| Title: | Datasets that Support the EDGE Server DIY Logic |
|---|---|
| Description: | Datasets from most recent Center for Consumer Information and Insurance Oversight (CCIIO) DIY entry in a tidy format. These support the Centers for Medicare and Medicaid Services' (CMS) risk adjustment Do-It-Yourself (DIY) process, which allows health insurance issuers to calculate member risk profiles under the Health and Human Services-Hierarchical Condition Categories (HHS-HCC) regression model. This regression model is used to calculate risk adjustment transfers. Risk adjustment is a selection mitigation program implemented under the Patient Protection and Affordable Care Act (ACA or Obamacare) in the USA. Under the ACA, health insurance issuers submit claims data to CMS in order for CMS to calculate a risk score under the HHS-HCC regression model. However, CMS does not inform issuers of their average risk score until after the data submission deadline. These data sets can be used by issuers to calculate their average risk score mid-year. More information about risk adjustment and the HHS-HCC model can be found here: <https://www.cms.gov/mmrr/Articles/A2014/MMRR2014_004_03_a03.html>. |
| Authors: | Ethan Brockmann [aut, cre, cph] |
| Maintainer: | Ethan Brockmann <[email protected]> |
| License: | GPL-3 |
| Version: | 0.3.0.9000 |
| Built: | 2024-11-10 03:59:22 UTC |
| Source: | https://github.com/eeethb/edgedata |
A dataset containing the adult model demographic factors for the risk adjustment model. Demographics vary by age (groupings) and sex.
adult_demoadult_demo
An object of class tbl_df (inherits from tbl, data.frame) with
6 columns
Whether or not the category is used in the RA model
Plan metal level (Benefit richness)
Demographic risk score coefficient
Male/Female demographic category
Maximum and minimum age for each risk score
Data import and cleaning at: https://github.com/EeethB/edgedata/tree/main/data-raw
Other factors:
adult_enroll_dur,
adult_group,
adult_hcc,
adult_interaction,
adult_rxc_hcc_inter,
adult_rxc,
child_demo,
child_group,
child_hcc,
infant_demo,
infant_mat_sev
A dataset containing the adult model enrollment duration factors for the risk adjustment model. Risk score is increased for members with less than 12 months' duration due to risk that is present but not accounted for in diagnoses and prescriptions during the enrollment window.
adult_enroll_duradult_enroll_dur
An object of class tbl_df (inherits from tbl, data.frame) with
4 columns
Whether or not the category is used in the RA model
Plan metal level (Benefit richness)
Enrollment duration risk score coefficient
Number of enrollment months for each risk score
Data import and cleaning at: https://github.com/EeethB/edgedata/tree/main/data-raw
Other factors:
adult_demo,
adult_group,
adult_hcc,
adult_interaction,
adult_rxc_hcc_inter,
adult_rxc,
child_demo,
child_group,
child_hcc,
infant_demo,
infant_mat_sev
A dataset containing the adult model HCC grouping factors for the risk adjustment model. Some condition categories have been grouped together, so that any number of HCCs within that group are zeroed out and replaced by the group.
adult_groupadult_group
An object of class tbl_df (inherits from tbl, data.frame) with
17 rows and 7 columns
Group label for risk scores
Whether or not the category is used in the RA model
Plan metal level (Benefit richness)
HCC grouping risk score coefficient
Data import and cleaning at: https://github.com/EeethB/edgedata/tree/main/data-raw
Other factors:
adult_demo,
adult_enroll_dur,
adult_hcc,
adult_interaction,
adult_rxc_hcc_inter,
adult_rxc,
child_demo,
child_group,
child_hcc,
infant_demo,
infant_mat_sev
Other HCC tables:
adult_hcc,
adult_interaction,
adult_rxc_hcc_inter,
cc_hier,
child_group,
child_hcc,
cpt_hcpcs,
icd_cc
A dataset containing the adult model HCC factors for the risk adjustment
model. Condition categories (CCs) are triggered by ICD-10 codes (See
icd_cc), and a hierarchy is then applied (See
cc_hier), creating hierarchical condition categories (HCCs).
adult_hccadult_hcc
An object of class tbl_df (inherits from tbl, data.frame) with
4 columns
Whether or not the category is used in the RA model
Plan metal level (Benefit richness)
HCC grouping risk score coefficient
HCC label for risk scores (Includes leading zeroes)
Data import and cleaning at: https://github.com/EeethB/edgedata/tree/main/data-raw
Other factors:
adult_demo,
adult_enroll_dur,
adult_group,
adult_interaction,
adult_rxc_hcc_inter,
adult_rxc,
child_demo,
child_group,
child_hcc,
infant_demo,
infant_mat_sev
Other HCC tables:
adult_group,
adult_interaction,
adult_rxc_hcc_inter,
cc_hier,
child_group,
child_hcc,
cpt_hcpcs,
icd_cc
A dataset containing the adult model interaction factors for the risk adjustment model. Certain HCCs are considered "high risk" HCCs, and when one of these high risk HCCs interacts with certain other HCCs, an additional interaction term is added to the risk score.
adult_interactionadult_interaction
An object of class tbl_df (inherits from tbl, data.frame) with
4 columns
Interaction group (M/H)
Whether or not the category is used in the RA model
Plan metal level (Benefit richness)
HCC grouping risk score coefficient
Data import and cleaning at: https://github.com/EeethB/edgedata/tree/main/data-raw
Other factors:
adult_demo,
adult_enroll_dur,
adult_group,
adult_hcc,
adult_rxc_hcc_inter,
adult_rxc,
child_demo,
child_group,
child_hcc,
infant_demo,
infant_mat_sev
Other HCC tables:
adult_group,
adult_hcc,
adult_rxc_hcc_inter,
cc_hier,
child_group,
child_hcc,
cpt_hcpcs,
icd_cc
A dataset containing the adult model prescription drug category (RXC)
factors for the risk adjustment model. Rx condition categories are
triggered by NDC codes (See ndc_rxc) or HCPCS codes (See
hcpcs_rxc), and a hierarchy is then applied (See
rxc_hier).
adult_rxcadult_rxc
An object of class tbl_df (inherits from tbl, data.frame) with
4 columns
Whether or not the category is used in the RA model
Plan metal level (Benefit richness)
HCC grouping risk score coefficient
RXC label for risk scores (Includes leading zeroes)
Data import and cleaning at: https://github.com/EeethB/edgedata/tree/main/data-raw
Other factors:
adult_demo,
adult_enroll_dur,
adult_group,
adult_hcc,
adult_interaction,
adult_rxc_hcc_inter,
child_demo,
child_group,
child_hcc,
infant_demo,
infant_mat_sev
Other RXC tables:
adult_rxc_hcc_inter,
hcpcs_rxc,
ndc_rxc,
rxc_hier
A dataset containing the adult model RXC/HCC interaction factors for the risk adjustment model. Some HCCs have built-in risk for the associated drugs, so if a member has both the diagnosis and the drug, their risk is overstated. Other drugs combined with conditions indicate a greater severity than either the drug or the condition alone, so risk is understated. The RXC/HCC interaction factors make these adjustments.
adult_rxc_hcc_interadult_rxc_hcc_inter
An object of class tbl_df (inherits from tbl, data.frame) with
5 columns
Whether or not the category is used in the RA model
Plan metal level (Benefit richness)
HCC grouping risk score coefficient
RXC label for risk scores (Includes leading zeroes)
HCC label for risk scores (Includes leading zeroes)
Data import and cleaning at: https://github.com/EeethB/edgedata/tree/main/data-raw
Other factors:
adult_demo,
adult_enroll_dur,
adult_group,
adult_hcc,
adult_interaction,
adult_rxc,
child_demo,
child_group,
child_hcc,
infant_demo,
infant_mat_sev
Other HCC tables:
adult_group,
adult_hcc,
adult_interaction,
cc_hier,
child_group,
child_hcc,
cpt_hcpcs,
icd_cc
Other RXC tables:
adult_rxc,
hcpcs_rxc,
ndc_rxc,
rxc_hier
A dataset used to apply the risk adjustment condition category hierarchies. The HHS-Hcc risk model uses hierarchical condition categories. This means that when an individual has e.g. HCC 8 (Metastatic Cancer), they do not also get the risk score for less serious cancer categories.
cc_hiercc_hier
An object of class tbl_df (inherits from tbl, data.frame) with
149 rows and 3 columns
Condition category code without leading zeroes
Condition category description
Condition category that falls below cc on the hierarchy.
No leading zeroes
Data import and cleaning at: https://github.com/EeethB/edgedata/tree/main/data-raw
Other HCC tables:
adult_group,
adult_hcc,
adult_interaction,
adult_rxc_hcc_inter,
child_group,
child_hcc,
cpt_hcpcs,
icd_cc
A dataset containing the mapping from HCC to interaction group "H".
cc_int_hcc_int_h
An object of class tbl_df (inherits from tbl, data.frame) with
9 rows and 3 columns
Hierarchical condition category (Currently includes some G*)
Variable mapped to (int_group_h)
Short description of the variable
Interaction group H (high?) takes priority over interaction group M (moderate?). If a member qualifies for group H, they should not get credit for group M.
Data import and cleaning at: https://github.com/EeethB/edgedata/tree/main/data-raw
Other Severe interaction tables:
cc_int_m,
cc_severe
A dataset containing the mapping from HCC to interaction group "M".
cc_int_mcc_int_m
An object of class tbl_df (inherits from tbl, data.frame) with
7 rows and 3 columns
Hierarchical condition category (Currently includes some G*)
Variable mapped to (int_group_m)
Short description of the variable
Interaction group H (high?) takes priority over interaction group M (moderate?). If a member qualifies for group H, they should not get credit for group M.
Data import and cleaning at: https://github.com/EeethB/edgedata/tree/main/data-raw
Other Severe interaction tables:
cc_int_h,
cc_severe
A dataset containing the mapping from HCC to severe status.
cc_severecc_severe
An object of class tbl_df (inherits from tbl, data.frame) with
8 rows and 3 columns
Hierarchical condition category (Currently includes some G*)
Variable mapped to (severe_v3)
Short description of the variable
Data import and cleaning at: https://github.com/EeethB/edgedata/tree/main/data-raw
Other Severe interaction tables:
cc_int_h,
cc_int_m
A dataset containing the child model demographic factors for the risk adjustment model. Demographics vary by age (groupings) and sex.
child_demochild_demo
An object of class tbl_df (inherits from tbl, data.frame) with
6 columns
Whether or not the category is used in the RA model
Plan metal level (Benefit richness)
Demographic risk score coefficient
Male/Female demographic category
Maximum and minimum age for each risk score
Data import and cleaning at: https://github.com/EeethB/edgedata/tree/main/data-raw
Other factors:
adult_demo,
adult_enroll_dur,
adult_group,
adult_hcc,
adult_interaction,
adult_rxc_hcc_inter,
adult_rxc,
child_group,
child_hcc,
infant_demo,
infant_mat_sev
A dataset containing the child model HCC grouping factors for the risk adjustment model. Some condition categories have been grouped together, so that any number of HCCs within that group are zeroed out and replaced by the group.
child_groupchild_group
An object of class tbl_df (inherits from tbl, data.frame) with
4 columns
Group label for risk scores
Whether or not the category is used in the RA model
Plan metal level (Benefit richness)
HCC grouping risk score coefficient
Data import and cleaning at: https://github.com/EeethB/edgedata/tree/main/data-raw
Other factors:
adult_demo,
adult_enroll_dur,
adult_group,
adult_hcc,
adult_interaction,
adult_rxc_hcc_inter,
adult_rxc,
child_demo,
child_hcc,
infant_demo,
infant_mat_sev
Other HCC tables:
adult_group,
adult_hcc,
adult_interaction,
adult_rxc_hcc_inter,
cc_hier,
child_hcc,
cpt_hcpcs,
icd_cc
A dataset containing the child model HCC factors for the risk adjustment
model. Condition categories (CCs) are triggered by ICD-10 codes (See
icd_cc), and a hierarchy is then applied (See
cc_hier), creating hierarchical condition categories (HCCs).
child_hccchild_hcc
An object of class tbl_df (inherits from tbl, data.frame) with
4 columns
Whether or not the category is used in the RA model
Plan metal level (Benefit richness)
HCC grouping risk score coefficient
HCC label for risk scores (Includes leading zeroes)
Data import and cleaning at: https://github.com/EeethB/edgedata/tree/main/data-raw
Other factors:
adult_demo,
adult_enroll_dur,
adult_group,
adult_hcc,
adult_interaction,
adult_rxc_hcc_inter,
adult_rxc,
child_demo,
child_group,
infant_demo,
infant_mat_sev
Other HCC tables:
adult_group,
adult_hcc,
adult_interaction,
adult_rxc_hcc_inter,
cc_hier,
child_group,
cpt_hcpcs,
icd_cc
A dataset containing the Current Procedural Terminology (CPT) and Health Care Procedure Coding System (HCPCS) codes that determine if a claim is eligible for risk adjustment.
cpt_hcpcscpt_hcpcs
An object of class tbl_df (inherits from tbl, data.frame) with
6557 rows and 8 columns
CPT/HCPCS code
Short description of the code
Whether or not the code was valid in the prior benefit year
Whether or not the code is valid in the current benefit year
Any footnotes included in the CMS DIY file
Risk adjustment requires that claims be face-to-face to count in the HHS-HCC model. The codes in this dataset denote a face-to-face procedure, so if one of these codes is found anywhere on a claim, it counts for risk adjustment.
Data import and cleaning at: https://github.com/EeethB/edgedata/tree/main/data-raw
Other HCC tables:
adult_group,
adult_hcc,
adult_interaction,
adult_rxc_hcc_inter,
cc_hier,
child_group,
child_hcc,
icd_cc
A dataset containing the HCPCS to Rx condition mappings.
hcpcs_rxchcpcs_rxc
An object of class tbl_df (inherits from tbl, data.frame) with
43 rows and 3 columns
Rx condition number without leading zeroes
Rx condition description
HCPCS code that maps to rxc
HCPCS codes create a system for identifying drugs given in a medical setting. But since there are so many drugs, and they very specific, the HHS-HCC model groups similar drugs into broader Rx condition categories.
Data import and cleaning at: https://github.com/EeethB/edgedata/tree/main/data-raw
Other crosswalks:
icd_cc,
ndc_rxc
Other RXC tables:
adult_rxc_hcc_inter,
adult_rxc,
ndc_rxc,
rxc_hier
A dataset containing the ICD-10 to condition category mappings.
icd_ccicd_cc
An object of class tbl_df (inherits from tbl, data.frame) with
8528 rows and 11 columns
ICD-10 code
Risk adjustment condition category
It's not yet clear how this is used
Effective date of ICD code
Term date of ICD code
Male/Female specification for ICD code (Risk adjustment currently only supports male and female)
Numeric sex encoding (1/M and 2/F)
Number corresponding to model: 0 = newborn, 1 = pediatric 2 = maternity, 3 = adult
Which regression model the age/sex filters apply to - Includes maternity, which is not used in actual score calculations
Minimum age for a given diagnosis code
Maximum age for a given diagnosis code
The ICD-10 system is a vast diagnosis coding system in healthcare. But since there are so many diagnoses, and they very specific, the HHS-HCC model groups similar codes into broader condition categories. Additionally, some diagnoses can only apply to one sex or the other, or to a particular age range.
Data import and cleaning at: https://github.com/EeethB/edgedata/tree/main/data-raw
Other crosswalks:
hcpcs_rxc,
ndc_rxc
Other HCC tables:
adult_group,
adult_hcc,
adult_interaction,
adult_rxc_hcc_inter,
cc_hier,
child_group,
child_hcc,
cpt_hcpcs
A dataset containing the infant model demographic factors for the risk adjustment model. Demographics vary by age and sex.
infant_demoinfant_demo
An object of class tbl_df (inherits from tbl, data.frame) with
5 columns
Whether or not the category is used in the RA model
Plan metal level (Benefit richness)
Demographic risk score coefficient
Age for each risk score
Male/Female demographic category
Data import and cleaning at: https://github.com/EeethB/edgedata/tree/main/data-raw
Other factors:
adult_demo,
adult_enroll_dur,
adult_group,
adult_hcc,
adult_interaction,
adult_rxc_hcc_inter,
adult_rxc,
child_demo,
child_group,
child_hcc,
infant_mat_sev
A dataset containing the infant model maturity/severity factors for the risk adjustment model. Risk scores are done a little differently in the infant model. Instead of grouping/applying a hierarchy to condition categories, infants have all conditions grouped into 5 severity levels (1-5). They also get a maturity level which corresponds to weeks of gestation at which they were born. There is also a maturity category for age 1.
infant_mat_sevinfant_mat_sev
An object of class tbl_df (inherits from tbl, data.frame) with
5 columns
Infant maturity level. Can be extremely immature, immature, premature multiples, term, or age 1
Infant severity level. 1-5
Whether or not the category is used in the RA model
Plan metal level (Benefit richness)
Maturity/severity risk score coefficient
Data import and cleaning at: https://github.com/EeethB/edgedata/tree/main/data-raw
Other factors:
adult_demo,
adult_enroll_dur,
adult_group,
adult_hcc,
adult_interaction,
adult_rxc_hcc_inter,
adult_rxc,
child_demo,
child_group,
child_hcc,
infant_demo
A dataset containing the NDC to Rx condition mappings.
ndc_rxcndc_rxc
An object of class tbl_df (inherits from tbl, data.frame) with
12323 rows and 3 columns
Rx condition number without leading zeroes
Rx condition description
NDC that maps to rxc
The NDC system is a unique drug identifier system. But since there are so many drugs, and they very specific, the HHS-HCC model groups similar drugs into broader Rx condition categories.
Data import and cleaning at: https://github.com/EeethB/edgedata/tree/main/data-raw
Other crosswalks:
hcpcs_rxc,
icd_cc
Other RXC tables:
adult_rxc_hcc_inter,
adult_rxc,
hcpcs_rxc,
rxc_hier
A dataset used to apply the risk adjustment Rx condition category hierarchies. The HHS risk model uses hierarchical condition categories. This means that when an individual has e.g. RXC 6 (Insulin), they do not also get the risk score for RXC 7 (Anti-Diabetic Agents, Except Insulin...).
rxc_hierrxc_hier
An object of class tbl_df (inherits from tbl, data.frame) with
1 rows and 3 columns
Rx condition code without leading zeroes
Rx condition code description
Rx condition code that falls below rxc on the hierarchy
No leading zeroes
Data import and cleaning at: https://github.com/EeethB/edgedata/tree/main/data-raw
Other RXC tables:
adult_rxc_hcc_inter,
adult_rxc,
hcpcs_rxc,
ndc_rxc