Claim Example 1

Patient Information

A 26 year old male presents to the ED complaining of a headache. The patient had labs with no other diagnostic testing. The patient received treatment and was discharged home. Below is a subset of the claim that was submitted for this visit.

Claim Information

Age: 26 External Cause of Injury Diagnosis Codes: None
Sex:* Male Principal Diagnosis Code: R51.0, Headache with orthostatic component, not elsewhere classified
Reason For Visit Diagnosis Code: R51.0, Headache with orthostatic component, not elsewhere classified Secondary Diagnosis Codes: D17.1, Benign lipomatous neoplasm of skin, subcutaneous tissue of trunk
R11.0, Nausea
Diagnostic Procedure Codes:
80053, Comprehensive metabolic panel
85025, Blood count complete auto & auto differential WBC
*Patient sex assigned at birth

Analyzer Processing

  1. Step 1: This claim contains one reason for visit diagnosis code (R51.0). This diagnosis code is assigned to a PSCA of 3 and a standard weight of 400.

  2. Step 2: This claim contains two lab services (80053 and 85025). Since there is one unique diagnostic category on this claim, this claim is assigned an extended weight of 100.

  3. Step 3: This claim contains a principal (R51.0) and two secondary diagnosis codes (D17.1 and R11.0). Since R51.0 is also billed as the reason for visit diagnosis code, it will be ignored in this step. Of the remaining diagnosis codes, only one (D17.1) is considered to be a diagnosis code that increases the complexity of the ED visit. As such, the patient complexity weight is 100.

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