27  Encounters

The Tuva encounter grouper organizes claims into encounters, assigning each claim and claim line to exactly one encounter. An encounter represents the interaction between a patient and a healthcare provider. For inpatient encounters, this encompasses the entire duration of an inpatient stay, which spans multiple days. Tuva consolidates all claims billed intermittently throughout a patient’s stay into a single encounter, regardless of the number of claims involved. In most outpatient and office-based settings, an encounter typically spans a single day and groups together all claims that occurred on that day within that specific care setting.

Encounters are summarized into encounter groups for organizational purposes. Below is an overview of the available encounter types and groups.

ENCOUNTER_GROUP ENCOUNTER_TYPE
inpatient acute inpatient
inpatient inpatient hospice
inpatient inpatient psych
inpatient inpatient rehabilitation
inpatient inpatient skilled nursing
inpatient inpatient substance use
outpatient ambulatory surgery center
outpatient dialysis
outpatient emergency department
outpatient home health
outpatient outpatient hospital or clinic
outpatient outpatient hospice
outpatient outpatient injections
outpatient outpatient psych
outpatient outpatient pt/ot/st
outpatient outpatient radiology
outpatient outpatient rehabilitation
outpatient outpatient substance use
outpatient outpatient surgery
outpatient urgent care
office based office visit
office based office visit injections
office based office visit pt/ot/st
office based office visit radiology
office based office visit surgery
office based office visit - other
office based telehealth
other ambulance - orphaned
other dme - orphaned
other lab - orphaned
other orphaned claim

The output of the encounter grouper is the Encounter table in the Core Data Model. The core.encounter table has flags associated with each encounter making it easy to find specific claims or claim lines that occurred during that encounter. Some flags apply only to specific encounter types, like delivery, which applies only to acute inpatient. The available flags are:

To count the number of inpatient encounters where the patient was in observation status during the stay, you can sum the observation flags and count the encounter IDs.

select sum(observation_flag) as encounters_with_observation
,count(encounter_id) as total_encounters
from core.encounter
where encounter_type = 'acute inpatient'

The start of an encounter is defined by an anchor claim that has been assigned to the same service category as the encounter type. An anchor can be either professional or institutional depending on the encounter type.

The date field used in the encounter algorithm is determined using the following priority of date fields (resulting in the first non null value): - start_date -> admission_date / claim_line_start_date / claim_start_date - end_date -> discharge_date / claim_line_end_date / claim_end_date

27.0.1 Inpatient

Inpatient encounters are created when an institutional claim with the service category corresponding to one of the inpatient encounter types occurs. The Patient/Date/NPI continuity algorithm checks if a claim overlaps with another claim, with the same facility NPI, person_id, and data_source. It also adds a specific check for the case where the end date and start date of two claims are within a day, checking if the discharge disposition code is 30 (still patient). This logic is in place to avoid grouping together claims where a patient is discharged and readmitted on the same day.

Each inpatient encounter type is listed below with the algorithm, anchor, and anchor claim type.

ENCOUNTER_GROUP ENCOUNTER_TYPE Algorithm Type Service Category Anchor Anchor Claim Type
inpatient acute inpatient patient/date/npi continuity acute inpatient institutional only
inpatient inpatient hospice patient/date/npi continuity inpatient hospice institutional only
inpatient inpatient psych patient/date/npi continuity inpatient psychiatric institutional only
inpatient inpatient skilled nursing patient/date/npi continuity skilled nursing institutional only
inpatient inpatient substance use patient/date/npi continuity inpatient substance use institutional only
inpatient inpatient rehabilitation patient/date/npi continuity inpatient rehabilitation institutional only

A simplified example of the algorithm is shown below. These 3 claims would be joined together into one encounter:

patient_name claim_id start_date end_date discharge disposition code encounter_id
john smith 1 1/1/2020 1/31/2020 30 1
john smith 2 2/1/2020 2/28/2020 30 1
john smith 3 3/1/2020 3/14/2020 01 1

These claims that overlap would also be grouped together:

patient_name claim_id start_date end_date encounter_id
john smith 1 1/1/2020 1/31/2020 1
john smith 2 1/14/2020 1/28/2020 1
john smith 3 3/1/2020 3/14/2020 2

These claims would not be joined together since the discharge code indicates the patient was discharged to home:

patient_name claim_id start_date end_date discharge disposition code encounter_id
john smith 1 1/1/2020 1/31/2020 01 1
john smith 2 2/1/2020 2/28/2020 30 2

27.0.2 Outpatient

Most outpatient encounters are formed with the combination of a person_id, data_source, and date, with the exception being radiology, which contains only the claim lines associated with a specific imaging code. This will group together the institutional claim for the imaging event, and the professional claim with the read. This can then be used for rate analysis and compared to other sites of service (including professional locations).

ENCOUNTER_GROUP ENCOUNTER_TYPE Algorithm Type Service Category Anchor Anchor Claim Type
outpatient ambulatory surgery center date continuity ambulatory surgery center both prof and inst
outpatient dialysis patient/date dialysis both prof and inst
outpatient emergency department patient/date/npi continuity emergency department both prof and inst
outpatient home health patient/date home health both prof and inst
outpatient outpatient hospital or clinic patient/date outpatient hospital or clinic both prof and inst
outpatient outpatient hospice patient/date outpatient hospice both prof and inst
outpatient outpatient injections patient/date hcpc codes beginning with J both prof and inst
outpatient outpatient psych patient/date outpatient psychiatric both prof and inst
outpatient outpatient pt/ot/st patient/date outpatient pt/ot/st both prof and inst
outpatient outpatient radiology patient/date/hcpc outpatient radiology both prof and inst
outpatient outpatient rehabilitation patient/date outpatient rehabilitation both prof and inst
outpatient outpatient substance use patient/date outpatient substance use both prof and inst
outpatient outpatient surgery patient/date outpatient surgery both prof and inst
outpatient urgent care patient/date urgent care both prof and inst

27.0.3 Office-Based

Office-based encounters use only professional claims as the anchor. Most use the patient/date combination to form an encounter, with the exception being radiology. The reason for this is so that radiology contains only the claim lines associated with a specific imaging code, which can then be used for rate analysis and compared to other sites of service.

ENCOUNTER_GROUP ENCOUNTER_TYPE Algorithm Type Service Category Anchor Anchor Claim Type
office based office visit patient/date office-based visit professional only
office based office visit injections patient/date hcpc codes beginning with J professional only
office based office visit pt/ot/st patient/date office-based pt/ot/st professional only
office based office visit radiology patient/date/hcpc office-based radiology professional only
office based office visit surgery patient/date office-based surgery professional only
office based office visit - other patient/date remaining office-based claims professional only
office based telehealth patient/date telehealth visit professional only

27.0.4 Other

Ambulance, DME (durable medical equipment), and lab are typically part of a higher level encounter (such as inpatient or emergency department). If an ambulance claim occured outside the dates of the inpatient encounter it isn’t joined and doesn’t become associated with the encounter. In this case, an encounter is created for the orphaned ambulance claim.

Other orphaned claims are claims that don’t produce an anchor event on their own, and weren’t attributed to one that does. This bucket is usually small, and if it is large is an indication of a data quality issue.

ENCOUNTER_GROUP ENCOUNTER_TYPE Algorithm Type Service Category Anchor Anchor Claim Type
other ambulance - orphaned patient/date ambulance both prof and inst
other dme - orphaned patient/date durable medical equipment both prof and inst
other lab - orphaned patient/date lab both prof and inst
other orphaned claim no grouping n/a both prof and inst