enc_10032
[Sample format] Duplicate-service flag: annual wellness + problem visit
Clinical scenario
An established patient came in for an annual wellness visit. The physician also performed and billed a separate problem-focused ECG the same day. Without modifier -25 on the E/M line, the system would treat the second service as bundled into the first and flag it. (This is a SAMPLE FORMAT example using US-CPT codes; Zorva's production ruleset is AHCIP — see enc_ahcip_001 for the Alberta version.)
The claim as submitted
Claim 1: 99396 (annual wellness). Claim 2: 99213 (problem-focused E/M, same day, same patient). No modifier applied.
What Zorva found
1 finding, sorted by severity (high → low).
-
HIGH
rule_overlap_001→ 99213-25“duplicate service on same date”
The problem-focused E/M needs modifier -25 to unbundle from the annual wellness service.
What the biller would have done without Zorva
Without Zorva, the biller submits both claims as-is. The system bundles them and flags claim 2 — a $165 write-off that takes 60+ days to appeal.
Dollar impact
Zorva catches the modifier-25 gap before submission. Biller adds -25 to the E/M line; both claims pay on first pass. $165 recovered per encounter, ~$1,650/mo at one such occurrence per week.
See it live
Open the enc_10032 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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