Milliman MedInsight


At this uncertain time, the Milliman MedInsight team has mobilized to support healthcare organizations so that they can proactively address operational challenges and plan for recovery.


COVID-19 coding resources

This reference provides coding resources for the analysis of COVID-19-related care. Please see the white paper Frameworks and considerations for COVID-19-related analyses for context and further details about how these can be used.

Please click here to request a copy of the coding resources. This includes all of the reference tables in the whitepaper and below.

Identifying Testing and Diagnosed COVID-19

COVID-19 Testing

The American Medical Association (AMA) released a new CPT code to identify COVID-19 testing.

COVID-19 Testing and Specimen-Related Codes are provided in the coding resources.

COVID-19 Cases

The CDC released new diagnostic codes to track confirmed COVID-19 cases.

COVID-19 ICD-10 diagnosis codes are provided in the coding resources.

Other Associated Conditions that may be due to COVID-19

Associated conditions

Symptoms, signs and medical conditions that may be related to COVID-19. These may help to identify patients who have a high likelihood of undiagnosed COVID-19.  Higher than average trends for these conditions may be the result of unrecognized COVID-19.

A partial List of Codes for Associated Symptoms, Signs & Conditions is provided in the coding resources.

Tracking ICU and Ventilator Utilization

Intensive Care – Revenue Codes are provided in the coding resources.

Intubation and Ventilation – ICD-10 Procedure Codes are provided in the coding resources.

Impact on Utilization of Other Services

Elective surgical procedures

CMS recommended limiting all non-essential planned surgeries and procedures, including dental. See Key Considerations for additional updates.

Potentially Deferrable Elective Surgery – A partial list of examples based on CMS’ Tiered Framework is provided in the coding resources.

Impact on other services

New coverage and payment rules for telehealth and communication technology-based services (CTBS) influence how utilization can be tracked.

Telehealth Services and CTBS Codes are provided in the coding resources.


Key Considerations

Some key considerations when conducting COVID-19 analyses are outlined below. Please see the white paper Frameworks and considerations for COVID-19-related analyses for context and further details about how these can be used.

Restricted testing

Diagnosed cases are highly dependent on who gets testing, and this varies over the time of the pandemic, including by country and region. Testing per capita is a major factor to consider in any analysis of claims data.

Reliability of test results

A negative COVID-19 test result may indicate that the patient does not have the virus; or it may mean the level of SARS-CoV-2 RNA in the sample was not above the limit of detection at the time the test was administered. False negatives can occur, potentially due to low viral load at early stages of disease, low amounts of virus in throat and nose for some patients, or technical issues in sample collection (inadequate nasopharyngeal swab), handling, shipping, or mutation of the virus. The World Health Organization advises that a negative result does not rule out or exclude the possibility of COVID-19.

Under-recognition of COVID-19

COVID-19 may be under-recognized and under-reported for a variety of reasons:

  • Testing is not conducted or recommended for 100% patients. Limited testing is likely to be the most significant cause of under-recognition, especially in the early stages of the pandemic.
  • Testing does not have 100% accuracy (false negatives can occur).
  • Symptoms of the early stages of the disease are nonspecific and have a broad range of differential diagnoses.
  • COVID-19 infection appears to have a varied clinical spectrum ranging from asymptomatic to multiple organ dysfunction syndromes.
  • Long term complications among survivors of COVID-19 are not yet known.

Other associated conditions

Clinical case studies continue to report new symptoms, signs and medical conditions in association with COVID-19. Used alone or in combination, these associated clinical conditions and characteristics may be helpful in identifying patients who have a high likelihood of undiagnosed COVID-19, or may be useful in monitoring population trends that may indicate the presence of unrecognized COVID-19. Note these symptoms and conditions may also have other causes unrelated to SARS-CoV-2.

Ventilator billing and reporting

The ICD-10 procedure codes for intubation and respiratory ventilation reported on inpatient facility claims may be used to identify mechanically ventilated patients. Ventilator management is typically billed as part of daily E/M, or part of critical care services, and is not usually reported on inpatient claims.

Elective surgery

On March 18, 2020, CMS recommended limiting all non-essential planned surgeries and procedures, including dental, until further notice, in order to conserve critical resources like Personal Protective Equipment (PPE) and ventilators, and to minimize potential exposure of patients and staff to the virus that causes COVID-19. Using the tiered decision support framework form CMS, we have included examples of low acuity procedures in Tier 1 and intermediate acuity procedures in Tier 2. Note that individual procedures are not always elective.

On April 19, 2020, CMS has provided healthcare facilities with flexibility to re-start currently postponed care for patients without symptoms of COVID-19 in regions with low COVID-19 incidence, depending on consideration of adequate facilities, workforce across phases of care, testing and supplies.


Data-driven dashboards

The coding resources described above can be used to create a set of data-driven dashboards. MedInsight has created a pre-built set of dashboards to be available to all clients through the MedInsight Portal. Our hope is that these serve as a jumping off point for analysis, providing useful information at a glance, and sample queries containing code sets that can be copied and modified for your organization.


Incurred but Not Paid (IBNP)

COVID-19 has affected almost every area of the healthcare delivery system, so it is no surprise that it is having a tremendous impact on incurred but not paid (IBNP) estimates. For more information on IBNP within MedInsight, download the following PDF.


Software Updates

MedInsight recognizes the need to mobilize our suite of products to ensure clients can access the most up to date codes established. The CDC approved the new COVID-19 ICD diagnosis codes on March 18 for use starting April 1, and we are working diligently to get these codes mapped into our products. As of today, all codes can flow into your MedInsight warehouse to be analyzed on a standalone basis or grouped together by codes.

For specific details on how to utilize MedInsight today as you start to see claims, download our white paper, Frameworks and Considerations for COVID-19-Related Analyses.

Here are the significant changes we are working on:

CMS updated the MS-DRG grouping logic to be effective beginning on April 1 and we are updating our DRG Grouper Utility.

The DRG Grouper changes will flow into the HCG Grouper and GlobalRVUs products, which will also be updated with the DRG grouping changes for standalone use.

The HCG Grouper and GlobalRVUs will handle the new HCPCS and ICD codes.
We have already updated our ICD diagnosis reference table and CCS grouping logic.

These changes are estimated to be ready in early July and will be rolled out to clients shortly thereafter. We are also monitoring if other changes are needed for other analytics within MedInsight, including:

Chronic Conditions Hierarchical Groups (CCHGs) – COVID-19 ICD codes will be mapped to a new Similar Diagnostic Category (SDC) for Pandemic-like diseases. These include COVID-19, H1N1, Zika, Ebola, Chikungunya, SARS, and MERS, to name a few. Additionally, we will create reference code sets, “MedInsight Clinical Sets,” which will subsequently upload into the MedInsight Data Mart and be accessible in the ad-hoc querying tools within the MedInsight Portal. These sets disclose key clinical assumptions and speed up analysis efforts.

Guideline Analytics – COVID-19 diagnostic coding will be supported in upcoming the 24th edition.

MARA – COVID-19 coding is supported in the upcoming release. MARA support within MedInsight will be rolled out in two waves, the first being in the core database in the upcoming MedInsight Database release, targeted for May/June. The MedInsight Data Mart support for the next release of MARA will be rolled out during summer 2020.

ETGs – We are awaiting updates from Optum.
MEGs – We are awaiting updates from IBM.
APR & Tricare DRGs – We are awaiting updates from 3M

There is no direct impact on the following products due to COVID-19:
MedInsight Health Waste Calculator
MedInsight Benchmarks
MedInsight Hayes Grouper

*Please note: the updates will only be supported for MedInsight clients who have given permission to process their data in the Microsoft Azure Cloud.


Research & Consulting Support

The COVID-19 pandemic has significantly disrupted almost all aspects of the healthcare system. At this time of uncertainty, Milliman has provided well-researched briefs and guidance.

One of the initial Milliman research efforts was hospital capacity (beds, ICU beds, and ventilators) and projected utilization. We have leveraged the most credible public methodologies to model projected utilization at the hospital and regional levels. This has helped us model when the peak utilization could occur and what kind of additional resources could be needed. State Medicaid agencies, payer clients, and the Department of Veterans Affairs have requested Milliman to help with these kind of analyses.

Milliman has also been creating models to estimate the impact of deferred care and COVID-19 care on current and projected utilization and costs. We have identified deferral percentages for HCG type of service categories and created models to estimate the impact on short term and longer-term costs and utilization. We have been engaged by a number of payers, providers, state Medicaid agencies and the VA with these types of analyses. This is especially relevant as we work to finalize 2021 ACA and Medicare Advantage rates for many clients.

Below are a few articles we think are most relevant for MedInsight clients. Visit Milliman’s COVID-19 page to view the entirety of the completed research.

Medicare’s telehealth coverage expansion during the COVID-19 pandemic

Implications of the COVID-19 pandemic on health payer operations

How the pharmacy benefit industry is reacting to a pandemic: Policy changes, actions, and potential impacts

Further Milliman projects and research include:

  • Review of federal and state legislation related to COVID relief efforts and providing highlights and impacts (especially relevant for MSSP and other CMS programs)
  • Evaluate the options for finance mechanisms to incentivize streamlined discharge processes to open up hospital capacity
  • Identify providers that are at risk for insolvency as a result of lost revenue (e.g., rural hospitals, small behavioral health providers), and helping to quantify estimates for lost revenue
  • Explore the options for direct provider payments under Medicaid managed care regulations
  • Discussion of potential case rate amounts for care in unlicensed overflow facilities (see news on “isolation and quarantine facilities”:
  • Support Medicaid agency clients in discussions with various stakeholders – MCOs, provider associations, CMS

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