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Version: 2.4

1. Inclusion Criteria

1a. CLD Spines​

The first step in the pipeline is to define the scope and gather the ingredients.

For example:

  1. What payers, networks, providers, codes are included?
  2. What are the entities unique IDs?
  3. What are their names?

The relevant code is here

warning

This section is somewhat temporary and will evolve as we make more progress in TQ spines.

In a future state, this step will focus solely on inclusion criteria and not "definining" or "naming" entities. As an example, as of 7/13/2025, there is no "network spine" and so Clear Rates creates a network_id field in this step. Unlike payer_id, which is used universally across TQ's data, network_id is unique to Clear Rates.

1b. Rate Object Space​

After collecting our ingredients (spines), we prepare all the possible combinations that can have a rate.

We get all combinations of payer, network, provider, and clinically plausible code.

The relevant code is here

Data Source Inclusion Criteria​

Hospital MRF Data​

Source: glue.hospital_data.hospital_rates

Payer MRF Data​

Source: Core Rates and Core Rates Physician Groups

Komodo Claims Data​

Source: External Komodo medical service lines

Included:

  • Claims data for validation and benchmarking
  • Used for code selection (top procedures by revenue)
  • Provider group identification and revenue analysis

Provider Inclusion Criteria​

Included Provider Types:​

  • All Hospitals (Short-term acute care, children's, etc.)
  • Ambulatory Surgery Centers (ASCs)
  • Laboratories
  • Physician Groups

We use provider spines to identify providers. "Closed" or "Possible" providers are excluded based on their status.

Code Selection Criteria​

CLD includes codes across multiple bill types and settings based on revenue analysis and clinical relevance. The selection logic is implemented in code spines.

Included Billing Codes:​

Inpatient:

  • All MS-DRG codes (excluding specific transplant, ECMO, and CAR-T codes: 001-019, 650-652)
  • All APR-DRG codes with severity of illness suffixes (-1, -2, -3, -4)
  • Excludes high-cost transplant and specialty codes (0001, 0002, 0004-0009, 0011, 0161, 0440)

Outpatient HCPCS:

  • Medicare payable HCPCS codes ranked by revenue (encounters × OPPS payment rate)
  • Codes starting with numbers 0-9 that have OPPS payment rates
  • Manual additions: High-priority codes (29826, 22558, 43775, 43644, 27487, 43845)
  • J1 HCPCS codes (status indicator J1 from OPPS)
  • SSP codes from specific package IDs with facility and optional fees

Drug Primary Rates (Life Sciences):

  • ASP-priced drugs: All codes in Medicare ASP pricing table
  • OPPS status G/K drugs: Codes with status indicators G or K and non-null rates
  • Drug names and therapeutic areas included where available

Professional Fees:

  • Physician Group codes: From curated codeset table, both facility and non-facility settings
  • Laboratory codes: Top 750 codes by revenue for clinical/physiological labs
  • Based on Clinical Lab Fee Schedule rates and Komodo claims volume

Special Categories:​

Surgical Codes Identification:

  • HCPCS codes starting with 1-6 automatically flagged as surgical
  • Codes appearing in OPG schedules (United, Aetna, Cigna, BCBS CA)
  • MS-DRGs marked as 'SURG' type in CMS weight tables

Drug Code Identification:

  • Codes appearing in ASP pricing OR OPPS status G/K
  • Therapeutic area classification applied where available
  • Drug names from CMV crosswalk and ASP-HCPCS mapping
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