Diagnosis
OHI applications store diagnoses in a two layer structure, i.e., a diagnosis record and one or more diagnosis setting records. The reason is that the properties of a diagnosis may change over time. However, from a set up point of view, it is still the same diagnosis. Having the two layers precludes the configuration users from having to update / add diagnosis codes to the configuration that relies on the diagnosis codes (e.g. benefit specifications) every time a diagnosis property changes.
Diagnosis
A Diagnosis has the following attributes:
Diagnosis
Field |
Description |
Code |
The code for this diagnosis |
Description |
The description of the diagnosis |
Flex Code Definition Code |
The definition to which the diagnosis belongs. |
Start Date |
The first day that this diagnosis can be used |
End Date |
The last day that this diagnosis can be used |
Display Access Restriction |
The access restriction on this diagnosis. See the chapter on data access restriction features in the user access implementation guide. |
The flex code definition code is the qualifier of the diagnosis code. The available definitions can be part of the seeded configuration or can be setup by a configuration user. An example: a diagnosis with the code '780.1', the description 'Hallucinations' and the definition 'ICD-09D'
The combination of a diagnosis code and flex code definition is unique. The start date is not part of this unique key: it is not possible to have two diagnoses with the same code and definition, even if they are specified for different non-overlapping periods in time. The start and end data represent a condition on the usage of the diagnosis. For example, a claim line can only refer to a diagnosis if the service date is between the diagnosis start and end date.
Even though there can exist only a single combination of code and definition for a diagnosis record, the attributes of the diagnosis may change over time. For this reason all attributes (with the exception of the description) are stored in a detail entity named diagnosis setting. A diagnosis setting has the following attributes:
Diagnosis Setting
Field |
Description |
Diagnosis |
The diagnosis to which this setting belongs |
Start Date |
The first day that this is setting is valid |
End Date |
The last day that this setting is valid. If not specified, this setting is valid indefinitely as of the specified start date. |
A diagnosis setting record does not have any fixed attributes; its purpose is to allow the diagnosis to be extended with dynamic fields, such as an age indicator or a diagnostic category.
The start and end date on a diagnosis setting record are bounded by the start and end data on the diagnosis. Exactly one diagnosis setting must be time valid on each day between the start and end date of the diagnosis.
When another record refers to a diagnosis, like a claim or claim line, the reference is always to a diagnosis record; not to the setting. This makes it possible to change the attributes of a diagnosis over time, without breaking referential integrity or creating overhead setup maintenance.
Diagnosis Group
A diagnosis group represents a number of bundled diagnosis. The purpose of a diagnosis group is to support re-usability in the context of benefit and adjudication related setup. A diagnosis group has the following attributes:
Diagnosis Group
Field |
Description |
Code |
The unique code for this group. |
Description |
The description for this group |
The diagnosis group detail keeps track of which diagnosis belongs to which diagnosis group at which period in time. Diagnosis group details can specify a single diagnosis, a fixed diagnosis range or a free format diagnosis range:
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Single diagnosis . Specifying a single diagnosis means that that diagnosis is part of the diagnosis group.
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Fixed diagnosis range. A range can be specified by specifying a start diagnosis and an end diagnosis of the same diagnosis definition. This means both the start and the end diagnosis are part of the diagnosis group, as well as any other diagnosis with the same diagnosis definition and a code greater than the code of start diagnosis and smaller than the code of the end diagnosis [1] for details on how ranges work.].
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Free format diagnosis range. A free format range can be specified by the combination of a start range, an end range and a reference to a flex code definition code.
Diagnosis Group Detail
Field |
Description |
Diagnosis Group |
The Diagnosis Group to which the specified diagnosis belongs. |
Diagnosis |
The diagnosis that belongs to the specified group. This diagnosis is the start diagnosis of the diagnosis range if an end range diagnosis is also specified. |
End Range Diagnosis |
The last diagnosis in the diagnosis range that belongs to the specified group. If not specified, only the specified (start) diagnosis is part of the specified group. |
Start Range |
The start of the free format diagnosis range |
End Range |
The end of the free format diagnosis range |
Flex Code Definition |
The flex code definition for the free format diagnosis range |
Start Date |
The first day that the diagnosis belongs to the diagnosis group. |
End Date |
The last day that the diagnosis belongs to the diagnosis group. |
Notes:
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The time validity of a diagnosis group detail must lie within the time validity of a diagnosis, to preclude the possibility of illogical configuration. An update of the end date of a diagnosis automatically leads to an update of a diagnosis group detail for that diagnosis, if, and only if, not updating would lead to violation of the business rule.
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The code of the "End Range Diagnosis" must be greater than the code of the (start) "Diagnosis". Otherwise, an invalid range would be specified.
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The value of the "End Range" must be greater than the value of the "Start Range". Otherwise, an invalid range would be specified.
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Either free format style is used within a single record or fixed style, but not a hybrid combination.