ICD-10 Code:  ICD-10 codes are alphanumeric codes used by doctors, health insurance companies, and public health agencies across the world to represent diagnoses. Every disease, disorder, injury, infection, and symptom has its own ICD-10 code. ICD-10 codes are used for everything from processing to billing to disease classification.

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Disease Classification:  Each ICD-10 code is categorized by 1 of 3 primary diagnostic conditions:  Episodic, Acute and Chronic.  Episodic conditions are those that occur or appear randomly, at irregular intervals and are not likely to cause any residual impact on one's health.  For example, a common cold, cough or flu are considered episodic conditions due to their short duration and unlikely impact on one's health in the future. Acute conditions are those that occur or appear randomly, without notice and are typically major health events that are unavoidable.  Conditions such as car accidents, trauma, sudden cardiac arrest, etc. are considered acute due to their sudden onset, little warning and have little to no opportunity for avoidance.  Chronic conditions are illnesses and diseases that are persistent or have long-lasting effects over time. The term chronic often refers to a disease or illness that lasts for more than three months and impact's one's health in very irregular patterns.  Diabetes, hypertension are considered to be chronic due to their short and long-term effects on an individual's health.

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EDC:  EDC stands for Expanded Diagnostic Clusters.  EDCs are a first-level hierarchy for ICD-10 codes.  Each of the 90,000 plus ICD-10 codes roll up into one of 282 EDCs within the ACG system.  This allows for better grouping of like conditions based on common signs, symptoms, disease, illness, etc.

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MEDC:  Each EDC has its hierarchical category, known as Major Expanded Diagnostic Cluster or MEDC.  Each of the 282 EDCs roll up into one of 27 categories.  This provides a broad grouping of diagnosis codes and pinpoints specific risks based on broad categorization.

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ADG:  Aggregated Diagnostic Groups are similar to EDCs with the exception that they group conditions based on the expected health care need of an individual.  They group individuals based on severity, diagnostic certainty, expected resources and duration.  For example, sinusitis will have an EDC of "Allergies", whereas the corresponding ADG is "Time Limited, Minor" condition.  Collectively, using the EDC and the ADG will give you a deeper understanding of the likely outcome for the individual claimant.

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ACG:  Adjusted Clinical Groups, or ACG is the name of the Johns' Hopkins system; however, within the system are clinical groupers also referred to as "adjusted clinical groups."  These ACGs are the actuarial cells or building blocks of the entire system.  They are a series of mutually exclusive, health status categories defining an individual's morbidity, mortality rate, age and sex.  They focus on categorizing a individual's illness over time and how the particular illness can impact future health care needs.  For example, a patient who has 6 diagnoses or more with one being deemed catastrophic will be grouped under 6-9 ADGs with 1 Major ADG.  This allows the end user to realize that this particular individual is at high risk for catastrophic loss in the future where more than 6 diagnoses are influencing his/her health.

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RUBs: Resource Utilization Bands are the roll up of all ACG codes.  There are five (5) distinct RUBs:  None/Unknown Risk, Very Low Risk, Low Risk, Moderate Risk, High Risk and Very High Risk.  Each of these categories represent the expected future consumption of health care in the next twelve (12) months.  Someone with a Very High Risk RUB indicates that future health care needs are expected to be high in the upcoming 12 month period; whereas, someone with a None/Unknown RUB indicates that there is not enough claims data to indicate the future health care needs.  For simplicity purposes, Alliant has grouped the RUBs into four (4) categories by consolidating low risk into one group and high risk in to another.

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Risk Scoring:  The ACG uses three (3) types of concurrent risk scoring:  unscaled, rescaled and local. 

 

Unscaled Concurrent Risk compares the state of an individual's health versus those within the ACG national reference database.  The ACG system establishes a "mean" risk score based on utilization patterns, diagnosis, plan spend and demographic factors such as age, gender, and location. The ACG unscaled concurrent risk score is set at 1.0 ("average risk").  Therefore, an individual's unscaled concurrent risk score > 1.0 indicates he/she is sicker than the individuals in the database.

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Rescaled Concurrent Risk follows similar logic as above, but instead of using the mean value of the national reference database, it creates a risk score based on the member health profiles within your health plan.  Therefore, a rescaled concurrent risk score > 1.0 indicates he/she is sicker than the individuals within your health plan.

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Local Concurrent Risk scores are created when there are 30 or more individuals found in a regional cluster.  When this occurs, ACG creates a mean value of that cluster.  Similar to both unscaled and rescaled risk scoring, individuals with a mean value > 1.0 indicates he/she is sicker than the individuals in that regional cluster.  When there are fewer than 30 individuals in a regional cluster, local concurrent risk scores are defaulted to rescaled concurrent risk scores.

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EDC Impact:  EDC Impact indicates the risk burden of the individual's diagnosis.  A high impact EDC indicates the EDC diagnosis is known to cause high health care expenses and should be expected to have a RUB in the high/very high risk category; conversely, a low impact EDC is not expected to have a major influence on health care spend and is categorized as low/very low risk.

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Frailty:  The frailty flag (if present) indicates that the individual has one or more of the 10 EDCs that represent a medical condition associated with permanent disability.  Frailty diagnosis should be reviewed carefully as they may have high risk scores, elevated RUB status and have high EDC impact markers.  These individuals will have ongoing, high costs that will impact the health plan.

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Sources:  The Johns' Hopkins University ACG System, Version 11.2, 2018-2019.

                  The Centers for Disease Control and Prevention (CDC), 2019.

                  The Agency for Healthcare Research and Quality (AHRQ), 2019.