Health systems need to be able to count volumes across care settings to make informed planning and investment decisions. On the inpatient side, that’s easy: one encounter equals one claim and one MS-DRG code. However, outpatient volumes are more challenging. A single encounter can generate multiple claims, each with multiple procedure codes. Counting claims or codes in the outpatient setting results in overcounting and masks the total value of an encounter.

To address these challenges, we created our proprietary Outpatient Claims Grouper to retrospectively count coded encounters. The Grouper condenses an array of codes and descriptions into single, high-level procedure groups, subservice, and service lines. This tool utilizes a grouping algorithm designed to count each patient visit once, regardless of the number of services received, and categorizes it under the most clinically significant procedure in documentation for the visit.