enc_0011
[Sample format] Imaging coverage gap: echocardiogram ordered but unbilled
Clinical scenario
An established patient with hypertension returns for follow-up. The physician documents palpitations, orders an echocardiogram and a lipid panel. The biller submits an E/M claim (99214) and the lipid panel (80061), but forgets to bill the echocardiogram (93306). (This is a SAMPLE FORMAT example; see enc_ahcip_001 for the AHCIP version.)
The claim as submitted
99214 (E/M moderate), 80061 (lipid panel). Echocardiogram documented but unbilled. The clinic loses $240 of revenue for work that was already done.
What Zorva found
5 findings, sorted by severity (high → low).
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HIGH
rule_imaging_002→ 93306“echocardiogram ordered”
Echocardiogram was ordered and documented but the corresponding CPT code (93306) was not billed. This is recoverable revenue that would otherwise be lost.
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MEDIUM
rule_icd_001→ R00.2“palpitations reported”
Palpitations ICD-10 (R00.2) supports the medical necessity of the echocardiogram and lipid panel.
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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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LOW
rule_icd_004→ I10“essential hypertension”
Hypertension ICD-10 (I10) supports continuity of care and chronic condition management.
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LOW
rule_lab_001→ 80061“lipid panel ordered”
Lipid panel needs medical-necessity ICD linkage (the I10 above).
What the biller would have done without Zorva
Without Zorva, the biller submits 99214 + 80061 and leaves the documented echocardiogram unbilled. The clinic loses $240 in revenue per encounter, which adds up to $960/mo at one such encounter per week. The patient may also receive a surprise bill for the unbilled echo if the clinic submits a corrected claim months later — patient-relations risk.
Dollar impact
Zorva catches the imaging-coverage gap before submission. Biller adds 93306 + R00.2 to the claim; all three lines pay on first pass. $240 recovered per encounter, ~$960/mo at one such encounter per week. The HIGH-severity imaging-coverage finding alone covers a substantial fraction of the Zorva subscription.
See it live
Open the enc_0011 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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