Patient B Claim Examples

Example 1

Patient Information

A 60 year old male comes to the ED complaining of a bad cough. A chest CT scan and multiple nebulizer treatments are performed. In addition, an injection of steroids is provided. He is seen by a physician and is released home with a prescription and instructions to follow up with his primary care physician. Below is a subset of the claim that was submitted for this visit.

Claim Information

Age: 60 External Cause of Injury Diagnosis Codes: None
Gender: Male Principal Diagnosis Code: J45.51, Severe persistent asthma with (acute) exacerbation
Reason For Visit Diagnosis Code: R05, Cough Secondary Diagnosis Codes:
R06.02, Shortness of breath
R05, Cough
Diagnostic Procedure Codes:
94640 (2 units), Airway inhalation treatment
71270, CT thorax w/o & w/dye

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 CT scan (71270) and two breathing treatments (94640). 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 two secondary diagnosis codes (J45.51, R06.02, 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 (J45.51 and R06.02), only one is considered to be a diagnosis code that increases the complexity of the ED visit (J45.51). The patient complexity cost weight for this code is 100.

  4. Final Step: All 3 weights are added together to determine the total weight for the claim:
Total Weight = 400 + 300 + 100 = 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.


Example 2

Patient Information

A 60 year old male comes to the ED complaining of a bad cough and shortness of breath. A chest CT scan and multiple nebulizer treatments are performed. In addition, an injection of steroids is provided. He is seen by a physician and is released home with a prescription and instructions to follow up with his primary care physician. Below is a subset of the claim that was submitted for this visit.

Claim Information

Age: 60 External Cause of Injury Diagnosis Codes: None
Gender: Male Principal Diagnosis Code: J45.51, Severe persistent asthma with (acute) exacerbation
Reason For Visit Diagnosis Codes:
R05, Cough
R06.02, Shortness of breath
Secondary Diagnosis Codes:
R06.02, Shortness of breath
R05, Cough
Diagnostic Procedure Codes:
94640 (2 units), Airway inhalation treatment
71270, CT thorax w/o & w/dye

Analyzer Processing

  1. Step 1: This claim contains two reason for visit diagnosis codes (R05 and R06.02). Diagnosis code R05 is assigned to a PSCA of 3 and a standard cost weight of 400. Diagnosis code R06.02 is assigned to a PSCA of 5 and a standard cost weight of 1000. Since the highest weight is 1000, this claim is assigned to a standard cost weight of 1000.

  2. Step 2: This claim contains one CT scan (71270) and two breathing treatments (94640). 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 two secondary diagnosis codes (J45.51, R06.02, and R05). Since R05 and R06.02 are also billed as reason for visit diagnosis codes, they will be ignored in this step. The remaining diagnosis code (J45.51) is considered to be a diagnosis code that increases the complexity of the ED visit. The patient complexity cost weight for this code is 100.

  4. Final Step: All 3 weights are added together to determine the total weight for the claim:
Total Weight = 1000 + 300 + 100 = 1400

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.