Rules engine

What blocks a claim, and why. Each issue names its rule so a coder can dispute it.

Rule	Severity	What it catches
`unreviewed`	block	An agent proposal nobody has accepted or rejected. The agent never gets the last word.
`header-code`	block	A category header (E11, J45) accepted instead of a billable code at the highest specificity the note supports.
`excludes1`	block	Two accepted diagnoses that ICD-10-CM says cannot be reported together. Prefix-matched so a category rule covers every subcode.
`no-diagnosis`	block	Procedure codes with no accepted diagnosis to point at.
`multiple-em`	block	More than one evaluation-and-management code on one encounter.
`modifier-25`	block	An E/M billed on the same day as a procedure without modifier 25 documenting a separately identifiable service.
`symptom-integral`	warn	A symptom code (R-codes) alongside a definitive diagnosis. Drop it if the symptom is integral.
`unverified-evidence`	warn	A code accepted with a quote that does not appear in the note.

Excludes1 pairs loaded

E11* with E10*: type 1 diabetes mellitus (E10.-) is not coded with type 2 (E11.-)
F32* with F33*: F32 Excludes1: recurrent depressive disorder (F33.-)
J06* with J02.0*: J06 Excludes1: streptococcal pharyngitis (J02.0)

Code dictionary

ICD-10-CM (48)

`E03.9`	Hypothyroidism, unspecified
`E10.9`	Type 1 diabetes mellitus without complications
`E11`	Type 2 diabetes mellitus (category) (header, not billable)
`E11.40`	Type 2 diabetes mellitus with diabetic neuropathy, unspecified
`E11.65`	Type 2 diabetes mellitus with hyperglycemia
`E11.9`	Type 2 diabetes mellitus without complications
`E66.9`	Obesity, unspecified
`E78.5`	Hyperlipidemia, unspecified
`F32.A`	Depression, unspecified
`F33.1`	Major depressive disorder, recurrent, moderate
`F41.1`	Generalized anxiety disorder
`G47.00`	Insomnia, unspecified
`H61.21`	Impacted cerumen, right ear
`H61.22`	Impacted cerumen, left ear
`H61.23`	Impacted cerumen, bilateral
`H66.91`	Otitis media, unspecified, right ear
`I10`	Essential (primary) hypertension
`I48.91`	Unspecified atrial fibrillation
`J02.0`	Streptococcal pharyngitis
`J02.9`	Acute pharyngitis, unspecified
`J06.9`	Acute upper respiratory infection, unspecified
`J18.9`	Pneumonia, unspecified organism
`J20.9`	Acute bronchitis, unspecified
`J44.1`	Chronic obstructive pulmonary disease with (acute) exacerbation
`J44.9`	Chronic obstructive pulmonary disease, unspecified
`J45`	Asthma (category) (header, not billable)
`J45.20`	Mild intermittent asthma, uncomplicated
`J45.40`	Moderate persistent asthma, uncomplicated
`J45.909`	Unspecified asthma, uncomplicated
`K21.9`	Gastro-esophageal reflux disease without esophagitis
`L03.115`	Cellulitis of right lower limb
`L57.0`	Actinic keratosis
`M17.11`	Unilateral primary osteoarthritis, right knee
`M17.12`	Unilateral primary osteoarthritis, left knee
`M25.561`	Pain in right knee
`M25.562`	Pain in left knee
`M54.50`	Low back pain, unspecified
`N18.30`	Chronic kidney disease, stage 3 unspecified
`N39.0`	Urinary tract infection, site not specified
`R05.9`	Cough, unspecified
`R10.9`	Unspecified abdominal pain
`R50.9`	Fever, unspecified
`R51.9`	Headache, unspecified
`S61.411A`	Laceration without foreign body of right hand, initial encounter
`S61.412A`	Laceration without foreign body of left hand, initial encounter
`Z00.00`	Encounter for general adult medical examination without abnormal findings
`Z23`	Encounter for immunization
`Z79.4`	Long term (current) use of insulin

CPT (19)

`12001`	Simple repair of superficial wound, 2.5 cm or less
`17000`	Destruction of premalignant lesion, first lesion
`17003`	Destruction of premalignant lesions, 2-14, each additional
`20610`	Arthrocentesis / injection, major joint
`36415`	Collection of venous blood by venipuncture
`69210`	Removal of impacted cerumen requiring instrumentation, unilateral
`81002`	Urinalysis, dipstick, non-automated, without microscopy
`87880`	Rapid streptococcus group A antigen test
`90471`	Immunization administration, one vaccine
`90686`	Influenza vaccine, quadrivalent, preservative free, IM
`93000`	Electrocardiogram, routine, with interpretation and report
`94640`	Inhalation treatment for airway obstruction (nebulizer)
`99203`	Office visit, new patient, low medical decision making (E/M)
`99204`	Office visit, new patient, moderate medical decision making (E/M)
`99212`	Office visit, established patient, straightforward MDM (E/M)
`99213`	Office visit, established patient, low MDM (E/M)
`99214`	Office visit, established patient, moderate MDM (E/M)
`99215`	Office visit, established patient, high MDM (E/M)
`99396`	Periodic preventive visit, established patient, 40-64 years (E/M)