CPT Code Selection Validator
Validate CPT codes against documentation and CMS compliance rules
What You Can Do
You can validate CPT code assignments against source documentation to catch discrepancies, flag potential upcoding or downcoding, and verify compliance with bundling rules and medical necessity criteria. This skill identifies common coding errors, confirms modifier usage aligns with payer requirements, and provides evidence-based justification for code choices—reducing claim denials, audit risk, and revenue leakage.
Features
Cross-references clinical documentation against selected CPT codes to verify services match coded procedures
Identifies global surgery components, mutually exclusive codes, and CMS/payer bundling violations
Confirms coded services meet documentation standards and payer medical necessity thresholds
Validates modifier usage against specific payer policies, LCD updates, and CMS guidelines
Flags high-risk codes (E/M levels, imaging, surgery) and complex multi-procedural cases prone to audits
Generates documentation-to-code mapping and payer-specific rule adherence confirmation
Identifies common upcoding/downcoding patterns and suggests corrective coding actions
Produces evidence-based coding justification suitable for appeal responses and audit defense
Example Output
Example 1: E/M Code Validation
CODE UNDER REVIEW: 99215 (Office visit, established patient, high complexity)
DOCUMENTATION REVIEW:
✓ History of Present Illness: Detailed (documented)
✓ Review of Systems: Comprehensive (documented)
✓ Physical Exam: Comprehensive (documented)
✓ Medical Decision Making: High complexity (documented)
✓ Time threshold met: 40+ minutes (documented)
COMPLIANCE STATUS: VALID
Code 99215 supported by documentation. MDM complexity includes new problem workup with moderate risk. Meets 2015 CPT guidelines.
Example 2: Bundling Error Detection
CODES UNDER REVIEW: 27447 (Total knee replacement) + 20610 (Arthrocentesis, major joint)
BUNDLING CONFLICT DETECTED:
✗ Code 20610 is included in global surgical package for 27447
✗ Cannot bill separately without anatomical modifier (25) or distinct body part indicator
RECOMMENDATION:
Remove 20610 OR apply anatomically appropriate modifier if service performed on separate anatomical location.
Example 3: Modifier Validation
CODE: 92004 (Comprehensive eye exam) + Modifier 76 (Repeat procedure)
PAYER: Medicare
POLICY CHECK:
✗ Medicare LCD prohibits Modifier 76 on preventive eye exams within 12-month period
✓ Modifier 77 (Repeat by another physician) applies if different provider performed exam
RECOMMENDATION: Revise modifier to 77 or remove if within lookback period.
What's Included
- SKILL.md: Complete validation framework with CMS/payer rule references
- Documentation Review Checklist: Line-by-line documentation elements to verify against code requirements
- Bundling Rule Matrix: Quick-reference table for common global surgery components and mutually exclusive codes
- Payer Compliance Template: MAC/LCD policy tracking and code-specific requirement verification worksheet
- Audit Risk Assessment Grid: Flags high-risk codes and complex procedural combinations requiring secondary review
Who It's For
- Medical Coders — Validating CPT selections before claim submission and during secondary review
- Coding Managers — QA/QC review of coder work and compliance monitoring
- Revenue Cycle Compliance Officers — Pre-claim validation and audit risk mitigation
- Denial Management Specialists — Verifying coding accuracy on denied claims for appeal preparation
- Healthcare Auditors — Substantiating code selections during internal compliance audits
Best For
- Pre-claim CPT code validation against clinical documentation
- Multi-procedural case verification (surgical packages, E/M with procedures)
- High-risk code compliance checking (E/M audits, imaging appropriateness, global surgery rules)
- Payer-specific modifier and bundling rule adherence verification
- Denial case review and audit defense documentation preparation
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