Claim Example 1

Patient Information

A 31 year old female comes to the ED complaining of a bad cough. No labs or X-rays are completed. She is seen by a physician and is released home with a prescription. Below is a subset of the claim that was submitted for this visit.

Claim Information

Age: 31 Reason For Visit Diagnosis Code:
R05 - Cough
Gender: Female Principal Diagnosis Code:
J20.9 - Acute bronchitis, unspecified
Secondary Diagnosis Code(s):
R05 - Cough
Diagnostic Procedure Code(s): None

Analyzer Processing

  1. Step 1: This claim contains one reason for visit diagnosis code (R05). This diagnosis code is assigned to a PSCA of 3 and a standard cost weight of 400.

  2. Step 2: This claim contains no diagnostic procedure codes, so it is assigned to an extended cost weight of 0.

  3. Step 3: This claim contains a principal and one secondary diagnosis code (J20.9 and R05). Since R05 is also billed as the reason for visit diagnosis code, it will be ignored in this step. The remaining diagnosis code (J20.9) is not considered to be a diagnosis code that increases the complexity of the ED visit. As such, the patient complexity cost weight is 0.

  4. Final Step: All 3 weights are added together to determine the total weight for the claim:
Total Weight = 400 + 0 + 0 = 400

This total weight falls into the weight range used by the EDC Analyzer™ for a visit level 2. As such, the EDC Analyzer™ would recommend that the ED visit code on this claim be 99282 or G0381.