HCC Suspecting

Overview

Code

The HCC Suspecting data mart identifies patients who are suspected to have an HCC in the payment year but don't presently have one recorded based concepts that evaluate historical conditions and problems, comorbidities, lab test results, medications, and observations.

The 2024 CMS HCC model has 115 HCCs. Each condition category requires logic to identify suspecting conditions. So far, we have built out the logic for the following conditions:

• Chronic Kidney Disease
  • 326, "Chronic Kidney Disease, Stage 5"
  • 327, "Chronic Kidney Disease, Severe (Stage 4)"
  • 328, "Chronic Kidney Disease, Moderate (Stage 3B)"
  • 329, "Chronic Kidney Disease, Moderate (Stage 3, Except 3B)"
• Depression
  • 155, "Major Depression, Moderate or Severe, without Psychosis"
• Diabetes
  • 37, "Diabetes with Chronic Complications"
• Morbid Obesity
  • 48, "Morbid Obesity"

The terminology set SNOMED-CT to ICD-10-CM Map is used to capture additional suspecting conditions coded in a system not part of the CMS HCC model. This use case follows the default mapping guidance from NLM, which specifies that the map priority rule of “TRUE” or “OTHERWISE TRUE” should be applied if nothing further is known about the patient’s condition.

Instructions

Data Requirements

This data mart uses the following tables from the Tuva Core Data Model:

• condition
• lab_result
• medication
• observation
• patient
• pharmacy_claim

Check out the DAG to see the list of fields used from each core table.

Note: The Tuva Project will generate these Core tables. You just need to map your data to the input layer and run the project.

dbt Examples

# Runs all marts
dbt build

# Runs only the HCC Suspecting mart
dbt build --select tag:hcc_suspecting

Data Dictionary

list

This final model displays the list of suspecting conditions per patient with the reason and contributing factors.

Column	Data Type	Description	Terminology

list_rollup

This final model displays the list of suspecting conditions per patient and hcc with the latest contributing factor rolled up.

Column	Data Type	Description	Terminology

summary

This final model displays a rollup of suspecting conditions per patient.

Column	Data Type	Description	Terminology

Analytics

Total Suspected HCCs

select
      hcc_code
    , hcc_description
    , count(*) as gap_count
from hcc_suspecting.list
group by
      hcc_code
    , hcc_description
order by
      hcc_code
    , hcc_description;

Total Suspected HCCs by Reason Category

select
      reason
    , count(*) as gap_count
from hcc_suspecting.list
group by reason
order by reason;

Actionable Patient List

select
      patient_id
    , patient_birth_date
    , patient_age
    , patient_sex
    , suspecting_gaps
from hcc_suspecting.summary
order by suspecting_gaps desc;