URSA-PHU-006: PMPY Plan Spending on PPHEs

  • Published on May 20, 2026
  • 36 minute(s) read
Prev Next

Measure Description

Among active plan membership periods, the per-member-per-year plan spending on potentially preventable hospital encounters (PPHEs).

Metadata

  • Measure Identifier: URSA-PHU-006
  • Measure Type: Rate Measure
  • Temporal Structure: Interval
  • Component Class: Long-Form
  • Denominator Case Field: Patient ID
  • Denominator Observation Fields: Patient ID, Segmented Period Start Date [, segmented_period_start_date]
  • Target Direction: Down

Denominator Description

The elapsed patient-years of active plan membership periods during which the patient is alive.

Numerator Description

Total patient spending for claims with covered start date falling within the observation period start and end dates.

Published Fields

  • Data Model Keys

    • Patient ID -- The internal database identifier (used, e.g., for joins and primary keys) for the patient. This value is typically mastered, i.e., all records for the same patient, regardless of the source data system from which that record originated, should have the same Patient ID value. (Note that while the mastered Patient ID value might resemble a local identifier used in one of the upstream data sources, this does not indicate any special priority of that source system in determining the characteristics of the patient.) (See also [URSA-CORE] Patient)
    • Primary Payor ID -- The internal database identifier (used, e.g., for joins and primary keys) for the Primary Payor. (See also [URSA-CORE] Primary Payor)
    • Primary Plan ID -- The identifier for the health insurance plan product that is the first party responsible for payment.
    • Primary Plan Attributee Provider ID
    • Empirical Attributee Primary Care Individual Provider ID
    • Empirical Attributee Primary Care Provider Group Provider ID
    • Encounter ID -- The internal database identifier (used, e.g., for joins and primary keys) for the encounter. (See also [URSA-CORE] Encounter)
    • Facility Provider ID -- The internal database identifier (used, e.g., for joins and primary keys) for the facility provider. (See also [URSA-CORE] Facility Provider)
    • Prior Admission Facility Provider ID
    • Prior ED Visit Facility Provider ID
    • Prior SNF Stay Facility Provider ID

  • Patient Fields

    • Is Patient Alive
    • Is Hospice in Last 12 Months -- Evidence of CMS hospice status or evidence of hospice services in the last 12 months. Typically used as a denominator exclusion.
    • Patient Date of Birth -- The patient's date of birth. On the Patients Natural Object, this field reflects the "best" known value for the patient available from all data sources; on other Natural Objects, e.g., MMR Member-Months, the value faithfully reflects the date of birth found on that particular type of record in the source data.
    • Patient Age Integer -- Patient age, expressed as an integer, as of a reference date or interval.
    • Patient Age Category Tier 1 -- Non-overlapping ranges of the patient age in years into three categories; [01] Pediatrics < 19, [02] Adults 19 - 64, and [03] Older Adults >= 65. Coarser grain to the Patient Age Category Tier 2. (See also [URSA-CORE] Patient Age Category Tier 2)
    • Patient Age Category Tier 2 -- Non-overlapping ranges of the patient age in years representing finer grain categories than the Patient Age Category Tier 1. This field incorporates findings from publications on defining meaningful age groups in the context of disease. These ranges closely, but not exactly, align with standard age ranges such as those defined by the Medical Subject Headings (MeSH). See results of K-Means simple clustering method at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3825015/ (See also [URSA-CORE] Patient Age Category Tier 1)
    • Patient First Name
    • Patient Last Name
    • Patient State Abbreviation
    • Patient ZIP Code 5-Digit
    • Patient County Description
    • UW HIP Area Deprivation Index National Percentile -- A value between 1 and 100 representing the composite measure of socioeconomic deprivation from University of Wisconsin’s School of Medicine and Public Health. Scores are for Census Block Group geographic level, which generally contains between 600 and 3,000 people. Higher scores indicate more deprivation, so a score of 1 indicates the least deprivation while a score of 100 indicates the most deprivation. Percentiles are constructed by ranking the ADI from low to high for the nation and grouping the block groups into bins corresponding to each 1% range of the ADI. The 2019 ADI was constructed using the 2015-2019 5-year estimates from the US Census' American Community Survey and includes 17 component measures that span the domains of income, education, employment, and housing quality. It may be linked with the 9-digit ZIP code crosswalk, which was built to correspond directly to Census block groups. The 2019 ADI was released on 07/14/2021 and is the most recent version as of 02/02/22.
    • UW HIP ADI Quintile Category -- The UW HIP Area Deprivation Index National Percentile grouped into 5 levels, each spanning 20 percentile points (ADI 1 is percentile scores from 1 to 20 while ADI 5 is scores from 81 to 100). Higher scores indicate more deprivation, so ADI 1 is the least deprived while ADI 5 is the most deprived. Quintiles are frequently used in health research. They give larger sample sizes per group and are easier to plot and interpret. Quintiles also carry less information and group more dissimilar patients. Quintiles are good for descriptive analyses while the original percentile measure is preferable for predictive modeling. (See also [URSA-CORE] UW HIP Area Deprivation Index National Percentile)
    • UW HIP ADI Decile Category
    • CDC SVI Overall National Percentile -- Social Vulnerability Index is a composite score maintained by the Center for Disease Control and Prevention using data from the U.S. Census of Population and Housing. The score is a composite of 15 measures, with all directed so that higher values indicate more vulnerability. The composite finds the percentile ranking of each component value, sums the percentile rankings, and then finds the percentile ranking of the sums. Percentile ranks are found with the formula: Percentile Rank = (Rank-1) / (N-1). If any component is missing, then the composite is also recoded as missing. Measures are organized into the four themes of Socioeconomic Status, Household Composition & Disability, Minority Status & Language, and Housing Type & Transportation, and composites for these themes are constructed with the same methodology. SVI is reported at the Census Tract level. Tracts aim to include about 4000 people each. On average, there are about 4 Census Block groups for each Census Tract, so the SVI has less geographic resolution than the ADI. Ursa stores the 2018 version of the SVI, which was released on 01/31/2020 and is the most recent as of 02/02/22. (See also [URSA-CORE] CDC SVI Overall Quintile Category)
    • CDC SVI Overall Quintile Category -- The CDC SVI Overall National Percentile grouped into 5 levels, each spanning 20 percentile points (the first quintile is percentile scores from 1 to 20 while the fifth is scores from 81 to 100). Higher scores indicate more vulnerability, so the first quintile is the least vulnerable while the fifth is the most vulnerable. Quintiles are frequently used in health research. They give larger sample sizes per group and are easier to plot and interpret. Quintiles also carry less information and group more dissimilar patients. Quintiles are good for descriptive analyses while the original percentile measure is preferable for predictive modeling.
    • CDC SVI Socioeconomic Theme National Percentile -- Includes the five Census measures of (1) Percent below 150% poverty, (2) Unemployment rate, (3) Per-capita income, and (4) Percent with no high school diploma, (5) percent uninsured. Follows the same methodology as the overall SVI composite. (See also [URSA-CORE] CDC SVI Socioeconomic Quintile Category, [URSA-CORE] CDC SVI Overall National Percentile)
    • CDC SVI Socioeconomic Quintile Category -- The CDC SVI Socioeconomic Theme National Percentile grouped into 5 levels, each spanning 20 percentile points (the first quintile is percentile scores from 1 to 20 while the fifth is scores from 81 to 100). Higher scores indicate more vulnerability, so the first quintile is the least vulnerable while the fifth is the most vulnerable. (See also [URSA-CORE] CDC SVI Socioeconomic Theme National Percentile )
    • CDC SVI Household / Disability Theme National Percentile -- Includes the four Census measures of (1) Percent aged 65 or older (2) Percent aged 17 or younger, (3) Percent with a disability (noninstitutionalized and older than age 5), and (4) Percent single parent households. Follows the same methodology as the overall SVI composite. (See also [URSA-CORE] CDC SVI Household / Disability Quintile Category, [URSA-CORE] CDC SVI Overall National Percentile)
    • CDC SVI Household / Disability Quintile Category -- The CDC SVI Household/Disability Theme National Percentile grouped into 5 levels, each spanning 20 percentile points (the first quintile is percentile scores from 1 to 20 while the fifth is scores from 81 to 100). Higher scores indicate more vulnerability, so the first quintile is the least vulnerable while the fifth is the most vulnerable. (See also [URSA-CORE] CDC SVI Household / Disability Theme National Percentile )
    • CDC SVI Minority / Language Theme National Percentile -- Includes the two Census measures of (1) Percent minority (all persons except white, non-Hispanic), (2) Percent who speak English "less than well" (persons age 5+). Follows the same methodology as the overall SVI composite. (See also [URSA-CORE] CDC SVI Minority / Language Quintile Category, [URSA-CORE] CDC SVI Overall National Percentile)
    • CDC SVI Minority / Language Quintile Category -- The CDC SVI Minority/Language Theme National Percentile grouped into 5 levels, each spanning 20 percentile points (the first quintile is percentile scores from 1 to 20 while the fifth is scores from 81 to 100). Higher scores indicate more vulnerability, so the first quintile is the least vulnerable while the fifth is the most vulnerable. (See also [URSA-CORE] CDC SVI Minority / Language Theme National Percentile)
    • CDC SVI Housing / Transportation Theme National Percentile -- Includes the five Census measures of (1) Percent housing structures with 10 or more units, (2) Percent mobile homes, (3) Percent households with more people than rooms, (4) Percent households with no vehicle available, (5) Percent living in group quarters (such as correctional facilities, nursing homes, college dorms, and military barracks). Follows the same methodology as the overall SVI composite. (See also [URSA-CORE] CDC SVI Housing / Transportation Quintile Category, [URSA-CORE] CDC SVI Overall National Percentile)
    • CDC SVI Housing / Transportation Quintile Category -- The CDC SVI Housing/Transportation Theme National Percentile grouped into 5 levels, each spanning 20 percentile points (the first quintile is percentile scores from 1 to 20 while the fifth is scores from 81 to 100). Higher scores indicate more vulnerability, so the first quintile is the least vulnerable while the fifth is the most vulnerable. (See also [URSA-CORE] CDC SVI Housing / Transportation Theme National Percentile)
    • Census ACS Percentage Below Poverty
    • Census ACS Unemployment Rate
    • Census ACS Per Capita Income
    • Census ACS Percentage Without HS Diploma
    • Census ACS Percentage 65 and Older
    • Census ACS Percentage Aged 17 and Younger
    • Census ACS Percentage with Disability
    • Census ACS Percentage Single-Parent Households
    • Census ACS Percentage Minority
    • Census ACS Percentage Speak English Less Than Well
    • Census ACS Percentage Households Without Vehicle
    • Census ACS Percentage Uninsured
    • Patient Sex Category
    • Is Patient Sex Female -- Indicates the patient's sex is female. On the Patients Natural Object, this field reflects the "best" known value for the patient available from all data sources; on other Natural Objects, e.g., MMR Member-Months, the value faithfully reflects the patient sex documented on that particular type of record in the source data.
    • Is Patient Sex Male -- Indicates the patient's sex is male. On the Patients Natural Object, this field reflects the "best" known value for the patient available from all data sources; on other Natural Objects, e.g., MMR Member-Months, the value faithfully reflects the patient sex documented on that particular type of record in the source data.
    • Is Patient Race American Indian or Alaska Native
    • Is Patient Race Asian
    • Is Patient Race Black or African American
    • Is Patient Race Native Hawaiian or Other Pacific Islander
    • Is Patient Race White
    • Is Patient Race Other
    • Is Patient Ethnicity Hispanic or Latino

  • Date Fields

    • Period Start Date -- The date identifying the start of a period of time. Period Start Date values are inclusive; e.g., a period with Period Start Date = January 1 would begin be considered to begin at 00:00 on January 1.
    • Period End Date -- The date identifying the end of an period of time. Period End Date values are exclusive; e.g., a period with Period End Date = January 1 would begin be considered to end at precisely 00:00 on January 1 (meaning that the period did not include any time on January 1).
    • Last Continuous Primary Payor Membership Episode Start Date -- The start date of the most recent prior completed Continuous Primary Payor Membership Episode as of the (potentially historical) period covered by the record. (See also [URSA-CORE] Continuous Primary Payor Membership Episode)
    • Last Continuous Primary Payor Membership Episode End Date -- The end date of the most recent prior completed Continuous Primary Payor Membership Episode as of the (potentially historical) period covered by the record. Values follow the standard exclusive convention for Period End Dates. (See also [URSA-CORE] Continuous Primary Payor Membership Episode, [URSA-CORE] Period End Date)
    • Next Continuous Primary Payor Membership Episode Start Date -- The start date of the next Continuous Primary Payor Membership Episode starting after the (potentially historical) period covered by the record. (See also [URSA-CORE] Continuous Primary Payor Membership Episode)
    • Next Continuous Primary Payor Membership Episode End Date -- The end date of the next Continuous Primary Payor Membership Episode starting after the (potentially historical) period covered by the record. Values follow the standard exclusive convention for Period End Dates. (See also [URSA-CORE] Continuous Primary Payor Membership Episode, [URSA-CORE] Period End Date)
    • Current Continuous Primary Payor Membership Episode Start Date -- The start date of the Continuous Primary Payor Membership Episode in effect as of the (potentially historical) period covered by the record. (See also [URSA-CORE] Continuous Primary Payor Membership Episode)
    • Current Continuous Primary Payor Membership Episode End Date -- The end date of the Continuous Primary Payor Membership Episode in effect as of the (potentially historical) period covered by the record. Values follow the standard exclusive convention for Period End Dates. (See also [URSA-CORE] Continuous Primary Payor Membership Episode, [URSA-CORE] Period End Date)
    • Current Non-Membership Episode Start Date -- The start date of the Non-Membership Episode in effect as of the (potentially historical) period covered by the record. (See also [URSA-CORE] Non-Membership Episode)
    • Current Non-Membership Episode End Date -- The end date of the Non-Membership Episode in effect as of the (potentially historical) period covered by the record. Values follow the standard exclusive convention for Period End Dates. (See also [URSA-CORE] Non-Membership Episode, [URSA-CORE] Period End Date)
    • Current Continuous Medical Claim Data Coverage Episode Start Date -- The start date of the Continuous Medical Claim Data Coverage Episode in effect as of the (potentially historical) period covered by the record. (See also [URSA-CORE] Continuous Medical Claim Data Coverage Episode)
    • Current Continuous Medical Claim Data Coverage Episode End Date -- The end date of the Continuous Medical Claim Data Coverage Episode in effect as of the (potentially historical) period covered by the record. Values follow the standard exclusive convention for Period End Dates. (See also [URSA-CORE] Continuous Medical Claim Data Coverage Episode, [URSA-CORE] Period End Date)
    • Current Continuous Pharmacy Claim Data Coverage Episode Start Date -- The start date of the Continuous Pharmacy Claim Data Coverage Episode in effect as of the (potentially historical) period covered by the record. (See also [URSA-CORE] Continuous Pharmacy Claim Data Coverage Episode)
    • Current Continuous Pharmacy Claim Data Coverage Episode End Date -- The end date of the Continuous Pharmacy Claim Data Coverage Episode in effect as of the (potentially historical) period covered by the record. Values follow the standard exclusive convention for Period End Dates. (See also [URSA-CORE] Continuous Pharmacy Claim Data Coverage Episode)
    • Most Recent Prior Primary Care Visit Last 12 Months Encounter Date
    • Encounter Start Date
    • Encounter End Date
    • Segment Start Date -- The start date of the reporting segment. (See also [URSA-CORE] Reporting Segment)
    • Segment End Date -- The end date of the reporting segment. (See also [URSA-CORE] Reporting Segment)
    • Segmented Period Start Date
    • Segmented Period End Date

  • Encounter Fields

    • PPHE Category -- A categorical classification of the type of potentially preventable hospital encounter (PPHE). Each encounter is assigned to one of the following mutually exclusive categories based on which preventability criteria it meets:
      [01] ACS Hospital Inpatient Admission – The admission meets one or more AHRQ Prevention Quality Indicator (PQI) criteria (ambulatory care sensitive condition).
      [02] Hospital Inpatient Admission with Prior Related Encounter – The admission was preceded by a related encounter (prior ED visit, prior admission, or prior SNF stay) within defined lookback windows.
      [03] High Probability Preventable ED Visit with Inpatient Admission – An ED visit classified as high-probability preventable that also resulted in an inpatient admission.
      [04] High Probability Preventable ED Visit without Inpatient Admission – An ED visit classified as high-probability preventable that did not result in an inpatient admission.
      [05] Multiple Preventable Criteria Met – The encounter qualifies under more than one of the above criteria simultaneously.
      [99] Unclassifiable or Missing Data – The encounter could not be classified due to missing or ambiguous data.
    • Is ACS Hospital Inpatient Admission -- A hospital inpatient admission that meets the numerator criteria for one or more AHRQ Prevention Quality Indicators (PQIs 01, 02, 03, 05, 07, 08, 09, 10, 11, 12, 14, 15, 16). These are conditions for which high-quality outpatient care can potentially prevent hospitalization or for which early intervention can prevent complications or more severe disease. Qualification is determined by the principal discharge diagnosis matching an AHRQ PQI numerator value set, subject to age eligibility, non-newborn transfer-admit source exclusion, and PQI-specific procedure and diagnosis exclusions (e.g., cardiac procedures, immunocompromised state, kidney disease with dialysis access). Also known as an Ambulatory Care Sensitive (ACS) admission.
    • Is Hospital Inpatient Admission with Prior Related Encounter -- A binary indicator (1/0) identifying a hospital inpatient admission that was preceded by one or more related healthcare encounters within defined lookback windows. Specifically, the admission must have at least one of the following:
      [01] A prior ED visit (that did not itself result in an inpatient admission) within 2–7 days prior to the admission date, provided no intervening admission or SNF stay occurred between the ED visit and the index admission.
      [02] A prior hospital inpatient admission with a discharge date either (a) within 7 days prior to the index admission, or (b) within 30 days prior with a matching principal discharge diagnosis (at the AHRQ CCS single-level category). Prior admissions with a CMS discharge status code on the "Index Admission Exclusions for Readmission Measure" value set are excluded from consideration.
      [03] A prior SNF stay with a discharge date within 14 days prior to the index admission, provided no intervening admission occurred between the SNF discharge and the index admission.
    • Is High Probability Preventable ED Visit with Inpatient Admission -- A binary indicator (1/0) identifying an ED visit that is classified as high-probability preventable AND that resulted in the patient being admitted to hospital inpatient status. An ED visit is deemed "high probability preventable" when any of the following conditions are met (based on NYU Emergency Department Algorithm [NYUEDA] classification of the principal discharge diagnosis):
      [01] The principal diagnosis has a ≥67% pooled probability of being preventable (due to inappropriate setting and/or preventable condition), AND the visit did not involve a high-intensity E&M service (which would suggest clinical complexity warranting ED care); OR
      [02] The principal diagnosis has a ≥67% probability of representing a preventable condition (regardless of other factors).

These thresholds can be customized per client request. In this data mart, the encounter grain is the parent hospital inpatient admission encounter that contains the ED visit.

  • Is High Probability Preventable ED Visit without Inpatient Admission -- A binary indicator (1/0) identifying an ED visit that is classified as high-probability preventable AND that did NOT result in the patient being admitted to hospital inpatient status. The same preventability logic applies as described for "Is High Probability Preventable ED Visit with Inpatient Admission" (≥67% NYUEDA-based probability threshold which can be customized per client request, with high-intensity E&M exclusion for the inappropriate-setting pathway). These encounters represent ED utilization that may have been avoidable through timely ambulatory care, urgent care access, or chronic disease management.
  • ACS Admission PQI Category -- A categorical field identifying which specific AHRQ Prevention Quality Indicator (PQI) criterion the ambulatory care sensitive (ACS) admission meets. Values are:
    [01] PQI 01 Diabetes Short-Term Complications
    [02] PQI 02 Perforated Appendix
    [03] PQI 03 Diabetes Long-Term Complications
    [04] PQI 05 Older Adult COPD or Asthma
    [05] PQI 07 Hypertension
    [06] PQI 08 Heart Failure
    [07] PQI 09 Low Birth Weight
    [08] PQI 10 Dehydration
    [09] PQI 11 Bacterial Pneumonia
    [10] PQI 12 Urinary Tract Infection
    [11] PQI 14 Uncontrolled Diabetes
    [12] PQI 15 Younger Adult Asthma
    [13] PQI 16 Diabetic Lower-Extremity Amputation
    [97] Multiple PQI Criteria Met

This field is NULL for encounters that are not ACS admissions (i.e., where is_acs_hospital_inpat_admission = 0). Each PQI is determined by AHRQ-specified principal diagnosis value sets, age thresholds, and exclusion criteria (transfer admits, cardiac procedures, immunocompromised state, condition-specific exclusion diagnoses).

  • Prior Encounter Scenario Category -- A hospital inpatient admission with one or more of the following: (1) prior ED visit within 7 days prior to admission; (2) prior hospital inpatient admission with discharge date within 7 days prior to admission or within 30 days prior to admission and with similar principal discharge diagnoses; or (3) prior SNF stay with discharge date within 14 days prior to admission.
  • Preventable ED Visit Scenario Category -- A categorical field classifying the reason an ED visit is considered high-probability preventable, based on NYU Emergency Department Algorithm (NYUEDA) diagnosis-level probabilities. Values are:

[01] High Probability of Preventable ED Visit Due to Inappropriate Setting Only – The principal diagnosis has a ≥67% probability of representing an inappropriate use of the ED setting (i.e., the condition could have been treated in a lower-acuity setting), but does NOT independently meet the preventable condition threshold. The visit also did not involve a high-intensity E&M service.
[02] High Probability of Preventable ED Visit Due to Preventable Condition Only – The principal diagnosis has a ≥67% probability of representing a preventable condition (i.e., the condition itself could have been prevented with adequate ambulatory care), regardless of setting appropriateness or E&M intensity.
[03] High Probability of Preventable ED Visit Due to Pooled Probability of Inappropriate Setting and/or Preventable Condition – The principal diagnosis meets the ≥67% threshold on the combined/pooled preventability probability (inappropriate setting + preventable condition), and the visit did not involve a high-intensity E&M service, but does not independently meet either the setting-only or condition-only threshold at ≥67%.
[04] Not High Probability of Preventable ED Visit – The diagnosis was classifiable via NYUEDA but did not meet any ≥67% preventability threshold.
[99] Unclassifiable or Missing Data – The principal diagnosis could not be matched to the NYUEDA reference table.

  • Encounter LOS in Elapsed Midnights

  • Is Encounter LOS < 2 Midnights

  • Encounter LOS Category Tier 1

  • Encounter LOS in Distinct Calendar Days

  • Provider Fields

    • Is Patient with Primary Care Visit Last 12 Months
    • PCP Attribution Category
    • Primary Care Engagement Category
    • Count Primary Care Visits in Last 36 Months
    • Primary Plan Attributee Provider Description
    • Empirical Attributee Primary Care Individual Provider Description
    • Empirical Attributee Primary Care Provider Group Provider Description
    • Count Visits with Attributee Primary Care Provider Group in Last 36 Months
    • Count Primary Care Visits Last 12 Months
    • Specialty Care Engagement Category
    • Count Specialty Care Office Visits in Last 36 Months
    • Primary or Specialty Care Engagement Category
    • Count Clinician Office Visits in Last 3 Years
    • Count Visits with Attributee Individual Primary Care Provider in Last 36 Months
    • Facility Provider NPI -- The 10-digit National Provider Identifier for the facility provider. (See also [URSA-CORE] Facility Provider)
    • Facility Provider Description -- The natural language description of the facility provider. (See also [URSA-CORE] Facility Provider)
    • Facility Provider NUCC Taxonomy Code
    • Facility Provider Primary NUCC Provider Taxonomy Description
    • Facility Provider State Abbreviation
    • Facility Provider ZIP Code 5-Digit
    • Prior Admission Facility Provider Description
    • Prior ED Visit Facility Provider Description
    • Prior SNF Stay Facility Provider Description

  • Insurance Fields

    • Is Any Current Plan Membership
    • Count Active Plan Memberships
    • Primary Plan Financial Class Description
    • Is Any Plan Financial Class Commercial
    • Is Any Plan Financial Class Medicare FFS
    • Is Any Plan Financial Class Medicare Advantage
    • Is Any Plan Financial Class Medicaid
    • Is CMS Hospice Status -- Indicates the patient is considered to be Hospice status.
    • Is CMS ESRD Status -- Indicates the patient meets the Medicare ESRD eligibility criterion as of a particular date; can be derived from the CMS Medicare Beneficiary Status Code. (See also [URSA-CORE] CMS Medicare Beneficiary Status Code)

  • Diagnosis Fields

    • Count CCW Conditions -- The total of both Chronic Conditions and Potentially Disabling Events included in the CMS Chronic Condition Warehouse (CCW) library. (See also [URSA-CORE] CCW Comorbidity Category, [URSA-CORE] Count Potentially Disabling Events, [URSA-CORE] CMS Chronic Condition Warehouse (CCW), [URSA-CORE] Count Chronic Conditions)
    • Is CCW Acquired Hypothyroidism -- At least 1 inpatient, SNF, HHA OR 2 HOP or Carrier claims with one or more of the DX codes from the corresponding CCW value set in the prior 1 year.
    • Is CCW Acute Myocardial Infarction -- At least 1 inpatient claim with one or more of the DX codes from the corresponding CCW value set as the first or second diagnosis position in the prior 1 year.
    • Is CCW Alzheimers Disease -- At least 1 inpatient, SNF, HHA, HOP, or Carrier claim with one or more of the DX codes from the corresponding CCW value set in the prior 3 years.
    • Is CCW Anemia -- At least 1 inpatient, SNF, HHA, HOP, or Carrier claim with one or more of the DX codes from the corresponding CCW value set in the prior 1 year.
    • Is CCW Asthma -- At least 1 inpatient, SNF, HHA OR 2 HOP or Carrier claims with one or more of the DX codes from the corresponding CCW value set in the prior 1 year.
    • Is CCW Atrial Fibrillation -- At least 1 inpatient OR 2 HOP or Carrier claims with one or more of the DX codes from the corresponding CCW value set as the first or second diagnosis position in the prior 1 year.
    • Is CCW Benign Prostatic Hyperplasia -- At least 1 inpatient, SNF, HHA OR 2 HOP or Carrier claims with one or more of the DX codes from the corresponding CCW value set in the prior 1 year. Exclusion: If any of the qualifying claims also have an ICD-10 DX of D29.1, then it is excluded.
    • Is CCW Breast Cancer -- At least 1 inpatient, SNF OR 2 HOP or Carrier claims with one or more of the DX codes from the corresponding CCW value set in prior 1 year.
    • Is CCW Cataract -- At least 1 HOP or Carrier claim with one or more of the DX codes from the corresponding CCW value set as the principal diagnosis position in the prior 1 year.
    • Is CCW CKD -- Indicates that the patient meets the CMS Chronic Condition Warehouse criteria for chronic kidney disease; i.e., 2 or more qualifying outpatient or professional ICD codes in the prior 2 years, or 1 or more non-outpatient institutional claim ICD codes in the prior 2 years.
    • Is CCW COPD and Bronchiectasis -- At least 1 inpatient, SNF, HHA OR 2 HOP or Carrier claims with one or more of the DX codes from the corresponding CCW value set in the prior 1 year.
    • Is CCW Colorectal Cancer -- At least 1 inpatient, SNF OR 2 HOP or Carrier claims with one or more of the DX codes from the corresponding CCW value set in the prior 1 year.
    • Is CCW Depression -- At least 1 inpatient, SNF, HHA, HOP, or Carrier claim with one or more of the DX codes from the corresponding CCW value set in the prior 1 year.
    • Is CCW Diabetes -- At least 1 inpatient, SNF, HHA OR 2 HOP or Carrier claims with one or more of the DX codes from the corresponding CCW value set in the prior 2 years.
    • Is CCW Endometrial Cancer -- At least 1 inpatient, SNF OR 2 HOP or Carrier claims with one or more of the DX codes from the corresponding CCW value set in the prior 1 year.
    • Is CCW Glaucoma -- At least 1 Carrier claim with one or more of the DX codes from the corresponding CCW value set as the principal diagnosis position in the prior 1 year.
    • Is CCW Heart Failure -- At least 1 inpatient, HOP, or Carrier claim with one or more of the DX codes from the corresponding CCW value set in the prior 2 years.
    • Is CCW Hip or Pelvic Fracture -- At least 1 inpatient or SNF claim with one or more of the DX codes from the corresponding CCW value set in the prior 1 year.
    • Is CCW Hyperlipidemia -- At least 1 inpatient, SNF, HHA OR 2 HOP or Carrier claims with one or more of the DX codes from the corresponding CCW value set in the prior 1 year.
    • Is CCW Hypertension -- At least 1 inpatient, SNF, HHA OR 2 HOP or Carrier claims with one or more of the DX codes from the corresponding CCW value set in the prior 1 year.
    • Is CCW Ischemic Heart Disease -- At least 1 inpatient, SNF, HHA, HOP, or Carrier claim with one or more of the DX codes from the corresponding CCW value set in the prior 2 years.
    • Is CCW Lung Cancer -- At least 1 inpatient, SNF OR 2 HOP or Carrier claims with one or more of the DX codes from the corresponding CCW value set in the prior 1 year.
    • Is CCW Osteoporosis -- At least 1 inpatient, SNF, HHA OR 2 HOP or Carrier claims with one or more of the DX codes from the corresponding CCW value set in the prior 1 year.
    • Is CCW Prostate Cancer -- At least 1 inpatient, SNF OR 2 HOP or Carrier claims with one or more of the DX codes from the corresponding CCW value set in the prior 1 year.
    • Is CCW Rheumatoid Arthritis or Osteoarthritis -- At least 2 inpatient, SNF, HHA, HOP, or Carrier claims with one or more of the DX codes from the corresponding CCW value set in the prior 2 years.
    • Is CCW Stroke or Transient Ischemic Attack -- At least 1 inpatient OR 2 HOP or Carrier claims with one or more of the DX codes from the corresponding CCW value set in the prior 1 year.
      EXCLUSIONS: If any of the qualifying claims have : 800 <= DX Code <=
      804.9, 850 <= DX Code <= 854.1 in any DX position OR DX V57xx as the principal DX Code, then the claim is excluded.
    • Is CCW ADHD, Conduct Disorders, and Hyperkinetic Syndrome -- At least 1 inpatient claim OR 2 other non-drug claims of any service type with one or more of the DX codes from the corresponding CCW value set in the prior 2 years.
    • Is CCW Anxiety Disorders -- At least 1 inpatient OR 2 other nondrug claims of any service type with one or more of the DX codes from the corresponding CCW value set in the prior 2 years.
    • Is CCW Autism Spectrum Disorder -- At least 1 inpatient claim OR 2 other non-drug claims of any service type with one or more of the DX codes from the corresponding CCW value set in the prior 2 years.
    • Is CCW Bipolar Disorder -- At least 1 inpatient OR 2 other nondrug claims of any service type with one or more of the DX codes from the corresponding CCW value set in the prior 2 years.
    • Is CCW Blindness and Visual Impairment -- At least 1 inpatient OR 2 other nondrug claims of any service type with one or more of the DX codes from the corresponding CCW value set in the prior 2 years.
    • Is CCW Cerebral Palsy -- At least 1 inpatient claim OR 2 other non-drug claims of any service type with DX codes over the last 2 years (See also [URSA-CORE] CMS Chronic Condition Warehouse (CCW))
    • Is CCW Cystic Fibrosis and Other Metabolic Disorder -- At least 1 inpatient OR 2 other nondrug claims of any service type with one or more of the DX codes from the corresponding CCW value set in the prior 2 years.
    • Is CCW Deafness and Hearing Impairment -- At least 1 inpatient OR 2 other nondrug claims of any service type with one or more of the DX codes from the corresponding CCW value set in the prior 2 years.
    • Is CCW Depressive Disorders -- At least 1 inpatient OR 2 other nondrug claims of any service type with one or more of the DX codes from the corresponding CCW value set in the prior 2 years.
    • Is CCW Epilepsy -- At least 1 inpatient claim OR 2 other non-drug claims of any service type during the two-year period (See also [URSA-CORE] CMS Chronic Condition Warehouse (CCW))
    • Is CCW Fibromyalgia and Chronic Pain and Fatigue -- At least 1 inpatient OR 2 other nondrug claims of any service type with one or more of the DX codes from the corresponding CCW value set in the prior 2 years.
    • Is CCW Intellectual Disability -- At least 1 inpatient OR 2 other nondrug claims of any service type with one or more of the DX codes from the corresponding CCW value set in the prior 2 years.
    • Is CCW Learning Disability -- At least 1 inpatient OR 2 other nondrug claims of any service type with one or more of the DX codes from the corresponding CCW value set in the prior 2 years.
    • Is CCW Leukemia -- At least 1 inpatient OR 2 non-inpatient claims with one or more of the DX codes from the corresponding CCW value set in the prior 2 years.
    • Is CCW Migraine and Chronic Headache -- At least 1 inpatient claim OR 2 non-inpatient claims with DX codes within a 2 year period. (See also [URSA-CORE] CMS Chronic Condition Warehouse (CCW))
    • Is CCW Mobility Impairment -- At least 1 inpatient OR 2 other nondrug claims of any service type with one or more of the DX codes from the corresponding CCW value set in the prior 2 years.
    • Is CCW Multiple Sclerosis -- At least 1 inpatient OR 2 other nondrug claims of any service type with one or more of the DX codes from the corresponding CCW value set in the prior 2 years.
    • Is CCW Muscular Dystrophy -- At least 1 inpatient OR 2 other nondrug claims of any service type with one or more of the DX codes from the corresponding CCW value set in the prior 2 years.
    • Is CCW Obesity -- At least 1 inpatient OR 2 non-inpatient claims with one or more of the DX codes from the corresponding CCW value set in the prior 2 years.
    • Is CCW Other Developmental Delay -- At least 1 inpatient OR 2 other nondrug claims of any service type with one or more of the DX codes from the corresponding CCW value set in the prior 2 years.
    • Is CCW Personality Disorder -- At least 1 inpatient OR 2 other nondrug claims of any service type with one or more of the DX codes from the corresponding CCW value set in the prior 2 years.
    • Is CCW Pressure or Chronic Ulcer -- At least 1 inpatient OR 2 non-inpatient claims with one or more of the DX codes from the corresponding CCW value set in the prior 2 years.
    • Is CCW PTSD -- At least 1 inpatient OR 2 other nondrug claims of any service type with one or more of the DX codes from the corresponding CCW value set in the prior 2 years.
    • Is CCW PVD -- At least 1 inpatient OR 2 non-inpatient claims with one or more of the DX codes from the corresponding CCW value set in the prior 2 years.
    • Is CCW Schizophrenia -- At least 1 inpatient claim OR 2 other non-drug claims of any service type with DX codes at least one day apart in the prior within the 2 year reference period. Qualifying codes can also be found as a subset of those in the CCW "Schizophrenia or Other Psychotic Disorders". (See also [URSA-CORE] Is CCW Schizophrenia or Other Psychotic Disorders)
    • Is CCW Schizophrenia or Other Psychotic Disorders -- At least 1 inpatient OR 2 other nondrug claims of any service type with one ore more of the DX codes from the corresponding CCW value set in the prior 2 years.
    • CCW Systems Category
    • CCW Count Category
    • Count CCW Systems -- The count of distinct systems of the body with one or more active CCW Condition. CCW Systems are as a parent category to the individual CCW Conditions grouping them based primarily on the human body system they impact such as; Behavioral Health, Cancers, Cardiovascular, Cerebrovascular, Endocrine, Genitourinary, Musculoskeletal, and Pulmonary. (See also [URSA-CORE] CMS Chronic Condition Warehouse (CCW))
    • Is CCW System Behavioral Health -- Indicates the patient has one or more of the following CCW conditions; ADHD, Conduct Disorders, and Hyperkinetic Syndrome, Anxiety Disorders, Autism Spectrum Disorder, Bipolar Disorder, Depression, Depressive Disorders, Personality Disorders, PTSD, Schizophrenia, or Schizophrenia and Other Psychotic Disorders.
    • Is CCW System Cardiovascular -- Indicates the patient has one or more of the following CCW conditions; Acute Myocardial Infarction (AMI), Atrial Fibrillation, Heart Failure, Hypertension, Ischemic Heart Disease, or Peripheral Vascular Disease (PVD).
    • Is CCW System Congenital -- Indicates the patient has one or more of the following CCW conditions; Cerebral Palsy, Cystic Fibrosis and Other Metabolic Disorder, Intellectual Disability, Learning Disability, Muscular Dystrophy, or Other Developmental Delays.
    • Is CCW System Endocrine/Metabolic -- Indicates the patient has one or more of the following CCW conditions; Diabetes, Acquired Hypothyroidism, Hyperlipidemia, or Obesity.
    • Is CCW System Genitourinary -- Indicates the patient has one or more of the following CCW conditions; Benign Prostatic Hyperplasia or Chronic Kidney Disease (CKD).
    • Is CCW System Hematologic -- Indicates the patient has one or more of the following CCW conditions; Anemia.
    • Is CCW System Musculoskeletal -- Indicates the patient has one or more of the following CCW conditions; Hip or Pelvic Fracture, Rheumatoid Arthritis or Osteoarthritis, or Osteoporosis.
    • Is CCW System Neurological -- Indicates the patient has one or more of the following CCW conditions; Alzheimer's Disease, Alzheimer's Disease and Related Disorders or Senile Dementia, Stroke or Transient Ischemic Attack, Epilepsy, Migraine and Chronic Headache, Mobility Impairment, Multiple Sclerosis, or Deafness and Hearing Impairment.
    • Is CCW System Oncologic -- Indicates the patient has one or more of the following CCW conditions; Breast Cancer, Colorectal Cancer, Endometrial Cancer, Lung Cancer, Prostate Cancer, or Leukemia.
    • Is CCW System Ophthalmologic -- Indicates the patient has one or more of the following CCW conditions; Cataract, Glaucoma, or Blindness and Visual Impairment.
    • Is CCW System Pulmonary -- Indicates the patient has one or more of the following CCW conditions; Asthma, or Chronic Obstructive Pulmonary Disease (COPD) and Bronchiectasis.
    • Is CCW System Other -- Indicates the patient has one or more of the following CCW conditions; Fibromyalgia and Chronic Pain and Fatigue, Pressure or Chronic Ulcer.
    • Is CCW Alzheimers Disease and Related Disorders or Senile Dementia -- At least 1 inpatient, SNF, HHA, HOP, or Carrier claim with one or more of the DX codes from the corresponding CCW value set in the prior 3 years.
    • Principal Discharge Diagnosis ICD-10-CM Code
    • Principal Discharge Diagnosis ICD-10-CM Description
    • Principal Diagnosis AHRQ CCS Single-Level Diagnosis Category Code
    • Principal Diagnosis AHRQ CCS Single-Level Diagnosis Category Description
    • Principal Diagnosis WHO ICD-10 Block Description
    • Principal Diagnosis WHO ICD-10 Chapter Description
    • Principal Diagnosis AHRQ CCS Multi-Level Diagnosis Category Tier 1 Code
    • Principal Diagnosis AHRQ CCS Multi-Level Diagnosis Category Tier 1 Description
    • Principal Diagnosis AHRQ CCS Multi-Level Diagnosis Category Tier 2 Code
    • Principal Diagnosis AHRQ CCS Multi-Level Diagnosis Category Tier 2 Description

  • Financial Fields

    • Primary Plan Allowed Amount -- The maximum amount that the payor agrees to pay the provider for a service or product, typically governed by a contract. The Allowed Amount for a claim or billing record is calculated by adding the Contractual Adjustment Amount (which is typically negative) to the Charge Amount. Adding the total Non-Contractual Adjustment Amount to the Allowed Amount yields the Total Due Amount. On billing records, which may identify up to three plans responsible for payment, the Primary Plan Allowed Amount, Secondary Plan Allowed Amount, and Tertiary Plan Allowed Amount fields identify the amounts paid by the primary, secondary, and tertiary plans listed on the bill, respectively. (See also [URSA-CORE] Charge Amount, [URSA-CORE] Contractual Adjustment Amount, [URSA-CORE] Non-Contractual Adjustment Amount, [URSA-CORE] Total Due Amount)
    • Primary Plan Paid Amount -- The amount actually paid by the health plan to the provider for a service or product. Subtracting the plan paid amount from the total due amount typically yields the patient responsibility amount. On billing records, which may identify up to three plans responsible for payment, the Primary Plan Paid Amount, Secondary Plan Paid Amount, and Tertiary Plan Paid Amount fields identify the amounts paid by the primary, secondary, and tertiary plans listed on the bill, respectively; the total paid by any and all plans on a bill is identified by the Any Plan Paid Amount field.
    • Total Plan Paid Amount from All Plans
    • Patient Paid Amount -- The amount paid by the patient to the provider for health care services or products.

  • Metadata Fields

    • Is Medical Claim Data Coverage -- Indicates data coverage for medical claims (i.e., institutional and professional claims) from at least one data source for the patient and time period specified on the record. (See also [URSA-CORE] Data Coverage)
    • Is Pharmacy Claim Data Coverage -- Indicates data coverage for pharmacy claims from at least one data source for the patient and time period specified on the record. (See also [URSA-CORE] Data Coverage)
    • Random Integer 1 to 1000

  • Measure Fields

    • Denominator
    • Numerator

  • Module Fields

    • Is PPHE in Last 12 Months
    • ED PPHE Count Category
    • ACS PPHE Count Category
    • Admits with Prior Related Encounter Count Category
    • Is ED High-Utilizer with PPHE in Last 12 Months
    • Count Hospital Inpatient Admissions in Last 12 Months
    • Count ED Visits Without Inpatient Admissions in Last 12 Months
    • Is ED High-Utilizer -- Indicates that the patient meets at least one of the following criteria: (1) 3 or emergency department visits in the last 3 months; or (2) 6 or more emergency department visits in the last 6 months. (See also [URSA-PHU] Is New ED High-Utilizer)
    • Is New ED High-Utilizer -- Indicates that the patient is only recently qualified as a ED High-Utilizer; defined as meeting both of the following criteria: (1) the patient meets the definition of an ED High Utilizer; and (2) all the patient's emergency room visits in the last 12 months have occurred within the last 3 months. (See also [URSA-PHU] Is ED High-Utilizer)
    • Count ED Visits in Last 3 Months
    • Count ED Visits in Last 12 Months
    • Count Potentially Preventable ED Visits in Last 12 Months
    • Count Potentially Preventable ED Visits Due to Preventable Condition in Last 12 Months
    • Count Potentially Preventable ED Visits Due to Inappropriate Setting in Last 12 Months
    • Count Ambulatory Care Sensitive Admissions in Last 12 Months
    • Count Admissions with Prior Related Encounter in Last 12 Months
    • Count Potentially Preventable ED Visits Without Admissions in Next 12 Months
    • Count Potentially Preventable Inpatient Admissions in Next 12 Months
    • Count Ambulatory Care Sensitive Admissions in Next 12 Months
    • Count Admissions with Prior Related Encounter in Next 12 Months
    • Total Paid Amount for Potentially Preventable Hospital Encounters in Next 12 Months

  • [No Field Group]