Applying Logic to Sets of Rows - sql

Question

I want to add logic that calculates price per claim. Below, there are two claims, one for patient 5, and another for patient 6. Original idea is to create a unique list of patient numbers in a separate table, then sort the original table by these unique patient numbers and run conditional statements to output a single value (reimbursement value).Then iterate through the unique table until completed. Does this sound like a feasible workflow? Not necessarily looking for specific code but more of a workflow/process
For example/context:
PatNo
RevCode
CPT
BilledCharges
DRG
5
141
null
100
880
5
636
J1234
50
null
6
111
null
8000
783
6
636
J1234
300
null
PSYCH look up table: if claim has DRG on table then calculate 75% of BilledCharges for claim.
DRG
Service Category
876
PSYCH
880
PSYCH
881
PSYCH
882
PSYCH
883
PSYCH
884
PSYCH
885
PSYCH
886
PSYCH
887
PSYCH
C- Section look up table: if claim has DRG on table pay $5000 for claim.
DRG
Service
765
C-SECTION
766
C-SECTION
783
C-SECTION
784
C-SECTION
786
C-SECTION
787
C-SECTION
785
C-SECTION
788
C-SECTION
If claim has RevCode 636, then add 50% of charges to claim reimbusment.
OUTPUT:
PatNo
Reimburs.
5
100
6
5150

Answer 1

So...
Patient 5's reimbursement is...(75% of 100) + (50% of 50) = 100
Patient 6's reimbursement is...(5000) + (50% of 300)
Assuming you've told us all the rules...
You can left join the tables, to check if values are present there or not, then use case expressions to apply the logic, and finally aggregate it to sum it all up...
SELECT
YourTable.patno,
SUM(
CASE WHEN section.drg IS NOT NULL THEN 5000
WHEN psych.drg IS NOT NULL THEN 0.75 * yourTable.billedcharges
WHEN yourTable.revcode = 636 THEN 0.5 * yourTable.billedcharges
ELSE 0
END
)
FROM
yourTable
LEFT JOIN
section
ON section.drg = yourTable.drg
LEFT JOIN
psych
ON psych.drg = yourTable.drg
GROUP BY
yourTable.patno
Please forgive typos, I'm on my phone.