Step 3: Patient Complexity Costs

The EDC Analyzer™ reviews all principal, secondary, and external cause of injury diagnosis codes on the claim looking for complicating conditions or circumstances that may impact facility resource utilization. The EDC Analyzer™ then assigns a weight to each complicating diagnosis code that is found. The highest weighted diagnosis code on the claim is used to determine the overall patient complexity cost weight. Reason for visit diagnosis codes that are also reported as principal or secondary diagnosis codes are excluded from acting as complicating conditions during this step.

Patient complexity cost weights were developed for each complicating condition or circumstance by analyzing the additional services typically provided to patients with that complicating condition or circumstance.

Below are some examples showing how the EDC Analyzer™ assigns a patient complexity cost weight based on a diagnosis code:

Step 3 Examples

Diagnosis Code Code Description Patient Complexity Cost Weight*
M05.9 RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR, UNSPECIFIED ***
J44.9 CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED ***
I50.9 HEART FAILURE, UNSPECIFIED ***
F10.920 ALCOHOL USE, UNSPECIFIED WITH INTOXICATION, UNCOMPLICATED ***
G40.801 OTHER EPILEPSY, NOT INTRACTABLE, WITH STATUS EPILEPTICUS ***
E11.8 TYPE 1 DIABETES MELLITUS WITH UNSPECIFIED COMPLICATIONS ***
E11.29 TYPE 2 DIABETES MELLITUS WITH OTHER DIABETIC KIDNEY COMPLICATION ***
*Redacted