HFMA
Sample Analysis of an ED ClaimUnder a new policy effective March 1, UnitedHealthcare is analyzing emergency department (ED) claims that use a level 4 or 5 severity code to review whether the coding is appropriate. If the insurer’s automated audit determines the code is not justified, claims are being down coded, reducing ED service payments.Below is a sample analysis of an ED claim showing the criteria the health plan is using to determine appropriate level 4 and 5 coding.Patient InformationA 29-year-old female comes to the ED complaining of nausea and vomiting. Multiple labs and an abdominal ultrasound are completed. She is discharged home with a prescription. Below is a subset of the claim that was submitted for this visit.Claim InformationAge:29Reason for Visit Diagnosis Code:R11.2-Nausea with vomiting, unspecifiedGender:FemalePrincipal Diagnosis Code:R11.2-Nausea with vomiting, unspecifiedSecondary Diagnosis Code(s):N39.0-Urinary tract infection, site not specifiedR10.13-Epigastric painE07.9-Disorder of thyroid, unspecifiedZ88.6-Allergy status to analgesic agent statusZ87.891-Personal history of nicotine dependenceDiagnostic Procedure Code(s):76705-Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)80048-Basic metabolic panel (calcium, total) this panel must include the following:?calcium, total (82310) carbon dioxide (bicarbonate) (82374) chloride (82435) creatinine (82565) glucose (82947) potassium (84132) sodium (84295) urea nitrogen (BUN) (84520)80076-Hepatic function panel this panel must include the following:?albumin (82040) bilirubin, total (82247) bilirubin, direct (82248) phosphatase, alkaline (84075) protein, total (84155) transferase, alanine amino (ALT) (SGPT) (84460) transferase, aspartate am81001-Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy81025-Urine pregnancy test, by visual color comparison methods83690-Lipase85025-Blood count; complete (CBC), automated (HGB, HCT, RBC, WBC and platelet count) and automated differential WBC countAnalyzer ProcessingStep 1:?This claim contains one reason for visit diagnosis code (R11.2). This diagnosis code is assigned to a PSCA of 4 and a standard cost weight of 600.Step 2:?This claim contains six lab codes (80048, 80076, 81001, 81025, 83690, and 85025) and one abdominal ultrasound (76705). Since there are two unique diagnostic categories on this claim, this claim is assigned to an extended cost weight of 300.Step 3:?This claim contains a principal and five secondary diagnosis codes (R11.2, N39.0, R10.13, E07.9, Z88.6, and Z87.891). Since R11.2 is also billed as the reason for visit diagnosis code, it will be ignored in this step. Of the remaining diagnosis codes (N39.0, R10.13, E07.9, Z88.6, and Z87.891), only one is considered to be a diagnosis code that increases the complexity of the ED visit (E07.9). The patient complexity cost weight for this code is 110.Final Step:?All 3 weights are added together to determine the total weight for the claim:Total Weight = 600 + 300 + 110 = 1010This 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.Source: UnitedHealthcare, EDC Analyzer. Used with permission. ................
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