The goal of the Optum Emergency Department Claim (EDC) Analyzer is to achieve fair and consistent evaluation and management coding and reimbursement of facility outpatient emergency department claims. The EDC Analyzer™ systematically evaluates each ED visit level code in the context of other claim data (i.e., diagnosis codes, procedure codes, patient age, and patient gender) to ensure that it reasonably relates to the intensity of hospital resource utilization as required per CMS Guidelines. The methodology used by the EDC Analyzer™ is based on Optum's Lynx™ tool, which is used by 1,500 facilities nationwide to code outpatient emergency department claims. This idea of a shared methodology for both payers and providers underscores Optum's commitment to simplify the health care system, and promote transparency in the coding and reimbursement process. For more background information about the EDC Analyzer™, click here.

The appropriate visit level of an ED claim is determined by the EDC Analyzer™ using the following 4-step process:

Step 1: Standard Costs

Determines the standard cost of the visit based on the patient’s demographic characteristics and presenting problem. Assigns a standard cost weight to the visit based on this evaluation. More...

Step 2: Extended Costs

Evaluates the intensity of the diagnostic workup performed by the facility based on diagnostic CPT codes. Assigns an extended cost weight to the visit based on this evaluation. More...

Step 3: Patient Complexity Costs

Determines if the patient has any conditions that may increase the complexity of the visit. Assigns a patient complexity cost weight to the visit based on this determination. More...

Final Step: Calculate Visit Level

The cost weights from steps 1 through 3 are summed and a visit level is assigned based on that summation. More...

To view how the EDC Analyzer™ processes specific claim scenarios, review the following examples:

  1. Claim Example 1

  2. Claim Example 2

  3. Claim Example 3