Claim Example 3

Patient Information

A 29 year old female comes to the ED complaining of nausea and vomiting. Multiple labs and an abdominal ultrasound are completed. She is discharged home with a prescription. Below is a subset of the claim that was submitted for this visit.

Claim Information

Age: 29 Reason for Visit Diagnosis Code:
R11.2 - Nausea with vomiting, unspecified
Gender: Female Principal Diagnosis Code:
R11.2 - Nausea with vomiting, unspecified
Secondary Diagnosis Code(s):
N39.0 - Urinary tract infection, site not specified
R10.13 - Epigastric pain
E07.9 - Disorder of thyroid, unspecified
Z88.6 - Allergy status to analgesic agent status
Z87.891 - Personal history of nicotine dependence
Diagnostic Procedure Code(s):
76705 - Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)
80048 - Basic metabolic panel (calcium, total) this panel must include the following:
calcium, total (82310) carbon dioxide (bicarbonate) (82374) chloride (82435) creatinine (82565) glucose (82947) potassium (84132) sodium (84295) urea nitrogen (BUN) (84520)
80076 - Hepatic function panel this panel must include the following:
albumin (82040) bilirubin, total (82247) bilirubin, direct (82248) phosphatase, alkaline (84075) protein, total (84155) transferase, alanine amino (ALT) (SGPT) (84460) transferase, aspartate am
81001 - Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy
81025 - Urine pregnancy test, by visual color comparison methods
83690 - Lipase
85025 - Blood count; complete (CBC), automated (HGB, HCT, RBC, WBC and platelet count) and automated differential WBC count

Analyzer Processing

  1. Step 1: This claim contains one reason for visit diagnosis code (R11.2). This diagnosis code is assigned to a PSCA of 4 and a standard cost weight of 600.

  2. Step 2: This claim contains six lab codes (80048, 80076, 81001, 81025, 83690, and 85025) and one abdominal ultrasound (76705). Since there are two unique diagnostic categories on this claim, this claim is assigned to an extended cost weight of 300.

  3. Step 3: This claim contains a principal and five secondary diagnosis codes (R11.2, N39.0, R10.13, E07.9, Z88.6, and Z87.891). Since R11.2 is also billed as the reason for visit diagnosis code, it will be ignored in this step. Of the remaining diagnosis codes (N39.0, R10.13, E07.9, Z88.6, and Z87.891), only one is considered to be a diagnosis code that increases the complexity of the ED visit (E07.9). The patient complexity cost weight for this code is 110.

  4. Final Step: All 3 weights are added together to determine the total weight for the claim:
Total Weight = 600 + 300 + 110 = 1010

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.