CMS NCCI Claim Scrubber & Modifier Validator
Verify procedure bundling rules before claim submission. Test any two CPT codes against National Correct Coding Initiative (NCCI) edit indicators (0 vs 1), review modifier -25 and -59/-XS requirements, and prevent unbundling rejections.
Claim Scrubber & Modifier Validator
Test CPT code combinations against National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) bundling rules before submission to prevent instant CARC 97 denials.
Frequent Clinical Scenarios:
Recommended: Append Modifier -25 to bypass the claim bundling edit when supported by documentation.
CMS Clinical Coding Rationale
CMS considers minor surgical procedures (0 or 10-day global period) to include the routine pre- and post-procedure evaluation. An E/M service may only be paid separately if significant, separately identifiable medical care is provided beyond the injection.
CARC 97: Benefit included in the payment for another service/procedure.
Medical Record Audit Requirements
Payers perform pre- and post-payment audits on modifier claims. Ensure your physician note contains:
- Document a distinct history, exam, or medical decision-making unrelated to the decision to perform the injection (or evaluating chronic comorbidities).
- The clinical note must stand alone as a billable level 4 visit even if the injection portion is excised.
- Append Modifier -25 directly to CPT 99214 (never to 20610).
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