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Version: 2.1

Komodo Benchmarks

Documentation on the logic used in the creation of these tables exists here:

Allowed Amount Benchmark tables used:

  • hive.claims_benchmarks.claims_benchmarks_allowable_npi_payer
  • hive.claims_benchmarks.claims_benchmarking_allowable_cbsa_payer
  • hive.claims_benchmarks.claims_benchmarks_allowable_zip3_payer
  • hive.claims_benchmarks.claims_benchmarks_allowable_state_payer

These tables show aggregate allowed amounts at the various geographies, split by provider taxonomy or NPI. They allow us to pull the median_allowed_amount for any given service, provided there is enough encounter volume to support the benchmark. A minimum threshold of 11 encounters has been placed on this data set - meaning no Provider/geo <> Payer <> Code is displayed in the table unless supported by at least 11 encounters.

These tables also split by cases where a given billing_code is "primary" on a claim (is the code with the highest Medicare allowable on its claim) or "secondary" (there is another code on the claim with a higher Medicare allowable). It also shows all aggregates at the 'line_item' level (median_allowed_amount for an individual code) and 'claim' level (shows the total allowed amount on the claim when a given code is billed).

From here, we derive the median_allowed_amount_primary_line_item, median_allowed_amount_secondary_line_item, median_allowed_amount_primary_claim, and median_allowed_amount_secondary_claim for each code.

Code where this logic is implemented can be found here.

This is later used in the validation of rates from Payer and Hospital MRFs, or imputation of rates that may not exist in MRFs.

Utilization Benchmark tables used:

  • hive.claims_benchmarks.claims_benchmarks_utilization_national

This table is used for the calculation of Revenue in the creation of the CLD:

  • When calculating the "top" HCPCS to include in the final product, we find the top 5000 HCPCS by "revenue". Which is calculating by multiplying the number of encounters a code was found in by its Medicare Payment rate. Finally, any codes with an OPPS J1 status indicator are included, for a total of ~5,5000 HCPCS.

Code where this logic is implemented can be found here.

Note: The source of truth for these tables will soon be in the tq_production.claims_benchmarks schema. Once ready, should update SQL to pull from here.