Procedure code overutilization detection from healthcare claims using unsupervised deep learning methods

Table 5 Examples of claims where autoencoder model predictions with inconsistent with manual annotations. Italicized cells denote model predictions for overutilization

Claim #	ICD-10 Code	Diagnosis	CPT Code	Procedure	Age	Gender	FWA SMS comments
3	S43	Dislocation sprain and strain of joints and ligaments of shoulder girdle	29806	Incision of shoulder joint capsule using an endoscope	27	M	An incision would need to be made if surgical procedure was performed. Units would need to be taken into consideration.
3	M89	Other disorders of bone	L3670	Shoulder orthosis acromio/clavicular (canvas and webbing type) prefabricated off-the-shelf	27	M
4	M54	Dorsalgia	97110	Therapeutic exercise to develop strength endurance range of motion and flexibility each 15 minutes	31	F	Standard practice to bill 97110 and 97140 with diagnosis for same date of service
4	M54	Dorsalgia	97140	Established patient outpatient visit total time 10-19 minutes	31	F

ISSN: 1472-6947