Data contents in claims data

[m-bellaiche]

Hi!

I wanted to ask two questions regarding the contents of the Claim and ExplanationOfBenefit resources available in the 1k patient sample R4 dump from the Synthea downloads page.

Q1: Are there coded diagnosis and procedure information available?
I can't seem to find coded representations of the diagnoses or procedures associated with these resources, which I would expect to live in the diagnosis.diagnosis and procedure.procedure codeableConcept fields for both resources.

For Claim:

• I can see Claim.diagnosis.sequence and Claim.procedure.sequence populated for some resources (~10% and ~35% respectively), but no information beyond that.
• Claim.item.xSequence is populated for both x=diagnosis and procedure, making reference to those array entries.

For ExplanationOfBenefit:

• I see ExplanationOfBenefit.diagnosis.sequence or ExplanationOfBenefit.diagnosis.type populated for some (~15%) resources, but no ICD codes or any of the procedure fields.
• ExplanationOfBenefit.item.diagnosisSequence is populated

Q2: Are there explanation of benefits (EOB) available for corresponding pharmacy claims?
There are ~61k Claim resources vs ~47k ExplanationOfBenefits resources. As far as I can tell, none of the pharmacy claims have an associated EOB, all institutional claims have an associated EOB. Conversely, all EOB's refer to medical care.

Thank you!

[jawalonoski]

The download you linked to is from September 2019. We probably should update the Downloads because things have changed since then, although not much (if any) for FHIR Claims/EOB in particular.

FHIR Claim

Q1: Are there coded diagnosis and procedure information available?

Yes.

The way our code works:

• Claim.diagnosis is only populated if there is a new Condition diagnosed during the Encounter.
• Claim.procedure is only populated if there is a Procedure performed within the Encounter.
• The "coded" information is either in the resources referenced by Claim.diagnosis or Claim.procedure (within the same patient Bundle), or is captured in the Claim.item[x].productOrService.coding.
• If none of these are coded, the claim is for the Encounter code... no billable procedures were performed other than the visit itself (which is billable), and no new diagnosis was made.
• Sometimes an Encounter can have a reasonCode which could be a new diagnosis or an old diagnosis.
• All medications are in separate claims. For medications/pharmacy claims, find Claim.type.coding[x].code == 'pharmacy'. The medication prescribed is linked by reference within Claim.prescription.reference to another resource within the Bundle, where you can get the RxNorm code.
• If you want to find the diagnosed Condition related to the prescription, you have to follow that Claim.prescription.reference link and then follow the MedicationRequest.reasonReference.

FHIR ExplanationOfBenefit

Q2: Are there explanation of benefits (EOB) available for corresponding pharmacy claims?

No. An ExplanationOfBenefit is only generated for "encounter claims" and not "medication claims." I'm not sure the reasoning behind that -- it could be an oversight.

"... but no ICD codes or any of the procedure fields."

Synthea does not use ICD codes. Synthea mostly uses RxNorm, LOINC, and SNOMED.