislocation, closed, w/o surgery 
               
               
                 748 
                 Trunk fracture or dislocation, with surgery 
               
               
                 749 
                 Trunk fracture or dislocation, open, w/o surgery 
               
               
                 750 
                 Trunk fracture or dislocation, closed, w/o surgery 
               
               
                 751 
                 Malignant neoplasm of the bone and connective tissue, head and 
               
               
                   
                 neck 
               
               
                 752 
                 Malignant neoplasm of the bone and connective tissue other than 
               
               
                   
                 head and neck 
               
               
                 753 
                 Benign neoplasm of the bone and connective tissue, head and neck 
               
               
                 754 
                 Benign neoplasm of the bone and connective tissue other than head 
               
               
                   
                 and neck 
               
               
                 755 
                 Internal derangement of joints, with surgery 
               
               
                 756 
                 Internal derangement of joints, w/o surgery 
               
               
                 757 
                 Major orthopedic trauma other than fracture or dislocation, with 
               
               
                   
                 surgery 
               
               
                 758 
                 Major orthopedic trauma other than fracture or dislocation, w/o 
               
               
                   
                 surgery 
               
               
                 759 
                 Major neck and back disorders, with surgery 
               
               
                 760 
                 Major neck and back disorders, w/o surgery 
               
               
                 761 
                 Bursitis and tendinitis, with surgery 
               
               
                 762 
                 Bursitis and tendinitis, w/o surgery 
               
               
                 763 
                 Minor orthopedic disorder except bursitis and tendinitis, with 
               
               
                   
                 surgery 
               
               
                 764 
                 Minor neck and back disorder, except bursitis and tendinitis, 
               
               
                   
                 w/o surgery 
               
               
                 765 
                 Minor orthopedic disorder other than neck and back, except 
               
               
                   
                 bursitis and tendinitis, w/o surgery 
               
               
                 766 
                 Orthopedic congenital and acquired deformities, with surgery 
               
               
                 767 
                 Orthopedic congenital and acquired deformities, w/o surgery 
               
               
                 768 
                 Orthopedic and rheumatological signs &amp; symptoms 
               
               
                 780 
                 Uncomplicated neonatal management 
               
               
                 781 
                 Chromosomal anomalies 
               
               
                 782 
                 Metabolic related disorders originating the antenatal period 
               
               
                 783 
                 Chemical dependency related disorders originating in the 
               
               
                   
                 antenatal period 
               
               
                 784 
                 Mechanical related disorders originating in the antenatal period 
               
               
                 785 
                 Other disorders originating in the antenatal period 
               
               
                 786 
                 Other major neonatal disorders, perinatal origin 
               
               
                 787 
                 Other minor neonatal disorders, perinatal origin 
               
               
                 788 
                 Neonatal signs &amp; symptoms 
               
               
                 790 
                 Exposure to infectious diseases 
               
               
                 791 
                 Routine inoculation 
               
               
                 792 
                 Non-routine inoculation 
               
               
                 793 
                 Prophylactic procedures other than inoculation and exposure to 
               
               
                   
                 infectious disease 
               
               
                 794 
                 Routine exam 
               
               
                 795 
                 Contraceptive management, with surgery 
               
               
                 796 
                 Contraceptive management, w/o surgery 
               
               
                 797 
                 Conditional exam 
               
               
                 798 
                 Major specific procedures not classified elsewhere 
               
               
                 799 
                 Minor specific procedures not classified elsewhere 
               
               
                 800 
                 Administrative services 
               
               
                 801 
                 Other preventative and administrative services 
               
               
                 810 
                 Late effects and late complications 
               
               
                 811 
                 Environmental trauma 
               
               
                 812 
                 Poisonings and toxic effects of drugs 
               
               
                 900 
                 Isolated signs, symptoms and non-specific diagnoses or conditions 
               
               
                 990 
                 Drug record, no drug module 
               
               
                 991 
                 Orphan drug record 
               
               
                 992 
                 Non-Rx NDC code 
               
               
                 993 
                 Invalid NDC code 
               
               
                 994 
                 Invalid provider type, e.g., dentist 
               
               
                 995 
                 Record outside date range 
               
               
                 996 
                 Invalid CPT-4 code 
               
               
                 997 
                 Invalid Dx code 
               
               
                 998 
                 Inappropriate Dx-CPT-4 matched record 
               
               
                 999 
                 Orphan record
A computer-implemented method for profiling medical claims to assist health care managers in determining the cost-efficiency and service quality of health care providers. The method allows an objective means for measuring and quantifying health care services. An episode treatment group (ETG) is a patient classification unit, which defines groups that are clinically homogenous (similar cause of illness and treatment) and statistically stable. The ETG grouper methodology uses service or segment-level claim data as input data and assigns each service to the appropriate episode. The program identifies concurrent and recurrent episodes, flags records, creates new groupings, shills groupings for changed conditions, selects the most recent claims, resets windows, makes a determination if the provider is an independent lab and continues to collect information until an absence of treatment is detected.