Terms & Definitions

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For discharges or visits prior to October 1, 2015, the Agency for Healthcare, Research, and Quality’s (AHRQ) Clinical Classification Software (CCS) uses the primary ICD-9-CM diagnosis code to assign a CCS diagnosis category for inpatient discharges and emergency department visits. For outpatient surgery visits, the highest charge outpatient surgery ICD-9-CM procedure code is used to assign the CCS procedure category. Please visit the link below for more information.

AHRQ ICD-9-CM CCS Categories

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For discharges or visits on or after October 1, 2015, the Agency for Healthcare, Research, and Quality’s (AHRQ) Clinical Classification Software (CCS) uses the primary ICD-10-CM diagnosis code to assign a CCS diagnosis category for inpatient discharges and emergency department visits. Please visit the link below for more information.

AHRQ ICD-10-CM CCS Diagnosis Categories

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For outpatient surgery visits occurring on or after October 1, 2015, the highest charge Current Procedural Technology (CPT) code or Healthcare Common Procedure Coding System (HCPCS) code is used to assign the CCS Services and Procedures category. Please visit the link below for more information.

AHRQ CCS Services and Procedures Categories for CPT/HCPCS

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This is the total number of days spent in the hospital by a given set of patients, divided by the number of discharges. The average length of stay affects charges because longer stays generate higher charges. In addition, the average length of stay is a rough indicator of hospital efficiency or program philosophy. For example, two hospitals may have significantly different averages for psychiatric inpatient treatment. These differences may indicate a facility's choice between extended hospital stays, which tend to have higher charges, and alternatives such as outpatient treatment, which tend to have lower charges.

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This is the sum of all charges for a set of hospitalizations, divided by the number of discharges. For example, to determine the average charge for pneumonia cases, the charges for all pneumonia cases are added together and divided by the number of pneumonia cases. The average charge gives an approximation of what a typical patient would be charged.

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Defined as one patient visit, even though more than one procedure may be performed during the same surgical episode. For instance, if a myringotomy is performed on both ears during one visit, only one case will be counted even though two procedures are performed.

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The amount a facility bills for a patient's care is known as the charge. This may differ substantially from the amount that the facility collects for its services, as health care facilities frequently negotiate discounts with insurance companies or other large purchasers of health care services.

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The term discharge is roughly synonymous with hospitalization. A patient becomes a discharge once he or she officially leaves the health care facility. The number of discharges from a hospital affects how a hospital is staffed, what types of services a hospital offers, and how well it competes in the broader health care system. To some degree it also affects costs because, when viewed relative to the facility's capacity, the number of discharges is a partial indicator of efficiency. The number of discharges is used to calculate the average charge and the average length of stay at a facility.

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Each record submitted to the RFA contains information about the expected payer for the hospitalization. A facility compiles information about expected payers from the bills it generates. Each bill indicates whom the facility expects to pay for the services; however, the bills are not always paid by the expected payer. Insurance may not cover a procedure. A person may not actually be covered by the indicated insurer. Therefore, the expected payer is to be viewed as a preliminary determination of who's footing the bill.

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Charges and lengths of stay may also be presented as medians. The median represents the middle value of a distribution; half the values lie at or above the median, and half lie at or below it. If the median charge for pneumonia patients was $6,500, then half the patients were charged $6,500 or more and half were charged $6,500 or less. Averages (means) can be significantly affected by a few unusually low or high values (outliers). Medians, on the other hand, are not affected to such a degree by outliers. The median, which is also called the 50th percentile, may be more representative of the typical charge or length of stay than the mean.

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The primary disease or condition for which the patient was hospitalized or treated, as indicated in the patient's discharge record. In the RFA's data products, all diagnoses prior to October 1, 2015 are coded according to the ICD-9-CM scheme. Beginning with October 1, 2015 and forward, the RFA's data products use the ICD-10-CM scheme to code diagnoses.

Although a facility may report up to fifteen diagnosis codes (and an additional external cause of morbidity code when appropriate) on each patient record submitted to the RFA, the on-line data system currently contains only the principal diagnosis codes.

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A patient may undergo more than one procedure during an outpatient surgical operation. These procedures are in no particular order when they are sent to the RFA as part of the billing data. The RFA ranks the outpatient procedures by the highest charge and then uses this procedure for grouping purposes.