Claim Example 2

Patient Information

A 32 year old male comes to the ED complaining of low back pain. A lumbar CT scan is completed. He is given an injection of an anti-inflammatory and is discharged home. Below is a subset of the claim that was submitted for this visit.

Claim Information

Age: 32 External Cause of Injury Diagnosis Code: None
Gender: Male Principal Diagnosis Code: M51.26, Other intervertebral disc displacement, lumbar region
Reason for Visit Diagnosis Code: M54.5, Low back pain Secondary Diagnosis Codes:
J45.909, Unspecified asthma, uncomplicated
Z79.51,Long term (current) use of inhaled steroids
M54.5, Low back pain
Diagnostic Procedure Code: 72131, Computed tomography, lumbar spine; without contrast material

Analyzer Processing

  1. Step 1: This claim contains one reason for visit diagnosis code (M54.5). This diagnosis code is assigned to a PSCA of 3 and a standard cost weight of 400.

  2. Step 2: This claim contains one lumbar CT scan (72131). Since there is only one unique diagnostic category on this claim, this claim is assigned to an extended cost weight of 200.

  3. Step 3: This claim contains a principal and three secondary diagnosis codes (M51.26, J45.909, Z79.51, and M54.5). Since M54.5 is also billed as the reason for visit diagnosis code, it will be ignored in this step. Of the remaining diagnosis codes (M51.26, J45.909, and Z79.51), only one is considered to be a diagnosis code that increases the complexity of the ED visit (Z79.51). The patient complexity cost weight for this code is 200.

  4. Final Step: All 3 weights are added together to determine the total weight for the claim:
Total Weight = 400 + 200 + 200 = 800

This total weight falls into the weight range used by the EDC Analyzer™ for a visit level 4. As such, the EDC Analyzer™ would recommend that the ED visit code on this claim be 99284 or G0383.