IP - CA.1.heart_failure

CM Codes

Data Overview

15519 total codes in komodo_rii; 411 retained after n_claims > 500 filter.

CMS severity	n codes
No CC/MCC	281
CC	101
MCC	29

PCA Analysis

PC1 explains 42.0% of variance; PC1+PC2 together explain 55.3%.

Tier Clustering (k=4)

Tier Summary

tier	n_codes	n_claims	n distinct rev codes	length of stay	relative claim charge	n imaging lines	work rvu	n j code lines	organ system count	icu
1	219.000	6231645.000	15.309	5.766	0.976	0.533	0.487	0.342	5.703	0.334
2	130.000	1935394.000	16.270	6.711	1.133	0.619	0.633	0.408	5.744	0.361
3	50.000	673155.000	17.519	8.062	1.372	0.700	0.692	0.469	5.791	0.403
4	12.000	121645.000	19.614	9.976	1.916	1.072	1.009	0.658	5.918	0.530

CMS Severity × intensity Tier

cms_severity	Tier 1	Tier 2	Tier 3	Tier 4	All
CC	42	35	20	4	101
MCC	6	8	9	6	29
No CC/MCC	171	87	21	2	281
All	219	130	50	12	411

Feature Analysis

Feature Correlation

Feature Audit

	pc1_loading	r_with_volume	r_with_severity
avg_relative_claim_charge	0.388	-0.069	0.318
avg_n_distinct_rev_codes	0.364	-0.121	0.211
avg_length_of_stay	0.334	-0.108	0.210
rate_mechanical_ventilation	0.328	0.077	0.461
rate_or	0.321	-0.023	0.294
avg_n_imaging_lines	0.288	-0.215	0.169
rate_icu	0.275	0.122	0.263
rate_multiple_or_days	0.265	-0.003	0.243
rate_transfusion	0.251	-0.039	0.262
avg_n_j_code_lines	0.236	-0.031	0.240
avg_work_rvu	0.150	-0.094	0.255
rate_dialysis	0.143	0.016	0.217
avg_n_distinct_hcps	0.050	-0.225	-0.355
avg_organ_system_count	0.041	-0.276	-0.444

Top 6 Tier-Discriminating Features

Bottom 6 Tier-Discriminating Features

Score Validation

Misclassification Audit (N=10 samples)

Over-tiered: Tier 4, No CC/MCC (2 codes)

code	code_description	cms_severity	intensity_score	tier	n_claims	key_drivers
G928	Other toxic encephalopathy	No CC/MCC	9.415	4	9919	relative claim charge (+1.49), mechanical ventilation (+1.45), n imaging lines (+1.32)
K7682	Hepatic encephalopathy	No CC/MCC	7.159	4	1799	relative claim charge (+1.20), or (+1.01), n distinct rev codes (+0.97)

Under-tiered: Tier 1, MCC (5 codes)

code	code_description	cms_severity	intensity_score	tier	n_claims	key_drivers
I5031	Acute diastolic (congestive) heart failure	MCC	-1.953	1	48251	length of stay (-0.40), relative claim charge (-0.33), or (-0.23)
I5023	Acute on chronic systolic (congestive) heart failure	MCC	-1.656	1	230623	n distinct rev codes (-0.40), length of stay (-0.27), relative claim charge (-0.27)
I5021	Acute systolic (congestive) heart failure	MCC	-1.464	1	31146	length of stay (-0.40), relative claim charge (-0.25), n distinct rev codes (-0.25)
I5041	Acute combined systolic (congestive) and diastolic (congestive) heart failure	MCC	-1.352	1	8670	length of stay (-0.40), relative claim charge (-0.27), or (-0.18)
I5033	Acute on chronic diastolic (congestive) heart failure	MCC	-1.260	1	350393	length of stay (-0.18), relative claim charge (-0.16), or (-0.13)

Top Codes by Tier

Tier 1 (n=219 codes)

code	Description	CMS severity	Score	N claims	Key drivers
D72829	Elevated white blood cell count, unspecified	No CC/MCC	-0.579	18329	length of stay (-0.23), icu (+0.16), or (-0.15)
I071	Rheumatic tricuspid insufficiency	No CC/MCC	-0.603	19074	n j code lines (-0.10), n imaging lines (-0.10), mechanical ventilation (-0.10)
I951	Orthostatic hypotension	No CC/MCC	-0.625	7437	length of stay (+0.24), n imaging lines (+0.24), n j code lines (-0.23)
N185	Chronic kidney disease, stage 5	CC	-0.654	9261	n imaging lines (-0.48), transfusion (+0.45), icu (-0.21)
E1165	Type 2 diabetes mellitus with hyperglycemia	No CC/MCC	-0.664	64548	n imaging lines (-0.13), multiple or days (-0.11), length of stay (-0.11)
N401	Benign prostatic hyperplasia with lower urinary tract symptoms	No CC/MCC	-0.673	12230	n j code lines (-0.27), icu (-0.22), multiple or days (+0.20)
F331	Major depressive disorder, recurrent, moderate	CC	-0.684	3053	icu (-0.27), mechanical ventilation (-0.12), n j code lines (-0.11)
D7589	Other specified diseases of blood and blood-forming organs	No CC/MCC	-0.684	1709	relative claim charge (-0.20), multiple or days (-0.20), or (-0.12)
I483	Typical atrial flutter	CC	-0.688	2913	multiple or days (-0.31), n j code lines (-0.25), relative claim charge (+0.23)
I501	Left ventricular failure, unspecified	CC	-0.689	1784	n distinct rev codes (-0.34), length of stay (-0.32), work rvu (+0.26)

Tier 2 (n=130 codes)

code	Description	CMS severity	Score	N claims	Key drivers
J9811	Atelectasis	CC	1.900	32301	or (+0.44), n imaging lines (+0.43), n distinct rev codes (+0.37)
D61818	Other pancytopenia	CC	1.867	12045	transfusion (+0.66), or (+0.34), multiple or days (+0.30)
B961	Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere	No CC/MCC	1.805	3902	length of stay (+0.53), n distinct rev codes (+0.52), relative claim charge (+0.33)
E8809	Other disorders of plasma-protein metabolism, not elsewhere classified	No CC/MCC	1.791	13941	or (+0.43), n distinct rev codes (+0.34), relative claim charge (+0.26)
I50810	Right heart failure, unspecified	No CC/MCC	1.789	2465	n j code lines (+0.58), relative claim charge (+0.32), work rvu (+0.29)
I9589	Other hypotension	No CC/MCC	1.755	4231	icu (+0.44), or (+0.39), length of stay (+0.28)
E8351	Hypocalcemia	No CC/MCC	1.663	11427	or (+0.39), transfusion (+0.29), n distinct rev codes (+0.22)
I10	Essential (primary) hypertension	No CC/MCC	1.658	13240	work rvu (+1.76), n j code lines (+0.45), length of stay (+0.44)
I3139	Other pericardial effusion (noninflammatory)	No CC/MCC	1.618	24306	or (+0.41), n imaging lines (+0.33), n distinct rev codes (+0.24)
M898X9	Other specified disorders of bone, unspecified site	No CC/MCC	1.570	3251	dialysis (+0.79), or (+0.43), transfusion (+0.30)

Tier 3 (n=50 codes)

code	Description	CMS severity	Score	N claims	Key drivers
K921	Melena	CC	6.010	3714	transfusion (+1.32), multiple or days (+1.23), n distinct rev codes (+0.74)
I953	Hypotension of hemodialysis	No CC/MCC	5.404	1991	dialysis (+1.26), or (+0.95), relative claim charge (+0.83)
J918	Pleural effusion in other conditions classified elsewhere	CC	5.289	31727	or (+2.84), n distinct rev codes (+0.86), multiple or days (+0.50)
A0472	Enterocolitis due to Clostridium difficile, not specified as recurrent	CC	5.239	2684	length of stay (+1.07), relative claim charge (+0.99), n distinct rev codes (+0.71)
D689	Coagulation defect, unspecified	CC	5.212	5816	relative claim charge (+0.76), or (+0.65), n distinct rev codes (+0.59)
K922	Gastrointestinal hemorrhage, unspecified	CC	5.197	3787	transfusion (+1.72), n distinct rev codes (+0.66), work rvu (+0.59)
J9602	Acute respiratory failure with hypercapnia	MCC	4.847	21896	mechanical ventilation (+1.37), icu (+1.10), relative claim charge (+0.76)
E870	Hyperosmolality and hypernatremia	CC	4.697	14343	relative claim charge (+0.98), length of stay (+0.82), mechanical ventilation (+0.76)
D6832	Hemorrhagic disorder due to extrinsic circulating anticoagulants	CC	4.426	1710	transfusion (+0.92), relative claim charge (+0.92), length of stay (+0.81)
J9690	Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia	MCC	4.376	2242	mechanical ventilation (+0.98), icu (+0.71), multiple or days (+0.60)

Tier 4 (n=12 codes)

code	Description	CMS severity	Score	N claims	Key drivers
K7200	Acute and subacute hepatic failure without coma	MCC	13.635	4022	mechanical ventilation (+3.43), relative claim charge (+2.23), icu (+1.56)
A419	Sepsis, unspecified organism	MCC	13.485	8614	mechanical ventilation (+2.66), relative claim charge (+2.11), n distinct rev codes (+1.44)
J690	Pneumonitis due to inhalation of food and vomit	MCC	11.457	10074	mechanical ventilation (+2.13), relative claim charge (+1.72), n distinct rev codes (+1.41)
D62	Acute posthemorrhagic anemia	CC	9.486	12561	transfusion (+2.37), relative claim charge (+1.54), n distinct rev codes (+1.30)
G928	Other toxic encephalopathy	No CC/MCC	9.415	9919	relative claim charge (+1.49), mechanical ventilation (+1.45), n imaging lines (+1.32)
N170	Acute kidney failure with tubular necrosis	MCC	9.285	15459	relative claim charge (+1.76), mechanical ventilation (+1.33), n distinct rev codes (+1.14)
G9349	Other encephalopathy	CC	7.913	2819	relative claim charge (+1.33), mechanical ventilation (+1.05), n imaging lines (+1.04)
I639	Cerebral infarction, unspecified	MCC	7.225	1730	n imaging lines (+2.58), n distinct rev codes (+1.16), relative claim charge (+1.01)
K7682	Hepatic encephalopathy	No CC/MCC	7.159	1799	relative claim charge (+1.20), or (+1.01), n distinct rev codes (+0.97)
G9341	Metabolic encephalopathy	MCC	6.878	34572	n imaging lines (+1.06), relative claim charge (+1.05), n distinct rev codes (+1.00)

Key Driver Frequency

feature	count	pct
relative claim charge	209	50.900
n distinct rev codes	191	46.500
length of stay	156	38.000
multiple or days	121	29.400
icu	116	28.200
or	113	27.500
n imaging lines	110	26.800
n j code lines	110	26.800
transfusion	36	8.800
mechanical ventilation	33	8.000
work rvu	19	4.600
dialysis	18	4.400
n distinct hcps	1	0.200

PCS Codes

Data Overview

3188 total codes in komodo_rii; 49 retained after n_claims > 500 filter.

PCA Analysis

PC1 explains 51.5% of variance; PC1+PC2 together explain 67.2%.

Tier Clustering (k=4)

Tier Summary

tier	n_codes	n_claims	length of stay	n distinct rev codes	relative claim charge	work rvu	n j code lines	mechanical ventilation	n imaging lines	organ system count
1	15.000	161389.000	6.275	15.888	1.225	0.399	0.468	0.017	0.585	4.770
2	20.000	179452.000	8.251	19.215	1.699	0.600	0.553	0.074	0.748	5.166
3	13.000	69796.000	10.906	21.274	2.529	0.981	0.841	0.288	0.910	5.259
4	1.000	1972.000	18.091	24.598	5.202	1.808	1.640	1.000	1.422	5.401

Feature Analysis

Feature Correlation

Feature Audit

	pc1_loading	r_with_volume
avg_relative_claim_charge	0.352	-0.255
avg_length_of_stay	0.341	-0.284
avg_n_distinct_rev_codes	0.339	-0.204
avg_n_imaging_lines	0.316	-0.367
avg_work_rvu	0.301	-0.237
rate_multiple_or_days	0.268	-0.167
rate_icu	0.264	0.012
avg_organ_system_count	0.259	-0.236
rate_mechanical_ventilation	0.241	-0.148
rate_or	0.239	-0.078
avg_n_j_code_lines	0.226	-0.188
rate_transfusion	0.174	-0.182
rate_dialysis	0.162	0.015
avg_n_distinct_hcps	0.153	-0.122

Top 6 Tier-Discriminating Features

Bottom 6 Tier-Discriminating Features

Score Validation

Top Codes by Tier

Tier 1 (n=15 codes)

code	Description	Score	N claims	Key drivers
5A09457	ASSISTANCE WITH RESPIRATORY VENTILATION, 24-96 CONSECUTIVE HOURS, CONTINUOUS POSITIVE AIRWAY PRESSURE	-1.979	11155	n imaging lines (-0.30), work rvu (-0.29), n distinct rev codes (-0.23)
0T9B70Z	DRAINAGE OF BLADDER WITH DRAINAGE DEVICE, VIA NATURAL OR ARTIFICIAL OPENING	-2.026	4089	n distinct rev codes (-0.44), work rvu (-0.34), multiple or days (-0.23)
B246ZZ4	ULTRASONOGRAPHY OF RIGHT AND LEFT HEART, TRANSESOPHAGEAL	-2.262	3567	organ system count (-0.47), n imaging lines (-0.27), length of stay (-0.24)
5A09357	ASSISTANCE WITH RESPIRATORY VENTILATION, LESS THAN 24 CONSECUTIVE HOURS, CONTINUOUS POSITIVE AIRWAY PRESSURE	-2.406	73681	n imaging lines (-0.34), n distinct rev codes (-0.31), length of stay (-0.31)
4B02XTZ	MEASUREMENT OF CARDIAC DEFIBRILLATOR, EXTERNAL APPROACH	-2.523	1713	n distinct rev codes (-0.50), relative claim charge (-0.34), n imaging lines (-0.34)
B24BZZ4	ULTRASONOGRAPHY OF HEART WITH AORTA, TRANSESOPHAGEAL	-2.574	8608	organ system count (-0.42), multiple or days (-0.32), n imaging lines (-0.29)
4A033R1	MEASUREMENT OF ARTERIAL SATURATION, PERIPHERAL, PERCUTANEOUS APPROACH	-2.694	2162	work rvu (-0.48), length of stay (-0.39), multiple or days (-0.34)
B24BZZZ	ULTRASONOGRAPHY OF HEART WITH AORTA	-3.077	12915	n distinct rev codes (-0.47), length of stay (-0.40), relative claim charge (-0.37)
5A2204Z	RESTORATION OF CARDIAC RHYTHM, SINGLE	-3.080	18153	organ system count (-0.58), n imaging lines (-0.43), length of stay (-0.32)
3E03329	INTRODUCTION OF OTHER ANTI-INFECTIVE INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH	-3.099	1972	work rvu (-0.45), multiple or days (-0.41), icu (-0.40)

Tier 2 (n=20 codes)

code	Description	Score	N claims	Key drivers
5A1935Z	RESPIRATORY VENTILATION, LESS THAN 24 CONSECUTIVE HOURS	1.326	2756	mechanical ventilation (+0.78), icu (+0.39), n imaging lines (+0.23)
0DJ08ZZ	INSPECTION OF UPPER INTESTINAL TRACT, VIA NATURAL OR ARTIFICIAL OPENING ENDOSCOPIC	1.113	3885	organ system count (+0.37), transfusion (+0.36), multiple or days (+0.33)
0DJD8ZZ	INSPECTION OF LOWER INTESTINAL TRACT, VIA NATURAL OR ARTIFICIAL OPENING ENDOSCOPIC	0.931	2314	multiple or days (+0.41), organ system count (+0.38), transfusion (+0.38)
0DB78ZX	EXCISION OF STOMACH, PYLORUS, VIA NATURAL OR ARTIFICIAL OPENING ENDOSCOPIC, DIAGNOSTIC	0.885	1973	n distinct rev codes (+0.38), organ system count (+0.37), transfusion (+0.29)
0DB98ZX	EXCISION OF DUODENUM, VIA NATURAL OR ARTIFICIAL OPENING ENDOSCOPIC, DIAGNOSTIC	0.356	1804	n distinct rev codes (+0.36), organ system count (+0.34), transfusion (+0.32)
0DB68ZX	EXCISION OF STOMACH, VIA NATURAL OR ARTIFICIAL OPENING ENDOSCOPIC, DIAGNOSTIC	0.307	3954	n distinct rev codes (+0.36), organ system count (+0.34), transfusion (+0.27)
05HB33Z	INSERTION OF INFUSION DEVICE INTO RIGHT BASILIC VEIN, PERCUTANEOUS APPROACH	0.267	1696	multiple or days (+0.30), n distinct hcps (-0.29), or (+0.21)
30233N1	TRANSFUSION OF NONAUTOLOGOUS RED BLOOD CELLS INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH	0.234	22190	transfusion (+0.73), organ system count (+0.23), n imaging lines (-0.17)
05HY33Z	INSERTION OF INFUSION DEVICE INTO UPPER VEIN, PERCUTANEOUS APPROACH	-0.109	3287	n distinct hcps (-0.32), multiple or days (+0.25), or (+0.16)
5A0945A	ASSISTANCE WITH RESPIRATORY VENTILATION, 24-96 CONSECUTIVE HOURS, HIGH NASAL FLOW/VELOCITY	-0.197	4098	icu (+0.27), or (-0.19), n j code lines (+0.13)

Tier 3 (n=13 codes)

code	Description	Score	N claims	Key drivers
0BH17EZ	INSERTION OF ENDOTRACHEAL AIRWAY INTO TRACHEA, VIA NATURAL OR ARTIFICIAL OPENING	4.158	7377	n imaging lines (+0.67), mechanical ventilation (+0.66), relative claim charge (+0.61)
5A1945Z	RESPIRATORY VENTILATION, 24-96 CONSECUTIVE HOURS	4.135	3912	mechanical ventilation (+0.78), n imaging lines (+0.62), icu (+0.60)
03HY32Z	INSERTION OF MONITORING DEVICE INTO UPPER ARTERY, PERCUTANEOUS APPROACH	3.965	3802	work rvu (+0.75), icu (+0.51), relative claim charge (+0.50)
3E043XZ	INTRODUCTION OF VASOPRESSOR INTO CENTRAL VEIN, PERCUTANEOUS APPROACH	3.245	2403	icu (+0.50), work rvu (+0.46), n j code lines (+0.39)
02H633Z	INSERTION OF INFUSION DEVICE INTO RIGHT ATRIUM, PERCUTANEOUS APPROACH	2.980	5460	length of stay (+0.50), dialysis (+0.49), n distinct rev codes (+0.49)
0JH63XZ	INSERTION OF TUNNELED VASCULAR ACCESS DEVICE INTO CHEST SUBCUTANEOUS TISSUE AND FASCIA, PERCUTANEOUS APPROACH	2.869	10143	dialysis (+0.54), or (+0.52), n distinct rev codes (+0.49)
B548ZZA	ULTRASONOGRAPHY OF SUPERIOR VENA CAVA, GUIDANCE	2.608	2811	length of stay (+0.42), relative claim charge (+0.35), n distinct rev codes (+0.34)
02HV33Z	INSERTION OF INFUSION DEVICE INTO SUPERIOR VENA CAVA, PERCUTANEOUS APPROACH	2.538	20686	length of stay (+0.37), or (+0.31), n distinct rev codes (+0.31)
0W9930Z	DRAINAGE OF RIGHT PLEURAL CAVITY WITH DRAINAGE DEVICE, PERCUTANEOUS APPROACH	2.375	3313	multiple or days (+0.80), n imaging lines (+0.39), or (+0.32)
05HM33Z	INSERTION OF INFUSION DEVICE INTO RIGHT INTERNAL JUGULAR VEIN, PERCUTANEOUS APPROACH	2.289	2149	n distinct rev codes (+0.41), length of stay (+0.38), dialysis (+0.35)

Tier 4 (n=1 codes)

code	Description	Score	N claims	Key drivers
5A1955Z	RESPIRATORY VENTILATION, GREATER THAN 96 CONSECUTIVE HOURS	9.360	1972	relative claim charge (+1.60), length of stay (+1.34), n imaging lines (+1.11)

Key Driver Frequency

feature	count	pct
n distinct rev codes	20	40.800
length of stay	17	34.700
n imaging lines	16	32.700
work rvu	14	28.600
or	13	26.500
organ system count	12	24.500
multiple or days	11	22.400
icu	11	22.400
relative claim charge	9	18.400
n j code lines	8	16.300
transfusion	6	12.200
mechanical ventilation	4	8.200
dialysis	4	8.200
n distinct hcps	2	4.100