OP - DE.0.breast_biopsy

CM Codes

Data Overview

4131 total codes in komodo_rii; 80 retained after n_claims > 500 filter.

CMS severity	n codes
No CC/MCC	79
CC	1

PCA Analysis

PC1 explains 33.0% of variance; PC1+PC2 together explain 51.8%.

Tier Clustering (k=4)

Tier Summary

tier	n_codes	n_claims	organ system count	n j code lines	n distinct rev codes	work rvu	relative claim charge	or	n distinct hcps	n imaging lines
1	36.000	617341.000	1.377	0.358	4.412	5.995	1.015	0.618	0.768	0.016
2	30.000	173804.000	1.495	0.417	4.738	7.163	1.198	0.656	0.776	0.024
3	12.000	25938.000	3.094	1.127	5.230	6.546	1.220	0.720	0.745	0.015
4	2.000	2257.000	3.989	2.058	5.710	6.344	1.288	0.756	0.709	0.013

CMS Severity × intensity Tier

cms_severity	Tier 1	Tier 2	Tier 3	Tier 4	All
CC	0	0	1	0	1
No CC/MCC	36	30	11	2	79
All	36	30	12	2	80

Feature Analysis

Feature Correlation

Feature Audit

	pc1_loading	r_with_volume	r_with_severity
avg_n_distinct_rev_codes	0.509	-0.617	0.139
avg_organ_system_count	0.440	-0.492	0.017
avg_n_j_code_lines	0.434	-0.364	-0.066
rate_or	0.412	-0.506	0.129
avg_relative_claim_charge	0.334	-0.417	0.192
avg_work_rvu	0.153	-0.310	0.192
rate_icu	0.022	0.069	-0.018
avg_length_of_stay	0.000	nan	nan
rate_mechanical_ventilation	0.000	nan	nan
rate_multiple_or_days	0.000	nan	nan
avg_n_imaging_lines	-0.005	-0.039	-0.012
rate_dialysis	-0.074	0.250	-0.022
rate_transfusion	-0.119	0.485	-0.106
avg_n_distinct_hcps	-0.185	0.238	0.027

Top 6 Tier-Discriminating Features

Bottom 6 Tier-Discriminating Features

Score Validation

Misclassification Audit (N=10 samples)

Over-tiered: Tier 4, No CC/MCC (2 codes)

code	code_description	cms_severity	intensity_score	tier	n_claims	key_drivers
E669	Obesity, unspecified	No CC/MCC	6.639	4	618	n j code lines (+2.05), n distinct rev codes (+1.71), organ system count (+1.09)
K219	Gastro-esophageal reflux disease without esophagitis	No CC/MCC	5.408	4	1639	organ system count (+1.39), n distinct rev codes (+1.37), or (+1.21)

Under-tiered: Tier 1, MCC (0 codes)

None.

Top Codes by Tier

Tier 1 (n=36 codes)

code	Description	CMS severity	Score	N claims	Key drivers
N610	Mastitis without abscess	No CC/MCC	-0.961	6873	relative claim charge (-0.33), organ system count (-0.26), n distinct rev codes (-0.23)
N644	Mastodynia	No CC/MCC	-0.979	2661	or (-0.24), transfusion (-0.24), relative claim charge (-0.19)
N641	Fat necrosis of breast	No CC/MCC	-1.049	16465	relative claim charge (-0.34), organ system count (-0.20), n distinct rev codes (-0.19)
D241	Benign neoplasm of right breast	No CC/MCC	-1.123	52480	n distinct rev codes (-0.40), relative claim charge (-0.39), n j code lines (-0.19)
D242	Benign neoplasm of left breast	No CC/MCC	-1.135	52487	n distinct rev codes (-0.39), relative claim charge (-0.38), n j code lines (-0.19)
N62	Hypertrophy of breast	No CC/MCC	-1.176	24288	n distinct rev codes (-0.47), relative claim charge (-0.28), organ system count (-0.19)
N6081	Other benign mammary dysplasias of right breast	No CC/MCC	-1.290	18607	or (-0.30), relative claim charge (-0.26), organ system count (-0.22)
N6011	Diffuse cystic mastopathy of right breast	No CC/MCC	-1.314	23823	n distinct rev codes (-0.48), relative claim charge (-0.27), organ system count (-0.25)
N6082	Other benign mammary dysplasias of left breast	No CC/MCC	-1.323	19068	or (-0.30), n distinct rev codes (-0.24), relative claim charge (-0.22)
N649	Disorder of breast, unspecified	No CC/MCC	-1.374	3727	n distinct hcps (-0.48), n distinct rev codes (-0.38), relative claim charge (-0.30)

Tier 2 (n=30 codes)

code	Description	CMS severity	Score	N claims	Key drivers
C50012	Malignant neoplasm of nipple and areola, left female breast	No CC/MCC	1.253	645	relative claim charge (+0.53), n distinct hcps (+0.34), work rvu (+0.23)
C50011	Malignant neoplasm of nipple and areola, right female breast	No CC/MCC	0.842	634	n distinct hcps (+0.39), relative claim charge (+0.33), work rvu (+0.24)
C50112	Malignant neoplasm of central portion of left female breast	No CC/MCC	0.773	1296	relative claim charge (+0.32), n distinct rev codes (+0.31), work rvu (+0.19)
C50811	Malignant neoplasm of overlapping sites of right female breast	No CC/MCC	0.648	12457	relative claim charge (+0.44), n j code lines (-0.24), work rvu (+0.24)
C50111	Malignant neoplasm of central portion of right female breast	No CC/MCC	0.577	1304	relative claim charge (+0.41), n distinct rev codes (+0.37), work rvu (+0.24)
C50812	Malignant neoplasm of overlapping sites of left female breast	No CC/MCC	0.551	12478	relative claim charge (+0.43), work rvu (+0.24), n j code lines (-0.23)
C50211	Malignant neoplasm of upper-inner quadrant of right female breast	No CC/MCC	0.517	5913	relative claim charge (+0.32), n j code lines (-0.22), n distinct rev codes (+0.20)
C50312	Malignant neoplasm of lower-inner quadrant of left female breast	No CC/MCC	0.460	2742	relative claim charge (+0.28), n j code lines (-0.21), work rvu (+0.17)
C50212	Malignant neoplasm of upper-inner quadrant of left female breast	No CC/MCC	0.454	6537	relative claim charge (+0.34), n j code lines (-0.24), work rvu (+0.20)
C50411	Malignant neoplasm of upper-outer quadrant of right female breast	No CC/MCC	0.452	15999	relative claim charge (+0.38), n j code lines (-0.21), work rvu (+0.21)

Tier 3 (n=12 codes)

code	Description	CMS severity	Score	N claims	Key drivers
E785	Hyperlipidemia, unspecified	No CC/MCC	4.253	2005	organ system count (+1.14), n distinct rev codes (+1.04), or (+0.78)
E119	Type 2 diabetes mellitus without complications	No CC/MCC	3.838	1967	n distinct rev codes (+1.00), organ system count (+0.94), or (+0.87)
F419	Anxiety disorder, unspecified	No CC/MCC	3.600	917	organ system count (+1.16), n j code lines (+1.02), n distinct rev codes (+0.66)
F32A	Depression, unspecified	No CC/MCC	3.576	613	organ system count (+1.25), n j code lines (+0.94), n distinct rev codes (+0.75)
F17210	Nicotine dependence, cigarettes, uncomplicated	No CC/MCC	3.370	1073	organ system count (+0.87), n j code lines (+0.84), n distinct rev codes (+0.79)
I10	Essential (primary) hypertension	No CC/MCC	3.264	5620	organ system count (+0.95), n distinct rev codes (+0.78), or (+0.77)
J45909	Unspecified asthma, uncomplicated	No CC/MCC	3.201	926	organ system count (+1.12), n j code lines (+1.01), n distinct rev codes (+0.85)
E7800	Pure hypercholesterolemia, unspecified	No CC/MCC	3.196	1000	organ system count (+1.06), or (+0.81), n distinct rev codes (+0.71)
C773	Secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes	CC	2.910	8277	relative claim charge (+1.50), n distinct rev codes (+0.70), work rvu (+0.66)
D360	Benign neoplasm of lymph nodes	No CC/MCC	2.432	768	or (+1.49), n distinct rev codes (+0.98), relative claim charge (+0.64)

Tier 4 (n=2 codes)

code	Description	CMS severity	Score	N claims	Key drivers
E669	Obesity, unspecified	No CC/MCC	6.639	618	n j code lines (+2.05), n distinct rev codes (+1.71), organ system count (+1.09)
K219	Gastro-esophageal reflux disease without esophagitis	No CC/MCC	5.408	1639	organ system count (+1.39), n distinct rev codes (+1.37), or (+1.21)

Key Driver Frequency

feature	count	pct
n distinct rev codes	59	73.800
relative claim charge	49	61.300
n j code lines	37	46.200
or	35	43.800
organ system count	26	32.500
work rvu	19	23.800
n distinct hcps	9	11.200
transfusion	4	5.000
dialysis	2	2.500