DESCRIPTION / INTENT OF THE EPSIODE

An episode of care, also known as an episode, groups all relevant services provided to a patient for a particular condition within a pre-defined time range. An episode of care serves as a unit of accounting as well as a unit of accountability for providers who take on financial risk for the episode. Defining an episode in such a manner helps to identify sources of variation and to standardize care.

An episode of care for Colonoscopy, sometimes abbreviated COLOS, is an outpatient procedural episode. The Colonoscopy episode includes services related to the procedure as well as services within the 3 days pre- and 14 days post-operative care time window, such as diagnostic services, office visits, and ancillary services.

POPULATION

Patients 18 years of age and older that meet the trigger criteria are included in the population for this episode.

TRIGGER CRITERIA

A Colonoscopy episode can be triggered by an outpatient facility or professional claim with a trigger procedure code (in any position) and a qualifying diagnosis code (in any position) on the same claim line.

Examples of trigger procedure codes for this episode include:

• Colonoscopy
• Colonoscopy with biopsy, polypectomy
• Colonoscopy/Sigmoidoscopy Colorectal Cancer Screening

Examples of qualifying diagnosis codes include:

• Neoplasm – screening – colon
• Benign Carcinoid Tumor of the GI tract
• History of colon polyps, family history of colon cancer

EPISODE TIMEFRAME

A Colonoscopy episode has a look back period of 3 days prior to the initial trigger claim and a look forward period of up to 14 days post-discharge.

INCLUDED SERVICES

Services provided within the episode timeframe are included based on the presence and position of relevant diagnosis, procedure and pharmacy codes on the claim/claim line. Some procedure codes are sufficient to stand alone, while others require typical or actionable adverse event (AAE) diagnosis codes on the same claim/claim line to steer services into the episode. Included claim types consist of inpatient facility, outpatient facility, professional, ancillary and pharmacy claims.

Examples of relevant procedure code groups (ICD 10 PX codes; CPT/HCPCS codes) include: 

• Colonoscopy
• Imaging Abdomen
• Sigmoidoscopy

Relevant services with typical diagnosis codes(ICD 10 DX codes) indicate typical care. Claims with typical diagnosis codes, usually associated with Colonoscopy, help steer services into this episode. However, for many claim types a relevant procedure code is also required on the same claim/claim line for the indicated diagnosis code to be incorporated into the episode. Examples of relevant typical diagnoses include: 

• Ulcerative Colitis
• History of colon polyps, family history of colon cancer
• Prvn – screening – other

Actionable adverse events (AAE) are diagnosis codes (ICD 10 DX codes) indicating potential complications of care and require a relevant procedure code on the same claim/claim line to include the claim in the episode. Examples of actionable adverse events include:

• Dehydration
• Perforation, Peritonitis, Abd Abscess
• Complications of anesthesia

(Note that additional rules are used to identify AAEs in addition to the presence of AAE diagnosis codes.  For example, for procedural episodes, pre-procedure services in the look back window are not flagged as actionable adverse events regardless of the presence of AAE codes.)

RISK FACTORS

Patient risk factors (comorbidities) are used to adjust the target price; they are identified from diagnosis codes on the patient’s claims up to 90 days before the trigger date for procedural episodes. The following risk factors are some of the variables selected for this episode based on their clinical and statistical significance to the procedure:

Age (18-44, 45-64, 65+), Sex, Diabetes with/without Complications, Thyroid and Other Endocrine Disorders, Obesity, Nutritional and Metabolic Diseases and Immunity Disorders, Cystic Fibrosis, Anemia, Non-Anemic Blood Diseases, Emotional and Behavioral Mental Illness, Severe Behavioral Health Disorders, Substance-Related Mental Illness, Hereditary and Degenerative Nervous System Conditions, Epilepsy/Convulsions, Other Nervous System Disorders, Hypertension, Heart Disease, Cerebrovascular Disease, Artery Disease, Diseases of Veins and Lymphatics, COPD, Asthma, Lung Disease Due to External Agents, Other Upper/Lower Respiratory Disease, Disorders of the Teeth, Jaw, and Mouth, Upper/Lower/Other Gastrointestinal Disorders, Abdominal Hernia, Biliary Tract Disease, Liver Disease, Pancreatic Disorders, Diseases of the Urinary System/Male Genital Organs/Female Genital Organs, Diseases of the Skin, Non-Traumatic Joint Disorders, Spondylosis/Invertebral Disc Disorders/Other Back Problems, Osteoporosis, Acquired Deformities, Autoimmune and Connective Tissue Disorders, Other Connective Tissue Disease, Other Bone Disease and Musculoskeletal Deformities, Cardiac and Circulatory Congenital Anomalies, Digestive Congenital Anomalies, Genitourinary Congenital Anomalies, Nervous System Congenital Anomalies, Other Congenital Anomalies, Bilateral and Staged Procedures 

SUBTYPES

Episode subtypes are used to adjust the target price and/or to subset episode type for reporting purposes. They are specific to the episode and identified within the lookback and trigger windows for procedural episodes. Some of the subtypes for this episode include:

• Colonoscopy w biopsy
• Polypectomy
• Partial Colectomy
• Colonoscopy
• Cancer of Colon
• Cancer of Rectum and Anus
• Cancer of Other GI Organs

TERMINATIONS

Sometimes an episode is terminated due to incomplete information or in order to limit physician risk. Providers are not at risk for terminated episodes. Examples of termination criteria for a Colonoscopy episode of care include:

• Member has one or more of the following diagnoses before surgery: ESRD; hemophilia; sickle cell disease; previous organ transplant
• Member has an emergent procedure
• Member left against medical advice
• There is missing or insufficient claims history
• Member is pregnant