4.6 Diagnosis Analysis
Claims Review includes two reports that provide analysis based on the diagnostic
information included in claims: Diagnosis Analysis and Lifestyle Analysis.
Both reports are based on the International Classification of Diseases
(ICD) diagnosis coding system and provide a set of categories made up of
multiple ICD code ranges.
These reports can be used to assess the viability of disease management or wellness programs.
NOTE: Code ranges for both diagnosis and lifestyle categories may be customized. Please contact support if you would like the default categories modified.
Diagnosis Analysis
The covered population's proneness to morbidity can have a major impact on overall plan performance. The Diagnosis Analysis charts the distribution of cost across high level diagnosis categories:
The graph displays how much the plan sponsor (green) and member (red) paid as well as the amount of savings obtained through network discounts (blue); the top of each bar represents the total original charge billed by providers. The numbers along the bottom of the graph can be matched back to the number (#) column in the table.
The Diagnosis Analysis uses the standard top level "chapters" as defined by ICD for diagnoses. The code ranges are listed below with links to an interactive online browser:
- 001-139 Infectious And Parasitic Diseases
- 140-239 Neoplasms
- 240-279 Endocrine, Nutritional And Metabolic Diseases, And Immunity Disorders
- 280-289 Diseases Of Blood And Blood-Forming Organs
- 290-319 Mental Disorders
- 320-389 Diseases Of The Nervous System And Sense Organs
- 390-459 Diseases Of The Circulatory System
- 460-519 Diseases Of The Respiratory System
- 520-579 Diseases Of The Digestive System
- 580-629 Diseases Of The Genitourinary System
- 630-677 Complications Of Pregnancy, Childbirth, And The Puerperium
- 680-709 Diseases Of The Skin And Subcutaneous Tissue
- 710-739 Diseases Of The Musculoskeletal System And Connective Tissue
- 740-759 Congenital Anomalies
- 760-779 Certain Conditions Originating In The Perinatal Period
- 780-799 Symptoms, Signs, And Ill-Defined Conditions
- 800-999 Injury And Poisoning
- E800-E999 Supplementary Classification Of External Causes Of Injury And Poisoning
- V01-V86 Supplementary Classification Of Factors Influencing Health Status And Contact With Health Services
Lifestyle Analysis
The Lifestyle Analysis report is similar to the Diagnosis Analysis report documented above but uses a set of categories based on lifestyle specific diagnosis indicators.
The lifestyle categories include only a small portion of possible diagnoses. Non lifestyle related charges fall into an Other category. In normal cases, a large percentage of charges should fall into the Other category; a high percentage of lifestyle related claims can be a good indicator that a wellness program is required.
The following values are displayed for each lifestyle category in aggregate:
- # Claimants ( Claimant Count ): The number of individual members that incurred claims.
- Total Charge: Original total amount billed by provider before network discount or other types of savings are applied. More.
- Plan Paid: Total amount paid by plan sponsor.
- % Paid ( Plan Paid Percentage ): The percentage of original billed charges paid by the plan sponsor. More.
- % Usage ( Percentage of Usage ): The percentage of total dollars paid by the plan sponsor. More.