Claim Example 3

Patient Information

A 50 year old female presents to the ED with complaints of a bad cough. Several lab services and a chest X-ray are performed. She is seen by a physician and discharged home. Below is a subset of the claim that was submitted for this visit.

Claim Information

Age: 50 External Cause of Injury Diagnosis Codes: None
Sex:* Female Principal Diagnosis Code: J22, Unspecified acute lower respiratory infection
Reason For Visit Diagnosis Code: R05.9, Cough unspecified Secondary Diagnosis Code: R05.9, Cough unspecified
Diagnostic Procedure Codes:
71046, X-ray exam chest 2 views
87400, Influenza A/B AG IA
87430, Strep A AG IA
*Patient sex assigned at birth

Analyzer Processing

  1. Step 1: This claim contains one reason for visit diagnosis code (R05.9). This diagnosis code is assigned to a PSCA of 3 and a standard weight of 400.

  2. Step 2: This claim contains one X-ray (71046) and two lab services (87400 and 87430). Since there are two unique diagnostic categories on this claim, this claim is assigned an extended weight of 200.

  3. Step 3: This claim contains a principal (J22) and one secondary diagnosis code (R05.9). Since R05.9 is also billed as the reason for visit diagnosis code, it will be ignored in this step. The remaining diagnosis code (J22) increases the complexity of the ED visit with a patient complexity weight of 100.

  4. Final Step: All 3 weights are added together to determine the total weight for the claim:
Total Weight = 400 + 200 + 100 = 700

This total weight falls into the weight range used by the EDC Analyzer™ for a visit level 3. As such, the EDC Analyzer™ would recommend that the ED visit code on this claim be 99283 or G0382.