Claim Example 4

Patient Information

A 37 year old female comes to the ED complaining of pain in her right foot and ankle. An X-ray is completed and a splint is applied. She is discharged home with a prescription. Below is a subset of the claim that was submitted for this visit.

Claim Information

Age: 37 External Cause of Injury Diagnosis Code: W10.9XXA, Fall (on) (from) unspecified stairs and steps, initial encounter
Gender: Female Principal Diagnosis Code: S92.351A, Displaced fracture of fifth metatarsal bone, right foot, initial encounter for closed fracture
Reason for Visit Diagnosis Code: M25.571, Pain in right ankle and joints of right foot Secondary Diagnosis Code: M25.571, Pain in right ankle and joints of right foot
Diagnostic Procedure Code: 73610, Radiologic examination, ankle; complete, minimum of 3 views

Analyzer Processing

  1. Step 1: This claim contains one reason for visit diagnosis code (M25.571). This diagnosis code is assigned to a PSCA of 3 and a standard cost weight of 400.

  2. Step 2: This claim contains one X-ray service (73610). Since there is only one unique diagnostic category on this claim, this claim is assigned to an extended cost weight of 100.

  3. Step 3: This claim contains a principal, one secondary diagnosis code, and one external cause of injury diagnosis code (S92.351A, M25.571, and W10.9XXA). Since M25.571 is also billed as the reason for visit diagnosis code, it will be ignored in this step. Of the remaining diagnosis codes (S92.351A and W10.9XXA), only one is considered to be a diagnosis code that increases the complexity of the ED visit (W10.9XXA). 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 + 100 + 200 = 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.