Abstract:
A computerized system and method that allows healthcare providers to update the medical codes in health benefits provider member records using medical code models. Each medical code model has an identifier and associated medical codes. Each member record has a code model identifier that indicates which set of medical codes are appropriate for the member&#39;s medical conditions. In an example embodiment, the code model identifiers include a medical hierarchical condition code model, and an end-stage renal disease code model. When medical conditions are affirmed or added to a member&#39;s database medical record, the member&#39;s code model identifier is used to select the set of medical codes from which a computer user can choose. The use of the medical code model identifier limits a user&#39;s selection of medical codes and as a result, reduces the likelihood of medical record coding errors.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
       [0001]    This application is a continuation-in-part of U.S. application Ser. No. 13/769,981, filed Feb. 19, 2013 and titled COMPUTERIZED SYSTEM AND METHOD FOR CODING MEDICAL RECORDS TO FACILITATE PROVIDER REIMBURSEMENTS, which claims priority to U.S. Provisional Application Ser. No. 61/599,674, filed Feb. 16, 2012 and titled COMPUTERIZED SYSTEM AND METHOD FOR CODING MEDICAL RECORDS TO FACILITATE PROVIDER REIMBURSEMENTS, the contents of which are incorporated herein by reference. 
     
    
     BACKGROUND OF THE INVENTION 
       [0002]    To facilitate reimbursements to healthcare providers, organizations such as the Centers for Medicare &amp; Medicaid Services (CMS) and other health benefits payors require coding of medical records. Coding classifications, such as CMS&#39;s hierarchical condition categories (Medical HCC Model), CMS&#39;s end-stage renal disease codes (ESRD HCC Model) and CMS&#39;s prescription codes (Rx Model), are used to identify numerous health or medical conditions as well as prescriptions relevant to a patient&#39;s health. For example, one code identifies chronic pulmonary heart disease while another code identifies a diabetes health condition. The patient record of an individual with multiple chronic health conditions will have multiple codes identifying each of the associated health conditions. For example, an individual who has arthritis may also have osteoporosis and high blood pressure. The patient&#39;s electronic medical record therefore, may have a first code for arthritis, a second code for osteoporosis, and a third code for high blood pressure. 
         [0003]    Codes may be identified for medical records by healthcare providers, health benefit providers, and other organizations that may be granted access to a patient&#39;s records. Although great care is taken in coding medical records properly, errors and omissions can occur. For example, a healthcare provider may fail to add to a patient&#39;s record a code for a newly diagnosed health condition or to provide the correct code for the specific symptom of a patient&#39;s health condition. For example, various codes for renal failure are used to identify specific characteristics of the disease. In other instances, a healthcare provider may overlook codes for secondary conditions or complications related to a patient&#39;s primary problems. For example, a diabetic patient may occasionally present with a urinary tract infection or mild malnutrition that are identified by specific codes that differ from diabetes codes. To facilitate reimbursement and for other reasons, it is important for medical records to be coded completely and accurately. CMS, for example, uses HCC codes that are correlated to diagnosis codes to adjust capitation payments to private health care plans for the health expenditure risk of their members. 
         [0004]    Because the information most relevant to an individual&#39;s health status typically originates at a healthcare provider reimbursed by a health benefits provider or other third party payor, medical records received by payors are initially coded according to data received from the healthcare provider. The coding details are typically obtained from the provider&#39;s claim or request for reimbursement. Records are not always coded correctly and when coding errors are discovered, they are often discovered in connection with claims for reimbursement. Because the provider&#39;s reimbursement depends upon proper medical record coding, including the use of an appropriate code model, it is important for providers to have the ability to correct or change codes when questions regarding the coding are raised or when coding errors are discovered. 
         [0005]    Although coding problems may be resolved in various ways such as through direct communications between the healthcare provider and health benefits provider or payor, this approach is neither the most efficient nor effective. The volume of claims generated by healthcare providers and received by health benefits providers is so great that resolving problems by telephone, email, or fax communications is impractical. Even if the individuals involved in the telephone, email, or fax communications reach agreement on the resolution of a coding problem, one or more associated electronic medical or claims records must be updated. 
         [0006]    There is a need for a computerized system and method that allows healthcare providers to access and modify medical record codes for member medical database records of a health benefits provider. In particular, there is a need for a computerized system and method that allows healthcare providers to use an appropriate coding model and to further respond to “suspect conditions” identified in member medical database records for a member population using an appropriate set of medical codes. There is a need for a computerized system and method that allows healthcare providers using the correct medical code model to enter and correct codes for medical database records stored at a health benefits provider and used for reimbursement of services. 
       SUMMARY OF THE INVENTION 
       [0007]    The present disclosure is directed to a web-based tool that grants healthcare providers the ability to make real-time updates to the medical codes in health benefits provider member medical database records. In an example embodiment, healthcare providers access and update “suspect conditions” in a health benefits provider&#39;s Suspect Tracking And Reporting (STAR) database. The health benefits provider receives claims for services provided to its members as well as associated, supporting medical records and documentation for the claims. In connection with processing claims for reimbursement, the health benefits provider enters and tracks the claim and related medical data in a database and identifies one or more “suspect conditions.” The healthcare provider is provided with access to the database records and permitted to update records with codes from the appropriate code model (i.e. Medical HCC Model or ESRD HCC Model) while researching “suspect conditions” in supporting documentation and data. The healthcare provider may review written reports and other relevant data to affirm or deny the “suspected condition” identified in a member record. As a result, healthcare providers and the health benefits provider are assured that all data associated with a patient&#39;s medical record is as current, complete, and accurate as possible. The affirmed condition data for a member population along with revised encounter submissions may further be used in projecting risk scores to the population and a level of reimbursement for the healthcare provider. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0008]      FIG. 1  is a member search screen according to an example embodiment; 
           [0009]      FIGS. 2A and 2B  are member search results screens according to an example embodiment; 
           [0010]      FIG. 3A  is a member HCC profile screen for a Medical HCC Model member according to an example embodiment. 
           [0011]      FIG. 3B  is a member HCC profile screen for an ESRD HCC model member according to an example embodiment; 
           [0012]      FIG. 4A  is an example affirm condition screen for Medical HCC Model codes according to an example embodiment; 
           [0013]      FIG. 4B  is an Affirm Condition screen according to an example embodiment; 
           [0014]      FIG. 5A  is an example affirm condition screen for ESRD HCC Model codes according to an example embodiment; 
           [0015]      FIG. 5B  is an Affirm Condition screen according to an example embodiment; 
           [0016]      FIGS. 6A and 6B  are updated Member HCC Profile screens according to an example embodiment; 
           [0017]      FIGS. 7A and 7B  are example Member HCC Profile screens according to an example embodiment; 
           [0018]      FIG. 8A  is an example Add Affirmed Condition screen for a Medical HCC Model member according to an example embodiment; 
           [0019]      FIG. 8B  is a first Member HCC Profile screen according to an example embodiment; 
           [0020]      FIG. 9A  is an example Add Affirmed Condition screen for an ESRD Model member according to an example embodiment 
           [0021]      FIG. 9B  is a second Member HCC Profile screen according to an example embodiment; 
           [0022]      FIG. 10A  is a current status Member HCC Profile screen for a Medical HCC Model member according to an example embodiment; 
           [0023]      FIG. 10B  is an updated status Member HCC Profile screen for a Medical HCC Model member according to an example embodiment; 
           [0024]      FIG. 11A  is a current status Member HCC Profile screen for an ESRD HCC Model member according to an example embodiment; 
           [0025]      FIG. 11B  is an updated status Member HCC Profile screen for an ESRD HCC Model member according to an example embodiment; 
           [0026]      FIG. 12  is an Activity Log report screen according to an example embodiment; 
           [0027]      FIG. 13  is a Condition Status Summary report screen according to an example embodiment; 
           [0028]      FIG. 14  is a Member Listing—By Condition Status report screen according to an example embodiment; 
           [0029]      FIG. 15A  is a first Member Listing—By HCC search screen according to an example embodiment; 
           [0030]      FIG. 15B  is a first Member Listing—By HCC report screen according to an example embodiment; 
           [0031]      FIG. 16A  is a second Member Listing—By HCC search screen according to an example embodiment; 
           [0032]      FIG. 16B  is a second Member Listing—By HCC report screen according to an example embodiment; 
           [0033]      FIG. 17A  is a condition history screen for a Medical HCC Model member according to an example embodiment; and 
           [0034]      FIG. 17B  is a condition history screen for an ESRD HCC Model member according to an example embodiment. 
       
    
    
     DETAILED DESCRIPTION 
       [0035]    Referring to  FIG. 1 , a member search screen according to an example embodiment is shown. A user can search for a member by selecting any combination of search criteria. In addition to searching by provider  100 , member identifier, Medicare identifier, member date of birth, member name  102 , or product type (HMO, PFFS, LPPO, or RPPO)  104 , a user may select a condition status  106 . In an example embodiment, the member status conditions may include the following. 
         [0000]    
       
         
               
             
               
               
             
           
               
                 TABLE 1 
               
               
                   
               
               
                 Condition Status Categories 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                 Level One Open 
                 Conditions more likely to be seen in a provider 
               
               
                 Conditions 
                 office setting than a hospital setting. Example 
               
               
                   
                 “level one” Conditions are listed in Table 2. 
               
               
                 Members with Open 
                 List of members having at least one open suspect 
               
               
                 Conditions 
                 condition, regardless of whether the open 
               
               
                   
                 condition is a “level one” condition. All of 
               
               
                   
                 a member&#39;s conditions are displayed as long as 
               
               
                   
                 that member has at least one open condition. 
               
               
                 Affirmed 
                 List of members having at least one affirmed 
               
               
                 Conditions 
                 condition. All of a member&#39;s conditions are 
               
               
                   
                 displayed as long as that member has at least 
               
               
                   
                 one affirmed condition. 
               
               
                 “CMS accepted” 
                 List of members having at least one CMS accepted 
               
               
                 Conditions 
                 condition. All of a member&#39;s conditions are 
               
               
                   
                 displayed as long as that member has at least 
               
               
                   
                 one CMS accepted condition. 
               
               
                 Denied Conditions 
                 List of members having at least one denied 
               
               
                   
                 condition. All of a member&#39;s conditions are 
               
               
                   
                 displayed as long as that member has at least 
               
               
                   
                 one denied condition. 
               
               
                 Conditions 
                 List of members having at least one condition, 
               
               
                   
                 regardless of the status of that condition 
               
               
                   
                 (Open, Affirmed, “CMS accepted”, etc.). 
               
               
                 No Conditions 
                 List of members that do not have any conditions. 
               
               
                 Total Membership 
                 List of all members associated with the selected 
               
               
                   
                 physician, regardless of whether the members 
               
               
                   
                 have any conditions or not. 
               
               
                   
               
             
          
         
       
     
         [0000]    
       
         
               
             
               
               
             
           
               
                 TABLE 2 
               
             
             
               
                   
               
               
                 Example “Level One” Conditions 
               
             
          
           
               
                 HCC 
                 DESCRIPTION 
               
               
                   
               
               
                 10A 
                 BREAST, PROSTATE, COLORECTAL AND OTHER 
               
               
                   
                 CANCERS AND TUMORS 
               
               
                 15A 
                 DIABETES WITH RENAL OR PERIPHERAL 
               
               
                   
                 CIRCULATORY MANIFESTATION 
               
               
                 16A 
                 DIABETES WITH NEUROLOGIC OR OTHER 
               
               
                   
                 SPECIFIED MANIFESTATION 
               
               
                 18A 
                 DIABETES WITH OPHTHALMOLOGIC OR 
               
               
                   
                 UNSPECIFIED MANIFESTATION 
               
               
                 19A 
                 DIABETES WITHOUT COMPLICATION 
               
               
                 27A 
                 CHRONIC HEPATITIS 
               
               
                 38A 
                 RHEUMATOID ARTHRITIS AND INFLAMMATORY 
               
               
                   
                 CONNECTIVE TISSUE DISEASE 
               
               
                 68A 
                 PARAPLEGIA 
               
               
                 71A 
                 POLYNEUROPATHY 
               
               
                 73A 
                 PARKINSON&#39;S AND HUNTINGTON&#39;S DISEASES 
               
               
                 74A 
                 SEIZURE DISORDERS AND CONVULSIONS 
               
               
                 80A 
                 CONGESTIVE HEART FAILURE 
               
               
                 83A 
                 ANGINA PECTORIS/OLD MYOCARDIAL INFARCTION 
               
               
                 92A 
                 SPECIFIED HEART ARRHYTHMIAS 
               
               
                 100A  
                 HEMIPLEGIA/HEMIPARESIS 
               
               
                 105A  
                 VASCULAR DISEASE 
               
               
                 108A  
                 CHRONIC OBSTRUCTIVE PULMONARY DISEASE 
               
               
                 130A  
                 DIALYSIS STATUS 
               
               
                 131A  
                 RENAL FAILURE 
               
               
                 132A  
                 NEPHRITIS 
               
               
                 149A  
                 CHRONIC ULCER OF SKIN, EXCEPT DECUBITUS 
               
               
                 176A  
                 ARTIFICIAL OPENINGS FOR FEEDING OR 
               
               
                   
                 ELIMINATION 
               
               
                 177A  
                 AMPUTATION STATUS, LOWER LIMB AMPUTATION 
               
               
                   
                 COMPLICATIONS 
               
               
                   
               
             
          
         
       
     
         [0036]    Selection of the “level one open conditions” search criteria returns a list of members that have at least one open “level one” condition. In addition to displaying open “level one” conditions, the Member HCC Profile also includes all known conditions for a member, regardless of suspect status. 
         [0037]    Referring to  FIGS. 2A and 2B , a member search results screen according to an example embodiment is shown. The member search results screen displays all records that match the search criteria selected or entered in the member search screen. In addition to displaying results for the fields from the member search screen, the search results screen displays the members&#39; current risk score  110 , applicable HCC model  112 , and indicators for the members&#39; Level One open conditions  114 , open conditions  116 , affirmed conditions  117 , and CMS accepted conditions  119 . In an example embodiment, the HCC model indicator identifies an applicable set of codes for the member&#39;s medical records. In an example embodiment, the code models include the following. 
         [0000]    
       
         
               
             
               
               
               
             
           
               
                 TABLE 3 
               
               
                   
               
               
                 Code Models 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                   
                 2 Medical HCC Models 
                 149 conditions eligible for 
               
               
                   
                 General Medical Hierarchical 
                 Medicare Risk Adjustment 
               
               
                   
                 Condition Codes 
               
               
                   
                 1 ESRD HCC Model 
                 87 conditions eligible for 
               
               
                   
                 End Stage Renal Disease 
                 Medicare Risk Adjustment 
               
               
                   
                 Hierarchical Condition Codes 
               
               
                   
                   
               
             
          
         
       
     
         [0038]    The application of a code model reduces improper coding by limiting a user&#39;s selection to the appropriate codes for the member&#39;s conditions. 
         [0039]    By selecting one of the rows of member data  118 , a user can view the member&#39;s HCC profile. Referring to  FIG. 3A , a member HCC profile screen for a Medical HCC Model according to an example embodiment is shown. In the example, the member&#39;s conditions  120  are defined by two Medical HCC Model which combined include  149  health conditions eligible for Medicare Risk Adjustment. The member&#39;s health conditions, both confirmed and suspected, are displayed for multiple CMS data collection periods  122 . Referring to  FIG. 3B , a member HCC profile screen for an ESRD HCC model member is shown. The member&#39;s ESRD conditions  124  are defined by the ESRD HCC Model which includes 87 health conditions eligible for Medicare Risk Adjustment. 
         [0040]    Referring again to  FIG. 3A , to confirm a condition in a member&#39;s HCC profile, a user selects a drop-down arrow next to a suspect condition  126  (i.e., a condition with an “Open” status) in the member HCC profile screen. The user then selects the “Provider Affirmed Condition” option (not shown) from a drop-down list which causes an affirm condition screen to appear. Referring to  FIG. 4A , an example Affirm Condition screen for Medical HCC Model codes according to an example embodiment is shown. The user enters a diagnosis code  130  such as an ICD9 code specific to the condition to be affirmed. The user is also prompted to enter a Date of Service  132 . After entering the required information, the user selects the Validate option  134  to verify that the diagnosis code is valid for the Date of Service entered. Referring to  FIG. 4B , a message  136  is displayed below the Validate option, informing the user which health condition will be updated when the Confirm option  138  is selected. Selecting the Confirm option completes the condition status update operation. 
         [0041]    Referring to  FIG. 5A , an example Affirm Condition screen for ESRD HCC Model codes according to an example embodiment is shown. In the example, the user enters a diagnosis code  140  and a Date of Service  142 , then selects the Validate option  144 . Referring to  FIG. 5B , a message  146  is displayed below the Validate option, informing the user which health conditions will be updated when the Confirm option  148  is selected. Selecting the Confirm option  148  completes the condition status update operation. 
         [0042]    After completing a condition status update operation by selecting the Confirm option  148 , the user returns to the Member HCC Profile screen which reflects the updated health condition status. Referring to  FIG. 6A , an updated Member HCC Profile screen corresponding to the Member HCC Profile screen of  FIG. 3A  (Medical HCC Model) is shown. The screen of  FIG. 6A  reflects the updated health condition status for condition 38A Rheumatoid Arthritis and Inflammatory Connective Tissue Disease for CMS period 01/01/2013-12/31/2013 (165) and for condition 40 Rheumatoid Arthritis and Inflammatory Connective Tissue Disease for the CMS periods 01/01/2013-12/31/2013 (165) and 07/01/2013-06/30/2014 (170). The status is changed from “Open” to “Provider Affirmed Condition”  150 . Referring to  FIG. 6B , an updated Member HCC Profile screen corresponding to the Member HCC Profile screen of  FIG. 3B  (ESRD HCC Model) is shown. The screen of  FIG. 6B  reflects the updated condition status for condition 96 Specified Heart Arrhythmias by indicating the condition status of “Open” for the periods 01/01/2013-12/31/2013 ( 165 ) and 07/01/2013-06/30/2014 ( 170 ) is now “Provider Affirmed Condition”  152 . 
         [0043]    Referring to  FIG. 7A , an example Member HCC Profile screen according to an example embodiment is shown. If a user cannot find documentation to support the presence of a suspect condition for a specific CMS data collection period, the user may change the “Open” status of the suspect condition to “Provider Denied Condition” by selecting the option from a drop-down menu  160 . Following selection of the option, the screen appears as shown in  FIG. 7A  for the Medical HCC Model. Similarly, the screen appears as shown in  FIG. 7B  (ESRD HCC Model) following selection of the Provider Denied Condition option  162 . 
         [0044]    In addition to confirming or denying conditions, a user may add a health condition to a Member&#39;s HCC Profile. After selecting the Add New Condition option  154  as shown in  FIG. 6A  for Medical HCC Model or  FIG. 6B  for ESRD HCC Model  156 , an Add Affirmed Condition screen appears. Referring to  FIG. 8A , an example Add Affirmed Condition screen for a Medical HCC Model member according to an example embodiment is shown. The user is prompted to enter a diagnosis code such as an ICD9 code  170 , and the Date of Service  172 . Next, the user performs a validation step by selecting the Validate option  174 . A message  176  is displayed below the Validate option, informing the user which health condition codes will be added when the Confirm option  178  is selected. Selecting the Confirm option  178  causes the new conditions to be added to the member&#39;s profile. Referring to  FIG. 8B  (Medical HCC Model), the new conditions appear in the member profile as a “Provider Affirmed Condition”  180 . 
         [0045]    Referring to  FIG. 9A , an Add Affirmed Condition screen for an ESRD Model Member according to an example embodiment is shown. The user is prompted to enter a diagnosis code (e.g., ICD9 code)  190 , and the Date of Service  192 . Next, the user performs a validation step by selecting the Validate option  194 . A message  196  is displayed below the Validate option, informing the user which health conditions will be added when the Confirm option  198  is selected. Selecting the Confirm option  198  causes the new conditions to be added to the member&#39;s profile. Referring to  FIG. 9B , the new conditions appear in the member profile as a “Provider Affirmed Condition”  200 . 
         [0046]    Users are also able to correct the status of a condition that was previously identified as “Provider Denied Status.” Referring to  FIG. 10A  (Medical HCC Model), a current status Member HCC Profile screen for a Medical HCC Model member according to an example embodiment is shown. The user opens the menu for the “Provider Denied Condition”  210  and affirms the condition through the Medical HCC Model Affirm Condition screens as shown in  FIGS. 4A and 4B . After saving the condition status update, the Member HCC Profile screen displays the correct condition status of “Provider Affirmed Condition”  212  as shown in  FIG. 10B . 
         [0047]    Referring to  FIG. 11A , a current status Member HCC Profile screen for an ESRD HCC Model member according to an example embodiment is shown. The user opens the menu for the “Provider Denied Condition”  220  and affirms the condition through the ESRD HCC Model Affirm Condition screens as shown in  FIGS. 5A and 5B . After saving the condition status update, the Member HCC Profile screen displays the correct condition status of “Provider Affirmed Condition”  222  as shown in  FIG. 11B . 
         [0048]    Referring to  FIG. 12 , an Activity Log report screen according to an example embodiment is shown. In an example embodiment, the report presents a list of status updates based on the search criteria of provider, plan type (e.g., health maintenance organization HMO, private fee-for-service plan PFFS, local preferred provider organization LPPO, and regional preferred provider organization RPPO), condition year, and date range. For each updated health condition status, the report provides identifying information for the member as well as applicable plan product, HCC Model Identifier, HCC Description, and details related to when the condition was identified by the provider. 
         [0049]    Referring to  FIG. 13 , a Condition Status Summary report screen according to an example embodiment is shown. In an example embodiment, the report presents a series of counts related to health condition status changes, an average number of conditions  230  and an average risk factor  232  for the subject members. 
         [0050]    Referring to  FIG. 14 , a Member Listing—By Condition Status report screen according to an example embodiment is shown. For each condition status, the report provides identifying information for the member as well as the applicable plan product, HCC Model Identifier, HCC Description, condition status, current year risk score, and details related to when the condition was identified by the health care provider. 
         [0051]    Referring to  FIG. 15A , a first Member Listing—By HCC search screen according to an example embodiment is shown. After selecting one or more products  240  and an HCC model  242 , a user can select providers  244  and specific HCCs  246  from respective lists. The user can also specify a condition year  248 . Referring to  FIG. 15B , a first Member Listing—By HCC report screen according to an example embodiment is shown. The report presents a list of members&#39; condition records matching the selection criteria. 
         [0052]    Referring to  FIG. 16A , a second Member Listing—By HCC search screen according to an example embodiment is shown. After selecting one or more products  250  and an HCC model  252 , a user can select providers  254  and specific HCCs  256  from respective lists. The user can also specify a condition year  258 . Referring to  FIG. 16B , a second Member Listing—By HCC report screen according to an example embodiment is shown. The report presents a list of members&#39; condition records matching the selection criteria. 
         [0053]    Referring again to  FIGS. 3A and 3B , a user may select a history option  128  for each health condition to view all status changes to a condition within multiple CMS data collection periods. Referring to  FIG. 17A , a condition history screen for a Medical HCC Model member is shown. Referring to  FIG. 17B , a condition history screen for an ESRD HCC Model member is shown. The condition history screen displays a description of the history condition, the user that completed the status change, the condition year, the diagnosis code (if applicable), the date of service (if applicable), the claim number (if applicable), and the update date. 
         [0054]    Based upon information contained in the medical record there are several possible actions the user can perform: 
         [0000]    
       
         
               
             
               
               
             
           
               
                 TABLE 4 
               
               
                   
               
               
                 Activity Log Details 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                 Member Name 
                 (displays members who have been updated 
               
               
                   
                 in the STAR database during the 
               
               
                   
                 period for which the report was generated) 
               
               
                 Member ID 
                 unique member identifier 
               
               
                 DOB 
                 member date of birth 
               
               
                 HCC ID 
                 condition updated in the STAR database for 
               
               
                   
                 this member 
               
               
                 HCC Description 
                 condition description for condition updated 
               
               
                   
                 in the STAR database 
               
               
                 Provider ID 
                 primary care physician associated with the 
               
               
                   
                 member that was updated 
               
               
                 User Name 
                 STAR application user that performed the 
               
               
                   
                 update to this member 
               
               
                 ICD9 
                 diagnosis detail applicable to those conditions 
               
               
                   
                 that were “affirmed” during the 
               
               
                   
                 period for which the report was generated 
               
               
                 Date of Service 
                 applicable to those conditions that were 
               
               
                   
                 “affirmed” during the period for which 
               
               
                   
                 the report was generated 
               
               
                 Update Date 
                 date that the condition was updated in the 
               
               
                   
                 STAR database 
               
               
                 Status 
                 action that was performed for the updated 
               
               
                   
                 condition 
               
               
                   
               
             
          
         
       
     
         [0000]    
       
         
               
             
               
               
             
           
               
                 TABLE 5 
               
               
                   
               
               
                 Condition Status Summary Report Details 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                 Member Counts 
                 total number of membership associated with 
               
               
                   
                 provider(s) 
               
               
                 Open Suspects 
                 total suspects identified during the current period 
               
               
                 Open CMS 
                 total suspects that were “CMS accepted” 
               
               
                 Accptd. 1st 
                 conditions from prior period 
               
               
                 Prior Period 
               
               
                 Open CMS 
                 total suspects that were “CMS accepted” 
               
               
                 Accptd. 2nd 
                 conditions from two prior periods 
               
               
                 Prior Period 
               
               
                 Provd. Cont. 
                 total suspects for which the provider has been 
               
               
                   
                 contacted, but provider has neither affirmed or 
               
               
                   
                 denied the condition 
               
               
                 Provd. Affirmd. 
                 total suspects the provider has affirmed - no 
               
               
                   
                 supporting claim or encounter has yet been received 
               
               
                 Provd. Denied 
                 total suspects the provider has denied 
               
               
                 CMS Accptd. 
                 total conditions that have been accepted by CMS; 
               
               
                 No Provd. Cont. 
                 provider was never contacted 
               
               
                 CMS Accptd 
                 total conditions that have been accepted by CMS; 
               
               
                 Provd Cont. 
                 provider was contacted 
               
               
                 CMS Accptd. 
                 total conditions that have been accepted by CMS; 
               
               
                 No Suspect 
                 condition was not previously a Suspect 
               
               
                 CMS Total 
                 total of all “CMS accepted” conditions 
               
               
                 Accptd. Count 
               
               
                 Cond. Per 
                 average number of conditions per member 
               
               
                 Member 
               
               
                 Avg. Risk 
                 average risk score per member 
               
               
                 Factor 
               
               
                   
               
             
          
         
       
     
         [0055]    While certain embodiments of the present invention are described in detail above, the scope of the invention is not to be considered limited by such disclosure, and modifications are possible without departing from the spirit of the invention as evidenced by the claims. For example, elements of the user interface may be varied and fall within the scope of the claimed invention. Various aspects of status conditions and data presentation may be varied and fall within the scope of the claimed invention. Additional code models may be defined and integrated into menus that allow a user to select a code model. One skilled in the art would recognize that such modifications are possible without departing from the scope of the claimed invention. 
         [0000]    
       
         
               
             
               
               
             
           
               
                 APPENDIX A 
               
               
                   
               
               
                 GLOSSARY OF MEMBER CONDITION STATUS TERMS: 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                 ACTION REQUESTED 
                 in a review of the member&#39;s medical record, 
               
               
                   
                 a medical record coder found a previously 
               
               
                   
                 unreported condition and requested that it 
               
               
                   
                 be processed for submission to CMS. 
               
               
                 OPEN 
                 the “suspect condition” has been 
               
               
                   
                 identified but no other action has been 
               
               
                   
                 taken. 
               
               
                 OPEN/CMS 
                 this condition was accepted by CMS during 
               
               
                 ACC 1 st  PRIOR 
                 the most recent reporting year and is 
               
               
                 PERIOD 
                 automatically a suspect for the current 
               
               
                   
                 reporting year. 
               
               
                 OPEN/CMS 
                 this condition was accepted by CMS two 
               
               
                 ACC 2 nd  PRIOR 
                 reporting periods ago and is automatically 
               
               
                 PERIOD 
                 a suspect for the current reporting year. 
               
               
                 PROVIDER AFFIRMED 
                 provider agrees that the medical record 
               
               
                 CONDITION 
                 indicates the condition identified and 
               
               
                   
                 an encounter is forthcoming (also called 
               
               
                   
                 a “TRUE POSITIVE”) 
               
               
                 PROVIDER DENIED 
                 provider states that no encounter will 
               
               
                 CONDITION 
                 be submitted for the suspect condition 
               
               
                   
                 (also called a “FALSE POSITIVE”) 
               
               
                 CMS ACCEPTED, NO 
                 the suspect condition has been resolved 
               
               
                 PROVIDER CONTACT 
                 (encounter accepted) even though the 
               
               
                   
                 provider was not contacted regarding 
               
               
                   
                 this suspect condition. 
               
               
                 CMS ACCEPTED, 
                 an encounter for the suspect condition 
               
               
                 PROVIDER 
                 has been received and processed by CMS; 
               
               
                 CONTACTED 
                 prior to resolution, a health benefits 
               
               
                   
                 associate contacted the provider. 
               
               
                 CMS ACCEPTED, NO 
                 an encounter condition has been accepted 
               
               
                 SUSPECT STATUS 
                 by CMS but was not previously identified 
               
               
                   
                 by a healthcare benefits provider as a 
               
               
                   
                 suspect. 
               
               
                 CMS ACCEPTED, NOT 
                 an encounter condition has been accepted 
               
               
                 SUBMITTED BY 
                 by CMS but was submitted by a different 
               
               
                 HUMANA 
                 health plan 
               
               
                 CMS ACCEPTED, 
                 an encounter condition has been accepted 
               
               
                 ACTION REQUESTED 
                 by CMS; prior to resolution the condition 
               
               
                   
                 was in Action Requested status. 
               
               
                 HUMANA DELETED 
                 A health benefits associate submitted an 
               
               
                   
                 encounter for a condition to CMS, and 
               
               
                   
                 then submitted a delete request to CMS 
               
               
                   
                 for the same encounter at a later date. 
               
               
                 SUSPECT CONDITION 
                 for any variety of reasons, a health 
               
               
                 EXPIRED 
                 benefits associate has decided to withdraw 
               
               
                   
                 a suspect condition after deciding the 
               
               
                   
                 condition would not be worked. 
               
               
                 CMS CANCELLED 
                 CMS has informed the health benefits plan 
               
               
                   
                 that no payment will be issued for the 
               
               
                   
                 condition.