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Episodes And Clinical Chapters

What Is An Episode?

An episode of medical care consists of all the events and services related to an illness, an injury, the treatment thereof, or even a routine check-up. Each episode can last a specific period of time or a long duration. Each episode is defined by a set of codes – diagnosis codes that are used to specify the nature of the disease, illness, or injury; and procedure codes that are used to define the types of services or treatments that are provided in the context of a disease, illness, or injury. Accounting for the resources used during an episode requires feeding all the claims or clinical data generated for any patient into a software application that will group each claim to one or more episodes to which it is relevant. In that sense, an episode will include all clinically-related services provided for a discrete condition or in conjunction with performance of a procedure and the prices paid for them.

In defining PACES episodes, we have been guided by the following principles:

  • There are two types of Episodes: Condition Episodes and Procedure Episodes. Condition Episodes are divided into those for chronic and those for acute conditions. 

  • Episodes should have defined durations that make sense clinically

  • Episodes should have Categories that distinguish between clinically different variants, which may or may not have different resource use associated with them 

  • Services are considered to be relevant to an episode if they could be used in the care provided for that episode and are provided during the time window for that episode, whether those services might be considered to be clinically appropriate or not. Some relevant services can be flagged as indicative of a complication; in such instances they are called sequelae.

  • An episode can be clinically related to another concurrent episode for the same patient. 

What Is An Episode Grouper?

An episode grouper is a piece of software that operationalizes algorithms that determine when an episode should be opened and closed; identifies the healthcare services that should be assigned to one or more distinct healthcare episodes; and determines with which other episode(s) a particular episode can be associated.

What Are Clinical Chapters?

Although there were more than 1,000 episodes that covered nearly 90 percent of Medicare spending and 80% of commercial medical spending in the early successors to EGM, many of those episodes were not fully defined and many had not been vetted by clinical experts and weren't up to date from a coding perspective. Today all the episode triggers have been updated, and a significant number have been fully defined.

All the episodes are grouped into 15 Clinical Chapters based on their clinical domain. The episode examples posted here include relevant services, relevant diagnoses, sequelae and indications (for procedure episodes only). The clinical chapter document below provides a list of episodes within each chapter along with the trigger codes that open the episode. 


Episode Examples

See how the outputs of PACES can help you better understand which services belong to an episode, when the services were incurred, the price per service, and other information that can help any user derive significant insights about resource use and price


Clinical Chapters

The clinical chapter document provides a list of episodes within each chapter. Note that the vast majority of the episodes have not yet been fully defined, reviewed and updated.

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