enc_0000
[Sample format] Modifier-25 + ECG + palpitations + lipid panel: 5 findings
Clinical scenario
An established patient comes in for a problem-focused visit with palpitations. The physician performs an in-office ECG, reviews it, and orders a lipid panel. The chart supports a same-day E/M (99214) plus ECG (93000) plus lipid panel (80061). Five ground-truth findings span evaluation, cardiology, diagnosis, modifier, and laboratory categories. (SAMPLE FORMAT — see enc_ahcip_001 for the AHCIP version of this scenario.)
The claim as submitted
99214 (E/M moderate), 93000 (ECG with interpretation), 80061 (lipid panel). Documentation supports a same-day separately-identifiable E/M with procedure.
What Zorva found
5 findings, sorted by severity (high → low).
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HIGH
rule_modifier_25_001→ 99214-25“separately identifiable E/M”
Same-day E/M + procedure requires modifier -25 to unbundle the E/M from the ECG. Without it, the system bundles and denies the E/M.
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INFO
rule_em_001→ 99214“established patient moderate complexity”
Documentation supports moderate-complexity E/M. Verify chart review elements for 99214.
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MEDIUM
rule_ecg_001→ 93000“ECG performed in office”
ECG billed — verify interpretation is documented separately from the tracing acquisition.
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MEDIUM
rule_icd_001→ R00.2“palpitations reported”
Palpitations ICD-10 (R00.2) must support the ECG and lipid panel.
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LOW
rule_lab_lipid_001→ 80061“lipid panel ordered”
Lipid panel needs medical-necessity ICD linkage.
What the biller would have done without Zorva
Without Zorva, the biller submits 99214 + 93000 + 80061 with R00.2 as the only ICD. The system flags the 99214 because modifier -25 is missing (E/M bundled into the ECG), then flags the 80061 for medical necessity (lipid panel not linked to a diabetes ICD). $385 of denied revenue per encounter.
Dollar impact
Zorva catches all 5 gaps before submission. Biller adds modifier -25 + R00.2 + E11.65 (screening for lipid panel); all three lines pay on first pass. $385 recovered per encounter, ~$1,540/mo at one such encounter per week. The HIGH-severity modifier-25 finding alone pays for the entire Zorva subscription if caught once per month.
See it live
Open the enc_0000 encounter detail ↗
The encounter detail page renders the same findings as this case study, with verbatim quotes highlighted in the clinical note and per-finding Accept / Dismiss / Re-run buttons.
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