Episodes of Care Definitions

What is a Hip Replacement Episode? Back to the Top

The Hip Replacement episode includes all covered services across all providers related to the procedure of a hip replacement or hip revision surgery. The procedure could be performed in a hospital or in an outpatient facility, and includes all investigations done prior to the surgery, services related to the procedure itself, and those that are provided after the surgery, and for a certain period of time after the patient has been discharged from the hospital / outpatient facility.

Who is included in a Hip Replacement episode? Back to the Top

Patients who have a claim for at least one of these three types of service:

A patient has a hospital admission for a Hip Replacement
A patient has an outpatient facility admission for a Hip Replacement
A patient has a professional service indicating that a Hip Replacement has been performed

What is a Vaginal Delivery Episode? Back to the Top

The Vaginal Delivery episode includes all covered services across all providers related to the birth of a baby normally. The birth may occur in the hospital or in a birthing center. Services included are those that are provided during the delivery of a baby and up to a certain period of time after the mother leaves the hospital/ birthing center.

Who is included in a Vaginal Delivery episode? Back to the Top

Patients who have a medical claim for at least one of these three types of service:

A patient has a hospital admission for a Vaginal Delivery
A patient has an outpatient facility service for a Vaginal Delivery
A patient has a professional service for a Vaginal Delivery

What is a Hysterectomy Episode? Back to the Top

The Hysterectomy episode includes all covered services across all providers related to the procedure of hysterectomy. The procedure could be performed in a hospital or in an outpatient facility, and includes all investigations done prior to the surgery, services related to the procedure itself, and those that are provided after the surgery, and for a certain period of time after the patient has been discharged from the hospital / outpatient facility.

Who is included in a Hysterectomy episode? Back to the Top

Patients who have a medical claim for at least one of these three types of service:

A patient has a hospital admission for a Hysterectomy
A patient has an outpatient facility admission for a Hysterectomy
A patient has a professional service indicating that a Hysterectomy has been performed

What is a Knee Replacement Episode? Back to the Top

The Knee Replacement episode includes all services related to that medical need, including the surgery or procedure, anesthesia, lab tests, radiology, and all relevant pharmacy services such as antibiotics or pain medicines. The procedure could be performed in a hospital or in an outpatient facility. Other services may include all investigations done prior to the surgery, services related to the procedure itself, services provided after the surgery, and any follow-up services for a certain period of time after the patient was discharged.

Who is included in a Knee Replacement Episode? Back to the Top

Patients who have a medical claim for at least one of these three types of service:

A patient has a hospital admission for a Knee Replacement
A patient has an outpatient facility admission for a Knee Replacement
A patient has a professional service indicating that a Knee Replacement has been performed

What is a Bariatric Surgery Episode? Back to the Top

The Bariatric Surgery episode includes services related to the procedure such as a facility stay, anesthesia services, as well as services within the 30-day pre- and 90-day post-operative care time window, such as diagnostic services, (imaging, labs etc.), office visits, and ancillary services.

Who is Included in a Bariatric Surgery Episode? Back to the Top

Patients who have a medical claim for at least one of these three types of service:

A patient has a hospital admission for a Bariatric Surgery
A patient has an outpatient facility admission for a Bariatric Surgery
A patient has a professional service indicating that a Bariatric Surgery has been performed

What is a Colon Resection Episode? Back to the Top

The Colon Resection episode includes services related to the procedure such as a facility stay, anesthesia services, as well as services within the 30-day pre- and 90-day post-operative care time window, such as diagnostic services, (imaging, labs etc.), office visits and ancillary services.

Who is Included in a Colon Resection Episode? Back to the Top

Patients who have a medical claim for at least one of these three types of service:

A patient has a hospital admission for a Colon Resection
A patient has an outpatient facility admission for a Colon Resection
A patient has a professional service indicating that a Colon Resection has been performed

What is a Cesarean Section Episode? Back to the Top

The Cesarean Section episode includes services related to the procedure such as a facility stay, anesthesia services, as well as services within the 3-day pre- and 60-day post-operative care time window, such as diagnostic services, (imaging, labs etc.), office visits and ancillary services.

Who is Included in a Cesarean Section Episode? Back to the Top

Patients who have a medical claim for at least one of these three types of service:

A patient has a hospital admission for a Cesarean Section
A patient has an outpatient facility admission for a Cesarean Section
A patient has a professional service indicating that a Cesarean Section has been performed

What is a Gall Bladder Surgery Episode? Back to the Top

The Gall Bladder Surgery episode includes services related to the procedure such as a facility stay, anesthesia services, as well as services within the 30-day pre- and 90-day post-operative care time window, such as diagnostic services, (imaging, labs etc.), office visits and ancillary services.

Who is Included in a Gall Bladder Surgery Episode? Back to the Top

Patients who have a medical claim for at least one of these three types of service:

A patient has a hospital admission for a Gall Bladder
A patient has an outpatient facility admission for a Gall Bladder
A patient has a professional service indicating that a Gall Bladder has been performed

What is a Lumbar Laminectomy Episode? Back to the Top

The Lumbar Laminectomy Episode includes services related to the procedure such as a facility stay, anesthesia services, as well as services within the 30-day pre- and 90-day post-operative care time window, such as diagnostic services, (imaging, labs etc.), office visits and ancillary services.

Who is Included in a Lumbar Laminectomy Episode? Back to the Top

Patients who have a medical claim for at least one of these three types of service:

A patient has a hospital admission for a Lumbar Laminectomy
A patient has an outpatient facility admission for a Lumbar Laminectomy
A patient has a professional service indicating that a Lumbar Laminectomy has been performed

What is a Lumbar Spine Fusion Episode? Back to the Top

The Lumbar Spine Fusion Episode includes services related to the procedure such as a facility stay, anesthesia services, as well as services within the 30-day pre- and 90-day post-operative care time window, such as diagnostic services, (imaging, labs etc.), office visits and ancillary services.

Who is Included in a Lumbar Spine Fusion Episode? Back to the Top

Patients who have a medical claim for at least one of these three types of service:

A patient has a hospital admission for a Lumbar Laminectomy
A patient has an outpatient facility admission for a Lumbar Laminectomy
A patient has a professional service indicating that a Lumbar Laminectomy has been performed