Care Clusters are a unique and powerful way to improve targeting and move away from the one-dimensional world of "number of services" per billing/reimbursement code. Care Clusters encapsulate coding scenarios involving multiple codes, intersection and exclusivity of codes, as well as more advanced business rules.

Care Clusters are usually created for one of these reasons:

1. You want to pull apart a DRG code into its component procedure types
2. You want to count instances where multiple codes (either of the same or different types) occurred together on a single claim
3. You want to understand the reimbursement impact for special scenarios where codes receive an adjusted reimbursement when paired together
4. You want to differentiate a code based on the setting in which it occurred, i.e. office vs facility or outpatient vs inpatient
5. You want to combine codes (either of the same or different types) into a single count
6. You want to only count service lines where a specific diagnosis was used
7. You want to report on the utilization of a "procedure" across care settings ("knee replacements" combining inpatient, outpatient, and ASC settings)

Pulling apart an episode of care (claim)

DRGs codes, which hospitals use to bill for inpatient services, can be a great way to target because they represent a bundle of related services and are thus not granular; however they also have limitations because they represent a bundle of services and are thus not granular.

We have built the ability to decompose DRGs into their component parts to let you see the exact procedure breakdown using ICD10 PCS codes. In the example above, we might want only to count DRGs for Hip Replacements and Knees Replacement, and we might even further layer on CPT codes to count Knee Replacements or Hip Replacements that were done in the Outpatient setting as well.

Yet another example can be seen in the case of understanding minimally invasive surgery (MIS) vs. open surgery.

Intersecting Codes On Individual Patients

Another great use case for a Care Cluster is when you want to count codes only when they both occur on a single patient. We can do this, and the codes don't even have to be on the same claim!

Let's say we have two patients pools: We have a count of 100 patients who received Rehabilitation, and we also have a count of 100 patients who received stroke diagnoses. If we're using billing codes alone, we have no idea of knowing whether all 100 of those Rehab patients had stroke diagnoses, or 0, or 11, or 53 ...

Reimbursement Scenarios

Certain codes, when paired together, can qualify for a special reimbursement adjustment that is higher than the reimbursement for the codes individually. With Care Clusters, we can not only target both instances (when the pairing occurred and when it did not) but we can also observe the reimbursement difference.

Notice also the ability to layer in more complex boolean logic among many different codes. There is essentially no limit to the number of codes we can group together and logically connect!

Billing Setting

Care clusters are able to target not just inpatient vs outpatient procedures at a hospital; using certain claim flags we can also differentiate the same code's occurrence in a facility vs a practice setting.

Creating Singular Counts

Though it's undoubtedly the simplest application for Care Clusters, that doesn't mean it can't be useful. Taking many codes and placing them together into a single count can be incredibly convenient and much easier to digest.