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®

EDC Analyzer
™

 * EDC Analyzer™ Guide
   * Overview
   * Step 1
   * Step 2
   * Step 3
   * Final Step
   * Background
 * Claim Examples
   * Claim Example 1
   * Claim Example 2
   * Claim Example 3
   * Claim Example 4
   * Claim Example 5
 * Try A Claim Examples
   * Try Claim Example 1
   * Try Claim Example 2
   * Try Claim Example 3
   * Try Claim Example 4
   * Try Claim Example 5
   

EDC Analyzer™ Guide >Overview


OVERVIEW

The goal of the Optum Emergency Department Claim (EDC) Analyzer is to achieve
fair and consistent evaluation and management coding and reimbursement of
facility outpatient emergency department claims. The EDC Analyzer™
systematically evaluates each ED visit level code in the context of other claim
data (i.e., diagnosis codes, procedure codes, patient age, and patient sex*) to
ensure that it reasonably relates to the intensity of hospital resource
utilization as required per CMS Guidelines. The methodology used by the EDC
Analyzer™ is based on Optum's Lynx™ tool, which is used by 1,500 facilities
nationwide to code outpatient emergency department claims. This idea of a shared
methodology for both payers and providers underscores Optum's commitment to
simplify the health care system, and promote transparency in the coding and
reimbursement process. For more background information about the EDC Analyzer™,
click here.

*Patient sex assigned at birth

The appropriate visit level of an ED claim is determined by the EDC Analyzer™
using the following 4-step process:




STEP 1: STANDARD WEIGHTS

Determines the standard weight of the visit based on the patient’s demographic
characteristics and presenting problem. Assigns a standard weight to the visit
based on this evaluation. More...




STEP 2: EXTENDED WEIGHTS

Evaluates the intensity of the diagnostic workup performed by the facility based
on diagnostic CPT codes. Assigns an extended weight to the visit based on this
evaluation. More...



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STEP 3: PATIENT COMPLEXITY WEIGHTS

Determines if the patient has any conditions or has experienced any
circumstances that may increase the complexity of the visit. Assigns a patient
complexity weight to the visit based on this determination. More...



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FINAL STEP: CALCULATE VISIT LEVEL

The weights from steps 1 through 3 are summed and a visit level is assigned
based on that summation. More...




To view how the EDC Analyzer™ processes specific claim scenarios, review the
following examples:

 1. Claim Example 1
    
    
 2. Claim Example 2
    
    
 3. Claim Example 3
    
    
 4. Claim Example 4
    
    
 5. Claim Example 5
    
    

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© 2023 Optum, Inc. All rights reserved. | CPT only © 2022 American Medical
Association. All rights reserved. | U.S. Patent No. 10,417,382