Hello,
Our team is working to OMOP Claims data and we continue to see the same person, same procedure, same date with multiple records in the source - but different claim id’s on the record. We are wondering how to handle or de-dup these. In your experience is this reflecting multiple providers billing for the same procedure, or are these truly separate series of the same procedure occurring. Thank you in advance for any input!
You might need to provide a little more context. What kind of claims data is this? Are these submitted claims or are they paid claims adjudicated by the insurer?
This an open claims asset so they are submitted claims.
Hi @MNairn. I can think of three reasons why you are getting the same procedure and same date with different claim ids.
- Multiple providers are billing for the same procedure. This is very common for outpatient facility procedures (i.e. outpatient surgeries) where the surgeon and the ambulatory surgical center (or outpatient hospital facility) are billing the same CPT/HCPCS code. This is how the US healthcare system works, in general. The surgeon is billing her time and expertise for doing the surgery. The facility is billing it’s space and supplies used for the surgery. Both the surgeon and facility use the same procedure code, per U.S. billing standards. If the surgery included an assistant surgeon, you will also see a separate third bill from a different surgeon using the same CPT/HCPCS code and same date.
- Multiple procedures with different modifiers are being billed. It is possible that the same procedure code is being billed multiple times for different reasons, denoted by a procedure modifier. For example, cataract surgery can be billed twice, one procedure code for each eye. The provider specifies the difference using the “RT” or “LT” modifiers on the claim. This is very common with CT scans or diagnostic tests where providers may need the patient to get multiple scans/tests done on the same day. So providers bill with a modifier “76” to specify that the procedure was redone. Hopefully you’re dataset gives you modifier information so you can see if there is a difference in modifiers between duplicate procedures.
- If you are using an open claims set (as it looks like you are), it’s possible that the actual bill is being resubmitted to the payer, creating two different claim_ids for the same content in the claim. In practice, providers (i.e. physicians and hospital/facilities) can resubmit claims to payers for a variety of reasons, outside of patient care. Most often the resubmitting process is due to correcting typos from the original claim, or internet connection issues causing uncertainty whether the payer received claims in the first place. Your open claims database should denote whether the claim was considered a “resubmission” or not. But, if it doesn’t, I would look at the payment status of each of these “duplicate” procedure records and see if one procedure was paid and another procedure was denied due to a duplicate procedure rejection.
Hopefully that helps.
Thank you! This is helpful information.
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@jenniferduryea Thanks a lot for your expertise! Extremely helpful. Maybe, you can guide me in the similar situation with a more complicated scenario. How would you handle the case where a patient has the procedures that look the same in the same day, coded in different vocabularies:for example, HCPCS S9538 ‘Home transfusion of blood product(s); administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (blood products, drugs, and nursing visits coded separately), per diem’ and CPT4 36430 ‘Transfusion, blood or blood components’. Could we just close our eyes to the fact that they belong to different vocabs and treat them as duplicates?
I’m also wondering how would you consider different quantities? From what I read in your post, we may think of it as different facilities/people billing for the same procedure. Probably, in this particular case, we can eliminate the 2nd version with modifiers, as blood transfusions are pretty straightforward. But should we take minimal/maximal/other quantity as the real number of procedures that took place?
Thank you for your help again.
@aostropolets for your first question:
- We never want to close our eyes. That gets us into lots of trouble. It’s one of the main reasons observational research is a bit of a mess.
- Without commenting on blood products or even different types of codes you mention, I would not combine these codes as one event. Each code carries its own cost and the cost information should be maintained under each code.
- Now looking at the specific codes you mention, it looks like S9538 is billing for all of the services given to a patient to do home blood transfusions. These services include nursing staff time and supplies. Then 36430 bills for the processing cost of handling blood supplies (this is an admin cost the facility is billing just to specifically handle blood). These codes are billing for two entirely separate services. So even if your data does not have cost information, and you want to combine these two codes together, the definition of these two codes definitely do not look like duplicates to me. One code is looking at the services applied to the patient. The other code is looking at services for handling blood products (that the facility incurs).
- Billing codes for blood transfusions are very specific and require specific domain knowledge on billing blood products. I have never done this in practice. So any suggestions I may have should be double-checked with references.
For your second question:
- Please see #2 and #4 above. I do not think codes should be combined together. If you don’t combine them, then you don’t have to worry about combining quantities. There are reasons payers accept different codes - because they represent different services.
- To append on to #4, there are very specific units associated with each code - S9538 and 36430. For example, 36430 is billed on a daily basis (i.e. a processing charge is billed to the facility for as a daily fee for handling blood products). Then S9538 is billed for the actual blood transfusion per day. In this instance, you should only get units=1 for these codes billed on the same day.
- Again, a revamp of #4 above, but this is specific to the codes mentioned in your reply and it’s based on the 30 secs of google research I did to reply to this post. More research on billing practices, specific to billing blood products, should be done to get more familiarity of blood product codes.
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@jenniferduryea thanks a lot for the explicit answer! Of course, I didn’t mean to remove these “duplicates”, rather to figure out whether consider them as one event or separate (e.g. one blood transfusion performed or more). I appreciate that you share your expertise across the community. Learned a lot from the post 
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