The members included in this report had to have a CPT code from 10000-69999, and had to be readmitted to any hospital within 30 days after discharged from having surgery.   If a patient was readmitted more than once during the 30 days, it counts as a single complication.  This report allows the user to identify the complication types from surgical procedures that occur within their population. Additionally, the user can drill down by Specialty and by Specialist to the level of an individual Member/Patient and their corresponding complications.

 

 

Target Audience for this Report 

Chief Medical Officer, Compliance & Regulatory Department, Finance Department and CFO, Leadership Team, Medical management/Care Management Department, Physician Relations, and Quality Management.

 

Business Processes Impacted by this Report

For health plans with Medicaid and/or Medicare Advantage products the Complications report informs government reports and impacts reimbursement of hospitals.

 

As a quality indicator the report must be linked to health plan quality reports shared internally and with the network hospitals.  Performance improvement initiatives will incorporate this report to develop strategies for improvement.

 

Network development will use the report to determine inclusion/exclusion of hospitals or to create preferred status for hospitals who have low complication rates.

 

Detail and Definitions

The complication rate calculation; numerator is the total set of member with the complication flag set, divided by member months (in the selection criteria).  This report utilizes the CMS List of Potentially Preventable Complications Groups (PPCs).  This list is available in Appendix C.  

 

Header

  • Complication Claims
  • Patients w/Complications
  • Potential Savings
  • Complication Prev. Rate

 

Trending Graphs

 

 

Period By Period Trend – Complication Rate

  • Complication Rate
  • Trend Period

 

Period Over Period Trend – Complication Rate

  • Complication Rate
  • Trend Period

 

Complication Type

  • Complication Type
  • Cases
  • % Cases

 

Complications by Provider Specialty

  • Specialty
  • Patients
  • Avg Risk
  • Paid

 

Complications by Provider

  • Provider
  • Patients
  • Avg Risk
  • Paid
  • Complication Rate

 

Member Detail

  • Member Number
  • Member Name
  • Service Date
  • Complication Type
  • Diagnosis