NCCI bundling detection
Catch conflicts before they become denials
The National Correct Coding Initiative (NCCI) defines thousands of code pairs that cannot be billed together. When your AI extraction generates both codes in a pair, Filter 17 catches it instantly.
ClaimLens maintains a lookup table of 42 high-frequency NCCI edit pairs seen in primary care — covering office visits with venipuncture, overlapping procedure bundles, and modifier conflicts. Each pair is checked in O(1) time using a Map-based lookup.
The bundled code is automatically removed from your output, and an advisory explains exactly which NCCI rule applies. No more surprise denials from bundling errors.
Payer-specific rules
Medicare, Medicaid, and Commercial aren't the same
Medicare uses G-codes (G0438/G0439 for AWV, G0444 for depression screening, G2211 for visit complexity). Commercial payers reject these — they use standard CPT codes instead.
When you select a payer context, ClaimLens automatically swaps Medicare-specific codes for their commercial equivalents, suppresses codes that only apply to one payer type, and adds payer-specific modifiers where required.
The same logic handles Medicaid nuances — Medicaid-specific billing rules, state-level modifier requirements, and benefit coverage differences that vary by program.
Medication-diagnosis gap detection
Your med list tells a story your code set should match
Filter 20 scans the medication list block of your note and cross-references it against your coded diagnoses. When a medication implies a diagnosis or Z-code that wasn't captured, it flags the gap.
This covers long-term medication Z-codes (Z79.01 anticoagulants, Z79.84 oral hypoglycemics, Z79.899 injectable GLP-1s, Z79.3 hormonal contraceptives, and more), plus medication-diagnosis mismatches where a prescription implies an uncoded condition.
The filter is scoped to the active medication list only — it ignores allergies, discontinued meds, HPI mentions, and topical/cream/ointment preparations to prevent false positives.
TCM and prolonged services opportunity flags
Revenue you're leaving on the table
Filter 48 detects TCM opportunities by scanning for discharge-related language in your note — hospital follow-up, medication reconciliation, discharge summaries. When it finds a qualifying visit, it suggests 99495 or 99496 instead of a standard office visit.
TCM codes reimburse significantly more than standard E/M codes (99496 = 4.87 RVU vs 99214 = 1.92 RVU). Filter 22 ensures TCM and standard E/M codes aren't billed together, and Filter 33 suppresses G2211 on TCM encounters.
Filter 49 flags prolonged services (99417) when time documentation in the note exceeds 55 minutes for an established patient visit, capturing additional billable units that are often missed.
HCC recapture and RAF scoring
Every missed HCC is money and risk accuracy lost
CMS risk adjustment relies on annual recapture of HCC codes. If a Medicare patient has diabetes, CKD, or heart failure on their problem list but those conditions aren't assessed in today's note, they won't be captured for RAF scoring — and your practice loses risk adjustment revenue.
ClaimLens surfaces HCC-weighted conditions from the problem list and medication list as CONDITIONAL codes, flagged with their CMS v28 HCC weight. The provider decides whether to confirm and code each condition based on today's clinical encounter.
RAF score estimates are displayed with every Medicare extraction, showing the cumulative risk adjustment impact of captured HCC codes. Recapture reminders and trending help track HCC capture rates over time.