DESCRIPTION / INTENT OF THE EPISODE

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 Substance Use Disorders, sometimes abbreviated SUDS, is a chronic condition episode. There is a 30-day lookback period to capture services rendered prior to the trigger claim, such as diagnostic services, office visits, and ancillary services. The Substance Use Disorders episode does not have an end date regarding the look-forward period, but can be broken into distinct reporting periods for implementations and analysis (e.g., 12 months).

POPULATION

Patients 12 years of age and older that meet the trigger criteria are included in the population for this episode.

TRIGGER CRITERIA

A Substance Use Disorders episode can be triggered by an inpatient facility claim with a principal trigger diagnosis code for the condition, or an outpatient facility or professional claim with a trigger diagnosis code (in any position) and an E&M procedure code (in any position) on the same claim line. For professional claim triggers, a second trigger signal or confirming claim is required that meets the same criteria as any of the initial trigger claims above.  The confirming claim must be 30 to 365 days after the initial trigger claim.

Examples of trigger diagnosis codes for this episode include:

• Alcohol Abuse
• Opioid abuse/dependence
• Other Drug Use Disorder

EPISODE TIMEFRAME

A Substance Use Disorders episode has a look back period of 30 days prior to the initial trigger claim. It does not have an end to the look forward period after the trigger claim, but can be broken into distinct periods for analytic purposes, creating budgets and reporting for implementations (e.g., 12 months).

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 and pharmacy claims.

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

• Alcohol / Drug Use Screening
• Psychiatry Evaluations
• Counseling Services

Typical diagnosis codes(ICD 10 DX codes) indicate typical care. Claims with relevant typical diagnosis codes usually associated with Substance Use Disorders 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:

• Alcohol Abuse
• Opioid abuse / dependence
• Nausea, vomiting

Actionable adverse events (AAE) are events that are recognized by diagnosis codes (ICD 10 DX codes) and their timing to indicate potential complications of care. They require a relevant procedure code (ICD 10 PX codes; CPT/HCPCS codes) on the same claim/claim line to include the claim in the episode. Examples of actionable adverse events include:

• Alcohol intoxication
• Other injuries and conditions due to external
• Seizures / Convulsions

Note that additional rules are used to identify AAEs in addition to the presence of AAE diagnosis codes.  For example, for most chronic episodes, relevant acute inpatient admission claims are flagged as actionable adverse events regardless of the presence of AAE codes. However, in the case of SUD, an inpatient detoxification stay may be welcome and may indicate patient engagement, so it is not classified as an AAE.  But if a detox stay occurs “after” an inpatient rehab stay, it may indicate deterioration of a patient’s progress and be flagged as an AAE. Further business rules suggesting an increase in the level of care define which detox stays are considered as AAEs.  

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 365 days before the episode trigger date. The following risk factors are some of the variables selected for this episode based on their clinical and statistical significance:

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, 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, and Other Congenital Anomalies.

SUBTYPES

Episode subtypes are used to adjust the target price and/or to subset episode types for reporting purposes. They are specific to the episode and identified during the entire episode window for chronic episodes. Some of the subtypes for this episode include:

• Alcohol Abuse
• Sedative, hypnotic or anxiolytic dependence
• Stimulant Abuse

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 Substance Use Disorder episode of care include:

• Member has one or more of the following diagnoses: brain damage and coma; breast cancer; colorectal cancer; unspecified cancer; secondary cancer; other cancer; other gastrointestinal cancer; lung cancer; lymphatic/hematologic cancer; ESRD; hemophilia; sickle cell disease; previous organ transplant
• Member has a gap in health insurance enrollment greater than 6 months during the episode
• Member is pregnant