CPT Code Assignment Validator
Validate CPT codes against CMS guidelines and payer requirements before claim submission
What You Can Do
You can submit procedure documentation, assigned CPT codes, and patient factors to Claude for independent verification against CMS guidelines and payer-specific requirements. Claude cross-references codes against clinical details, flags bundling violations, validates modifier usage, and identifies compliance gaps before claims submission. This reduces coding errors, appeal rates, and denial risk by catching issues during the coding review phase rather than after claim submission.
Features
validates assigned codes match procedure documentation and clinical complexity
identifies unbundled codes, global period implications, and component code combinations that violate CMS rules
systematically checks appropriate use of -25, -50, -51, -59, -LT, -RT and other critical modifiers
cross-references codes against payer-specific bundling policies and coverage rules
systematically compares 2-3 CPT code options to recommend the most accurate assignment
generates audit-ready justification for code selection to support payer appeals
identifies all required component codes for multi-step procedures and validates their combination
highlights potential denial triggers and documentation gaps that need remediation
Example Output
Example 1: Bundling Issue Detection
Input: CPT 99213 (office visit) + 99214 (higher-level office visit) + 90834 (therapy) assigned to same date
Output:
- ⚠️ BUNDLING VIOLATION DETECTED
- CPT 99213 and 99214 cannot be billed together (mutually exclusive)
- RECOMMENDATION: Bill highest complexity level only (99214)
- CPT 90834 is billable with 99213/99214 when supported by documentation
- Use modifier -25 if psychotherapy adds significant, separately identifiable E/M
- Document time breakdown if -25 is claimed
Example 2: Modifier Validation
Input: CPT 20610 (arthrocentesis, major joint) bilateral knee with modifier -50
Output:
- ✅ MODIFIER USAGE CORRECT
- CPT 20610 is modifier -50 eligible (bilateral procedure)
- Single code + modifier -50 = appropriate billing method
- Payer reimbursement: 150% of single code value (100% + 50%)
- Alternative: CPT 20610 (left) + CPT 20610-RT (right) — verify payer preference
Example 3: Code Selection Comparison
Input: Laparoscopic cholecystectomy with unclear documentation of complexity
Output:
CODE OPTIONS ANALYSIS
- CPT 47562 (laparoscopic cholecystectomy, routine) — Base recommendation
- CPT 47563 (complex/inflamed) — Requires documentation of complication
- Current documentation supports: 47562
- Missing elements for 47563: No mention of adhesions, inflammation, or conversion risk
What's Included
- SKILL.md instruction file: Complete validator workflow and usage guidelines
- CPT Code Validation Checklist: Step-by-step verification template for bundling, modifiers, and payer rules
- Modifier Matrix Framework: Quick reference for -25, -50, -51, -59, laterality modifiers with bundling rules
- Complex Procedure Code Breakdown Template: Component code identification and combination validation for multi-step procedures
- Payer Compliance Quick Reference: Common bundling rules and coverage restrictions by payer type
Who It's For
- Medical Coders — Verify CPT assignments before claim submission and reduce denial rates
- Billing Managers — Audit coding accuracy and identify compliance gaps in claim submissions
- Healthcare Compliance Officers — Validate coding practices against CMS guidelines and payer requirements
- Coding Supervisors — Peer-review complex code assignments and document rationale for appeals
- Revenue Cycle Teams — Catch coding errors early to improve first-pass claim acceptance rates
Best For
- Validating CPT code assignments before claim submission
- Identifying bundling violations and global period issues
- Verifying modifier usage (especially bilateral, -25, -51, -59)
- Comparing multiple CPT code options for the same procedure
- Documenting coding rationale for payer appeals
- Auditing high-risk or complex procedure codes
- Ensuring compliance with payer-specific bundling and coverage rules
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