Claim Example 5

Patient Information

A 37 year old female presents to the ED with complaints of abdominal pain. Several lab services and a CT scan are performed. She is seen by a physician and discharged home. Below is a subset of the claim that was submitted for this visit.

Claim Information

Age: 37 External Cause of Injury Diagnosis Codes: None
Sex:* Female Principal Diagnosis Code: R10.11, Right upper quadrant pain
Reason For Visit Diagnosis Code: R10.9, Unspecified abdominal pain Secondary Diagnosis Codes: None
Diagnostic Procedure Codes:
80053, Comprehensive metabolic panel
81001, Urinalysis dip stick/tablet reagent auto microscopy
85025, Blood count complete auto & auto differential WBC
74177, CT abdomen and pelvis with contrast
*Patient sex assigned at birth

Analyzer Processing

  1. Step 1: This claim contains one reason for visit diagnosis code (R10.9). Diagnosis code R10.9 is assigned to a PSCA of 4 and a standard weight of 600.

  2. Step 2: This claim contains one CT scan (74177) and three lab services (80053, 81001, 85025). Since there are two unique diagnostic categories on this claim, this claim is assigned an extended weight of 300.

  3. Step 3: This claim contains a principal (R10.11) and no secondary diagnosis codes. The principal diagnosis code does not increase the complexity of the ED visit. As such, the patient complexity weight is 0.

  4. Final Step: All 3 weights are added together to determine the total weight for the claim:
Total Weight = 600 + 300 + 0 = 900

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.