Admission – The formal acceptance by a hospital or other inpatient health care facility of a patient who is to be provided with room, board, and continuous nursing service in an area of the hospital or facility where patients generally reside at least overnight. Based off of inpatient claim type. Hospital admissions are defined by place of service code “21”, and admission types in general are defined by the CMS place of service code table. 

Admits/1000 – The calculation is the sum of inpatient admissions for a specific period of time, divided by the total number of covered members in that same period, and multiplied by 1000. 

ALOS –Average length of stay (ALOS) is computed by dividing the total number of inpatient days, counted from the date of admission to the date of discharge by the total number of discharges (including deaths) in all hospitals during a given period of time. A patient admitted and discharged on the same day has a length of stay = 0. These patients are not counted as admissions and are considered as Observation Visits. 

Avoidable ER% - QualMetrix uses the NYU Algorithm (Algorithm) to determine whether or not an ER visit is avoidable. Once a visit is determined to be an AER visit, all charges associated with the visit, including facility, professional, labs, non-staff physicians, and radiologists are used to calculate the cost of the visit. The calculation is the sum of avoidable ER visits divided by the total number of ER visits. 

Color-coded Visual Trend Arrows – The red arrows either up or down indicate a negative trend where the outcome is not desirable, green arrows either up or down indicate a positive trend. These offer the user a quick reference point. 

Emergency Room Visit – Defined by revenue codes between 450 and 459, or 981. Place of Service codes are then used to define the type of ER visit (e.g. POS 23 is Acute Hospital ER). Paid amounts are not considered as there may be a significant number of visits where a $0 paid is valid. 

Emergency Room (ER) Visits/1000 - The number of emergency room visits per 1000 health plan members. The calculation is ER visits / panel size * 1,000. 

ER SuperUser – A patient/member with more than “X” number of visits in the 12-month reporting period, where “X” is the variable defined by the user in the header of the ER SuperUsers report. 

ICD – Diagnosis codes are classified as either ICD-9 or ICD-10. The current cataloging system, ICD-10, offers more classification options (meaning there are more diagnosis codes) compared to those for ICD-9. QualMetrix uses 3 CCS diagnosis categories for ICD-9 and 2 CCS diagnosis categories for ICD-10.


Length of Stay – Calculated considering the admission to and from dates, where present. If those fields are not present, the next option is “service from” and “service to” dates. 

Level 4/5 E&M % - Level 4 and Level 5 refer to office consultations, inpatient consultations, outpatient visits, and emergency department visits. Usually the presenting problems are of moderate to high severity. The level of E&M service is determined by patient history, physical examination, medical decision-making, counseling, coordination of care and the nature of the patient’s presenting problem PLUS the amount of time required to provide the service. This KPI represents the percentage of bills coded 4 or 5 of the total office visits billed per a specific time period. This is an important indicator to monitor a number of member and provider characteristics: 

  1. The acuity of the provider’s population which can assist in anticipating high risk/high cost members; 
  2. The comparison across same-specialty provider groups which can assist in understanding the provider panel and review of outliers leading to additional evaluation and audits as warranted; and, 3) the 4/5 level offers an opportunity to review the use of the CPT codes and determine if education is needed for providers regarding coding and billing.

Medical KPI – Key Performance Indicator for medical services. The Medical KPI’s described on the Home Screen are typical and can be compared to regional and national databases.

Medical PMPM – Medical cost per member, per month. Calculated using total monthly medical costs divided by the number of members in the group. This is a measure of the total cost of treating a population in a given time period. The data includes all services captured in claims – inpatient, outpatient, professional, pharmacy, and ancillary. This allows for objective comparisons between providers and payers as the ability to filter for specialty, lines of business, and market segment is available.

NDC – National Drug Code. QualMetrix uses the NDC table to populate drug name, and class, based off drug codes supplied on pharmacy claims.

Paid/Admit – Calculated dividing the total costs by the number of admissions to obtain an average for the period being reviewed.

Paid/Claim - The Paid/Claim KPI measures the average cost of each claim over time. This KPI assists an organization in understanding broadly the cost of doing business and trends in cost. Using the available filters provides additional clarity.

PCP – Primary Care Physician; a role defined by the National Provider Index, which includes an associated taxonomy assigned by QualMetrix via an attribution algorithm. The description for this algorithm is available upon request. Note that a member may change PCPs over time, including within the 12-month reporting period. This may cause some reports that include PCPs and members, to not reconcile where it appears they should.

Pharmacy PMPM – Pharmacy cost per member, per month. Calculated using only pharmacy costs divided by the number of members in the group.

Pharmacy KPI – Key Performance Indicator for pharmacy services. The Pharmacy KPI’s described on the Home Screen are typical and can be compared to regional and national databases.

Readmission Rate - A performance measure showing the percentage of hospitalized patients who are readmitted to the same or a different facility within 30 days of initial discharge. Multiple readmissions and discharges are treated separately: Consider a patient discharged on January 10, January 20, and January 26 and March 30. January 10 is the first admission; January 20 qualifies as a 30-day readmission for the January 10 admission. January 26 qualifies as a 30-day readmission for the January 20th admission. March 30 falls outside of the 30 days since last admission so is not a readmission. The 30-day readmission rate is 50% because there are two 30-day readmissions for the four admissions. The calculation is the number of readmissions divided by the total number of admissions.

Savings Calculation – Avoidable ER The entire amount paid for any Avoidable ER Visit is considered as Savings.

Savings Calculation – Complications The amount paid for Complications multiplied by Complications Rate of the Provider over the Complications Rate of each Complication Type.

Savings Calculation – Choosing Wisely The entire amount paid for any Choose Wisely procedure is considered as Savings.

Savings Calculation – E&M The amount paid for Level 4 and 5 office visits multiplied by percentage of Level 4/5 visits of the Provider over the percentage of Level 4/5 visits of the Specialty.

Savings Calculation – ER SuperUsers The amount paid for any ER Visit over the limit specified in SuperUsers page is considered as Savings.

Savings Calculation The amount paid for Readmissions multiplied by Readmissions Rate of the Provider over the Readmissions Rate of the Specialty.

Utilization KPI Trends measure and compare over time the ER Visits/1000, the Admits/1000, ALOS – Average Length of Stay, and Lab/Radiology Services/1000.