CMS-certain findings block. Model findings advise, and say so

Two classes of finding that never blend. Only deterministic data can stop a claim; a model's opinion is always labelled as one.

What this changes for you

Your billers stop overriding the scrub

Only deterministic findings block, so a block means something. That is the difference between a gate people respect and one they click through.

A guess must never hold up a clean claim

Scrubs that block on model output train billers to override everything, which defeats the point of blocking at all.

A fact must never be softened into a guess

An NCCI edit, an MUE limit or an ICD tabular rule is not an opinion. Those block, and the reason is shown with the table it came from.

The gate answers one question

May this claim go out? Not a score, not a risk band — a verdict, with whatever blocks it named in full.

Try it on your own words

Put two codes NCCI forbids together and watch it block. Leave it empty to run the sample case. Use made-up details — this is a public page, so do not paste real patient information.

What the engine returned

real_time_policy_checker.scrub_assigned_codes + billing_trust.claim_readiness_gate

blockedSubmit gate: blocked NOT ready to submit — 1 CMS-certain issue(s) must be fixed (or overridden by a supervisor).

blocksNCCI PTP: 99214 with 20610 is allowed only with an appropriate distinct-service modifier (indicator 1). Without it the line denies as a bundle. CMS-verified · Append a distinct-procedural-service modifier (e.g. 59 / XS / 25 as appropriate) and document that the services were separate; otherwise drop the bundled line.

advisesProcedure code(s) 20610 are billed, but the note describes the procedure as planned or scheduled rather than performed at this encounter. AI — verify · advisory, does not block

advisesPrior denial for this code pair — The x-ray exists but the note never says what it showed. AI — verify · advisory, does not block

advisesPrior denial for this code pair — Not medically necessary AI — verify · advisory, does not block

cached run · 12.3s — press Run this engine for your own text

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