Claim Example 2

Patient Information

A 27 year old female presents to the ED with complaints of chest pain. The patient was ordered applicable diagnostic testing. The patient received treatment and was discharged home. Below is a subset of the claim that was submitted for this visit.

Claim Information

Age: 27 External Cause of Injury Diagnosis Codes: None
Sex:* Female Principal Diagnosis Code: R07.89, Other chest pain
Reason For Visit Diagnosis Code: R07.9, Chest pain unspecified Secondary Diagnosis Code: R07.9, Chest pain unspecified
Diagnostic Procedure Codes:
71046, X-ray exam chest 2 views
80047, Metabolic panel ionized ca
84484, Assay of troponin, quant
84703, Chorionic gonadotropin assay
85025, Complete CBC w/auto diff WBC
85379, Fibrin degradation, quant
93005, Electrocardiogram, tracing
*Patient sex assigned at birth

Analyzer Processing

  1. Step 1: This claim contains one reason for visit diagnosis code (R07.9). This diagnosis code is assigned to a PSCA of 5 and a standard weight of 1000.
  2. Step 2: This claim contains several diagnostic services, including x-ray (71046), five lab services (80047, 84484, 84703, 85025, 85379), and EKG (93005). Since there are three unique diagnostic categories on this claim, this claim is assigned an extended weight of 300.
  3. Step 3: This claim contains a principal (R07.89) and one secondary diagnosis code (R07.9). Since R07.9 is also billed as the reason for visit diagnosis code, it will be ignored in this step. The remaining diagnosis code (R07.89) is not considered to be a diagnosis code that increases the complexity of the ED visit. As such, the patient complexity weight is 0.
  4. Final Step: All 3 weights are added together to determine the total weight for the claim:
Total Weight = 1000 + 300 + 0 = 1300

This total weight falls into the weight range used by the EDC Analyzer™ for a visit level 5. As such, the EDC Analyzer™ would recommend that the ED visit code on this claim be 99285 or G0384.