CLINICAL EPISODE DEFINITIONS

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Preventive Care (PREVNT)

Preventive Care (PREVNT) is an episode open from the date of the trigger service until the end of the study period, or until the patient’s date of death. The trigger service can be an inpatient service with a preventive care-specific principal diagnosis code or an outpatient facility or professional claim with a trigger diagnosis...

Urinary Tract Infection (UTI)

This is a system related failure (SRF) episode. SRFs are acute conditions that may be complications in other episodes but they may also occur independently. If they occur when no other related episode is open, then an SRF episode will trigger. For an SRF episode to trigger, it needs the trigger diagnosis code to...

Shock / Cardiac Arrest (SHOCK)

This is a system related failure (SRF) episode. SRFs are acute conditions that may be complications in other episodes but they may also occur independently. If they occur when no other related episode is open, then an SRF episode will trigger. For an SRF episode to trigger, it needs the trigger diagnosis code to...

Sepsis (SEPSIS)

This is a system related failure (SRF) episode. SRFs are acute conditions that may be complications in other episodes but they may also occur independently. If they occur when no other related episode is open, then an SRF episode will trigger. For an SRF episode to trigger, it needs the trigger diagnosis code to...

Respiratory Failure (RESPFL)

This is a system related failure (SRF) episode. SRFs are acute conditions that may be complications in other episodes but they may also occur independently. If they occur when no other related episode is open, then an SRF episode will trigger. For an SRF episode to trigger, it needs the trigger diagnosis code to...

Poisoning (POISON)

This is a system related failure (SRF) episode. SRFs are acute conditions that may be complications in other episodes but they may also occur independently. If they occur when no other related episode is open, then an SRF episode will trigger. For an SRF episode to trigger, it needs the trigger diagnosis code to...

Pancreatitis (PNCRTS)

This is a system related failure (SRF) episode. SRFs are acute conditions that may be complications in other episodes but they may also occur independently. If they occur when no other related episode is open, then an SRF episode will trigger. For an SRF episode to trigger, it needs the trigger diagnosis code to...

Nutritional Deficiency (NUTDEF)

This is a system related failure (SRF) episode. SRFs are acute conditions that may be complications in other episodes but they may also occur independently. If they occur when no other related episode is open, then an SRF episode will trigger. For an SRF episode to trigger, it needs the trigger diagnosis code to...

Malignant Hypertension (MGHTN)

This is a system related failure (SRF) episode. SRFs are acute conditions that may be complications in other episodes but they may also occur independently. If they occur when no other related episode is open, then an SRF episode will trigger. For an SRF episode to trigger, it needs the trigger diagnosis code to...

Intestinal Obstruction (INTOBS)

This is a system related failure (SRF) episode. SRFs are acute conditions that may be complications in other episodes but they may also occur independently. If they occur when no other related episode is open, then an SRF episode will trigger. For an SRF episode to trigger, it needs the trigger diagnosis code to...

Infections (INFECT)

This is a system related failure (SRF) episode. SRFs are acute conditions that may be complications in other episodes but they may also occur independently. If they occur when no other related episode is open, then an SRF episode will trigger. For an SRF episode to trigger, it needs the trigger diagnosis code to...

Hypotension / Syncope (HYPOTN)

This is a system related failure (SRF) episode. SRFs are acute conditions that may be complications in other episodes but they may also occur independently. If they occur when no other related episode is open, then an SRF episode will trigger. For an SRF episode to trigger, it needs the trigger diagnosis code to...

Hepatitis (HPTTIS)

This is a system related failure (SRF) episode. SRFs are acute conditions that may be complications in other episodes but they may also occur independently. If they occur when no other related episode is open, then an SRF episode will trigger. For an SRF episode to trigger, it needs the trigger diagnosis code to...

GI Bleed (GIBLD)

This is a system related failure (SRF) episode. SRFs are acute conditions that may be complications in other episodes but they may also occur independently. If they occur when no other related episode is open, then an SRF episode will trigger. For an SRF episode to trigger, it needs the trigger diagnosis code to...

Diabetes, poor control (DMUNC)

This is a system related failure (SRF) episode. SRFs are acute conditions that may be complications in other episodes but they may also occur independently. If they occur when no other related episode is open, then an SRF episode will trigger. For an SRF episode to trigger, it needs the trigger diagnosis code to...

Dermatitis, Urticaria (DRMTIS)

This is a system related failure (SRF) episode. SRFs are acute conditions that may be complications in other episodes but they may also occur independently. If they occur when no other related episode is open, then an SRF episode will trigger. For an SRF episode to trigger, it needs the trigger diagnosis code to...

Decubitus Ulcer (DECUB)

This is a system related failure (SRF) episode. SRFs are acute conditions that may be complications in other episodes but they may also occur independently. If they occur when no other related episode is open, then an SRF episode will trigger. For an SRF episode to trigger, it needs the trigger diagnosis code to...

C-Difficile Infection (CDIFF)

This is a system related failure (SRF) episode. SRFs are acute conditions that may be complications in other episodes but they may also occur independently. If they occur when no other related episode is open, then an SRF episode will trigger. For an SRF episode to trigger, it needs the trigger diagnosis code to...

Aspiration Pneumonia (ASPPNE)

This is a system related failure (SRF) episode. SRFs are acute conditions that may be complications in other episodes but they may also occur independently. If they occur when no other related episode is open, then an SRF episode will trigger. For an SRF episode to trigger, it needs the trigger diagnosis code to...

Acute Renal Failure (ARF)

This is a system related failure (SRF) episode. SRFs are acute conditions that may be complications in other episodes but they may also occur independently. If they occur when no other related episode is open, then an SRF episode will trigger. For an SRF episode to trigger, it needs the trigger diagnosis code to...

Accidental Falls (FALL)

This is a system related failure (SRF) episode. SRFs are acute conditions that may be complications in other episodes but they may also occur independently. If they occur when no other related episode is open, then an SRF episode will trigger. For an SRF episode to trigger, it needs the trigger diagnosis code to...

Rectal Cancer (RCLCAN)

Rectal Cancer (RCLCAN) is a condition that is triggered by the presence of a Colonoscopy (COLOS) episode followed by a definitive radiotherapy service with a qualifying diagnosis code of rectal cancer between 7 and 60 days after the Colonoscopy. The Rectal Cancer episode is open from the date of the Colonoscopy episode’s trigger until...

Colon Cancer (CLNCAN)

Colon Cancer (CLNCAN) is a condition that is triggered by the presence of a Colon Resection (COLON) episode followed by a definitive chemotherapy service with a qualifying diagnosis code of colon cancer between 7 and 60 days after the Colon Resection. The Colon Cancer episode is open from the date of the Colon Resection...

Breast Cancer (BRSTCA)

Breast Cancer (BRSTCA) is a condition that is triggered by the presence of a Mastectomy (MSTCMY) episode followed by a primary diagnosis code of breast cancer on an inpatient stay service or a breast cancer diagnosis code in any position on an outpatient facility/professional E&M service between 7 and 60 days after the Mastectomy....

Lung Cancer (LNGCAN)

Lung Cancer (LNGCAN) is a condition that is triggered by a definitive chemotherapy or radiotherapy service with a qualifying diagnosis code of lung cancer. The Lung Cancer episode is open from 90 days prior to the date of trigger service until 240 days after the date of trigger. Services with diagnosis codes for signs...

Prostate Cancer (PRSTCA)

Prostate Cancer (PRSTCA) is a condition that is triggered by a definitive chemotherapy or radiotherapy service with a qualifying diagnosis code of prostate cancer. The Prostate Cancer episode is open from the date of the trigger until 365 days after the date of trigger. Services with diagnosis codes for signs and symptoms related to...

Vaginal Delivery (VAGDEL)

Within the Vaginal Delivery population, there are patients that have the index trigger event in an inpatient setting and others that deliver in an outpatient setting. Services and costs associated with a Vaginal Delivery (VAGDEL) are grouped together to include the index stay during which the procedure was performed (when applicable), a 3-day look...

C-Section (CSECT)

Most Cesarean Sections are currently done in an inpatient setting, but the system is programmed to identify and trigger an episode of C-Section even if it is conducted in an outpatient setting. Services and costs associated with a Cesarean Section (CSECT) are grouped together to include the index stay during which the procedure was...

Pregnancy (PREGN)

Pregnancy (PREGN) is a condition that is triggered retroactively by the presence of a Vaginal Delivery or Cesarean Section episode. Since Pregnancy is triggered by a delivery episode, it has a 270-day look back and no look forward period. Services with diagnosis codes for signs and symptoms related to Pregnancy such as absence of...

Ulcerative Colitis (ULCLTS)

Ulcerative colitis is a chronic disease of the large intestine, also known as the colon, in which the lining of the colon becomes inflamed and develops tiny open sores, or ulcers, that produce pus and mucous. The combination of inflammation and ulceration can cause abdominal discomfort and frequent emptying of the colon....

Osteoarthritis (OSTEOA)

Osteoarthritis (OSTEOA) is a chronic condition open from 30 days prior to the date of the trigger service until the end of the study period, or until the patient’s date of death. The trigger service can be an inpatient service with an osteoarthritis-specific principal diagnosis code or an outpatient or professional E&M service with...

Glaucoma (GLCOMA)

Glaucoma (GLCOMA) is a chronic condition open from 30 days prior to the date of the trigger service until the end of the study period, or until the patient’s date of death. The trigger service can be an inpatient service with a glaucoma-specific principal diagnosis code or an outpatient or professional E&M service with...

Heart Failure (HF)

Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn’t pump blood as well as it should. Certain conditions, such as narrowed arteries in your heart (coronary artery disease) or high blood pressure, gradually leave your heart too weak or stiff to fill and pump efficiently....

Low Back Pain (LBP)

Low Back Pain is a chronic condition open from 30 days prior to the date of the trigger service until the end of the study period, or until the patient’s date of death. The trigger service can be an inpatient service with a low back pain-specific principal diagnosis code or an outpatient or professional...

Diverticulitis (DIVERT)

Diverticulitis (DIVERT) is an acute episode with a 14-day look back and a 90-day look forward window. Within the Diverticulitis population, there are patients that have the index trigger event in an inpatient setting and others who are diagnosed and initially, or completely, managed in an outpatient setting. For the purposes of this episode,...

Hypertension (HTN)

Hypertension (HTN) is a chronic condition open from 30 days prior to the date of the trigger service until the end of the study period, or until the patient’s date of death. The trigger service can be an inpatient service with a hypertension-specific principal diagnosis code or an outpatient or professional E&M service with...

Asthma (ASTHMA)

Asthma is a chronic condition open from 30 days prior to the date of the trigger service until the end of the study period, or until the patient’s date of death. The trigger service can be an inpatient service with an asthma-specific principal diagnosis code or an outpatient or professional E&M service with an...

Diabetes (DIAB)

Diabetes is a chronic condition open from 30 days prior to the date of the trigger service until the end of the study period, or until the patient’s date of death. The trigger service can be an inpatient service with a diabetes-specific principal diagnosis code or an outpatient or professional E&M service with a...

Trauma and Stressors Disorders (PTSD)

Post-traumatic stress disorder (PTSD) is a mental health condition that’s triggered by a terrifying event — either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event. Most people who go through traumatic events may have temporary difficulty adjusting and coping, but with...

Schizophrenia (SCHIZO)

Schizophrenia is a serious mental disorder in which people interpret reality abnormally. Schizophrenia may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning, and can be disabling. People with schizophrenia require lifelong treatment. Early treatment may help get symptoms under control before serious complications develop and...

Bipolar Disorder (BIPLR)

Bipolar Disorder (BIPLR) is a chronic condition open from 30 days prior to the date of the trigger service until the end of the study period, or until the patient’s date of death. The trigger service can be an inpatient service with a bipolar disorder-specific principal diagnosis code or an outpatient or professional E&M...

Substance Use Disorder (SUDS)

Drug addiction, also called substance use disorder, is a disease that affects a person’s brain and behavior and leads to an inability to control the use of a legal or illegal drug or medication. Substances such as alcohol, marijuana and nicotine also are considered drugs. When you’re addicted, you may continue using the drug...

Upper Respiratory Infection (URI)

Upper Respiratory Infection (URI) is an acute episode with a 21-day look forward window. Within the URI population, there are patients who have the index trigger event in an inpatient setting and others who are diagnosed and initially, or completely, managed in an outpatient setting. Even though URI by itself is associated as a...

Upper GI Endoscopy (EGD)

Most upper GI endoscopies are currently done in an outpatient setting, either in a doctor’s office or in an ambulatory surgery center, so these are the ones intended to be captured in the EGD episode. Services and costs associated with a procedure of Esophagogastroduodenoscopy Upper GI (EGD) are grouped together to include the index...