Patient A Claim Examples

Example 1

Patient Information

A 50 year old female comes to the ED complaining of a bad cough. No labs or X-rays are completed. She is seen by a physician and is released home with a prescription. Below is a subset of the claim that was submitted for this visit.

Claim Information

Age: 50 External Cause of Injury Diagnosis Codes: None
Gender: Female Principal Diagnosis Code: J20.9, Acute bronchitis, unspecified
Reason For Visit Diagnosis Code: R05, Cough Secondary Diagnosis Code: R05, Cough
Diagnostic Procedure Codes: None

Analyzer Processing

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

  2. Step 2: This claim contains no diagnostic procedure codes, so it is assigned to an extended cost weight of 0.

  3. Step 3: This claim contains a principal and one secondary diagnosis code (J20.9 and R05). Since R05 is also billed as the reason for visit diagnosis code, it will be ignored in this step. The remaining diagnosis code (J20.9) is not considered to be a diagnosis code that increases the complexity of the ED visit. As such, the patient complexity cost weight is 0.

  4. Final Step: All 3 weights are added together to determine the total weight for the claim:
Total Weight = 400 + 0 + 0 = 400

This total weight falls into the weight range used by the EDC Analyzer™ for a visit level 2. As such, the EDC Analyzer™ would recommend that the ED visit code on this claim be 99282 or G0381.


Example 2

Patient Information

A 50 year old female comes to the ED complaining of a bad cough. Several lab services, a chest X-ray, and a breathing treatment are performed. She is seen by a physician and is released home with a prescription. Below is a subset of the claim that was submitted for this visit.

Claim Information

Age: 50 External Cause of Injury Diagnosis Codes: None
Gender: Female Principal Diagnosis Code: J20.9, Acute bronchitis, unspecified
Reason For Visit Diagnosis Code: R05, Cough Secondary Diagnosis Code:
R05, Cough
Diagnostic Procedure Codes:
71046, X-ray exam chest 2 views
87400, Influenza A/B AG IA
87430, Strep A AG IA

Analyzer Processing

  1. Step 1: This claim contains one reason for visit diagnosis code (R05). 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 (71046) and two lab services (87400 and 87430). Since there are two unique diagnostic categories on this claim, this claim is assigned to an extended cost weight of 200.

  3. Step 3: This claim contains a principal and one secondary diagnosis code (J20.9 and R05). Since R05 is also billed as the reason for visit diagnosis code, it will be ignored in this step. The remaining diagnosis code (J20.9) is not considered to be a diagnosis code that increases the complexity of the ED visit. As such, the patient complexity cost weight is 0.

  4. Final Step: All 3 weights are added together to determine the total weight for the claim:
Total Weight = 400 + 200 + 0 = 600

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.


Example 3

Patient Information

A 50 year old female comes to the ED complaining of a bad cough. She has a history of congestive heart failure and COPD/emphysema. Several lab services, a chest X-ray, and a breathing treatment are performed. She is seen by a physician and is released home with a prescription. Below is a subset of the claim that was submitted for this visit.

Claim Information

Age: 50 External Cause of Injury Diagnosis Codes: None
Gender: Female Principal Diagnosis Code: J20.9, Acute bronchitis, unspecified
Reason For Visit Diagnosis Code: R05, Cough Secondary Diagnosis Codes:
J44.9, Chronic Obstructive Pulmonary Disease, unspecified
I50.9, Heart failure, unspecified
R05, Cough
Diagnostic Procedure Codes:
71046, X-ray exam chest 2 views
87400, Influenza A/B AG IA
87430, Strep A AG IA

Analyzer Processing

  1. Step 1: This claim contains one reason for visit diagnosis code (R05). 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 (71046) and two lab services (87400 and 87430). Since there are two unique diagnostic categories 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 (J20.9, J44.9, I50.9, and R05). Since R05 is also billed as the reason for visit diagnosis code, it will be ignored in this step. Of the remaining diagnosis codes (J20.9, J44.9, and I50.9), only two are considered to be diagnosis codes that increase the complexity of the ED visit (J44.9 and I50.9). Both of these diagnosis codes have a weight of 200 and, as such, this claim is assigned to a patient complexity cost weight of 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.