shashanks/medical_coding
0
1{2 "icd10_guidelines": {3 "E10.9": {4 "description": "Type 1 diabetes mellitus without complications",5 "excludes1": ["E11", "E08", "E09", "E13"],6 "gender_restriction": null,7 "note": "Excludes1: Type 2 diabetes mellitus (E11.-), Drug or chemical induced diabetes mellitus (E09.-), Diabetes mellitus due to underlying condition (E08.-), Other specified diabetes mellitus (E13.-). Use additional code to identify complications."8 },9 "E11.9": {10 "description": "Type 2 diabetes mellitus without complications",11 "excludes1": ["E10", "E08", "E09", "E13"],12 "gender_restriction": null,13 "note": "Excludes1: Type 1 diabetes mellitus (E10.-), Drug or chemical induced diabetes mellitus (E09.-), Diabetes mellitus due to underlying condition (E08.-), Other specified diabetes mellitus (E13.-). Excludes2: gestational diabetes mellitus (O24.4-)."14 },15 "O80": {16 "description": "Encounter for full-term uncomplicated delivery",17 "excludes1": [],18 "gender_restriction": "female",19 "note": "Requires that the delivery be spontaneous, full term, of a single healthy infant without documentation of any complication of antepartum care. APPLICABLE TO FEMALE PATIENTS ONLY. This code is in the Pregnancy, Childbirth and the Puerperium chapter (O00-O9A) which by definition applies only to female patients. Coding this for a male patient represents a gender-sex clinical logic error.",20 "age_restriction": "15-55",21 "chapter": "Pregnancy, Childbirth and the Puerperium"22 },23 "Z00.00": {24 "description": "Encounter for general adult medical examination without abnormal findings",25 "excludes1": [],26 "gender_restriction": null,27 "note": "Use additional code to identify any abnormal findings. Excludes1: encounter for examination for administrative purposes (Z02.-). Applicable to adults of any gender."28 },29 "Z87.891": {30 "description": "Personal history of other specified conditions",31 "excludes1": [],32 "gender_restriction": null,33 "note": "Applicable to patients of any age or gender with a personal history of specified conditions not elsewhere classified."34 },35 "J44.1": {36 "description": "Chronic obstructive pulmonary disease with acute exacerbation",37 "excludes1": ["J45"],38 "gender_restriction": null,39 "note": "Excludes1: asthma (J45.-). Code also type of asthma if applicable. Excludes2: acute bronchitis (J20.-)."40 },41 "J45.20": {42 "description": "Mild intermittent asthma, uncomplicated",43 "excludes1": [],44 "gender_restriction": null,45 "note": "Excludes1 within J45 category: chronic obstructive pulmonary disease (J44.-). Code also: eosinophilic asthma if applicable."46 },47 "S52.501A": {48 "description": "Unspecified fracture of the lower end of right radius, initial encounter for closed fracture",49 "excludes1": [],50 "gender_restriction": null,51 "note": "7th character extensions for category S52: A = initial encounter for closed fracture (use during the active phase of treatment when the patient is receiving definitive treatment for the fracture, e.g., surgical treatment, emergency department encounter, evaluation and treatment by a new physician). D = subsequent encounter for fracture with routine healing (use for encounters after the patient has received active/definitive treatment for the fracture and is receiving routine care during the healing phase). G = subsequent encounter for fracture with delayed healing. K = subsequent encounter for fracture with nonunion. P = subsequent encounter for fracture with malunion. S = sequela. IMPORTANT: A follow-up visit after active treatment has concluded must use 7th character D (subsequent encounter), not A (initial encounter).",52 "seventh_char_guidance": "Character 'A' (initial encounter) is appropriate ONLY during the active/definitive treatment phase. For follow-up visits after the fracture was initially treated, character 'D' (subsequent encounter for fracture with routine healing) must be used."53 },54 "S52.501D": {55 "description": "Unspecified fracture of the lower end of right radius, subsequent encounter for fracture with routine healing",56 "excludes1": [],57 "gender_restriction": null,58 "note": "Use 7th character D for encounters after active treatment is completed, when patient is receiving routine care during healing phase (e.g., cast checks, follow-up X-rays, physical therapy oversight)."59 },60 "M79.621": {61 "description": "Pain in right upper arm",62 "excludes1": [],63 "gender_restriction": null,64 "note": "Excludes1: pain in right shoulder (M79.611). Applicable to any patient with pain specifically localized to the right upper arm. No gender or age restriction."65 },66 "Z99.999": {67 "description": null,68 "excludes1": [],69 "gender_restriction": null,70 "note": "INVALID/UNTRACEABLE CODE: Z99.999 does not exist in the official ICD-10-CM tabular list. Z99 category covers 'Dependence on enabling machines and devices, not elsewhere classified' with valid codes Z99.0 through Z99.89. Z99.999 is not a valid billable code and cannot be verified against any official coding reference. Must be flagged as an untraceable code requiring correction before submission.",71 "is_valid": false72 }73 },74 "cpt_guidelines": {75 "99213": {76 "description": "Office or other outpatient visit for a new or established patient, requires a medically appropriate history and/or examination and low to moderate level of medical decision making or 20-29 minutes of total time",77 "gender_restriction": null,78 "note": "Level 3 E/M office visit. Cannot be billed with 99214 for the same encounter as they represent different complexity levels of the same service type.",79 "bundling_note": "When billed on the same claim as 99214, represents unbundling - only the highest complexity E/M should be billed."80 },81 "99214": {82 "description": "Office or other outpatient visit for a new or established patient, requires a medically appropriate history and/or examination and moderate to high level of medical decision making or 30-39 minutes of total time",83 "gender_restriction": null,84 "note": "Level 4 E/M office visit. Cannot be billed with 99213 for the same encounter."85 },86 "93306": {87 "description": "Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography",88 "gender_restriction": null,89 "note": "Complete transthoracic echocardiography. This is a comprehensive study that by definition includes all components that would be separately reported by 93307 (limited TTE) or 93308 (follow-up/limited TTE). Per NCCI policy, billing 93306 together with 93307 or 93308 on the same date of service for the same patient constitutes unbundling and is subject to automatic claim denial. The complete study (93306) inherently encompasses all elements of the limited/follow-up study.",90 "ncci_conflicts": ["93307", "93308"]91 },92 "93307": {93 "description": "Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, without spectral or color Doppler echocardiography",94 "gender_restriction": null,95 "note": "Limited transthoracic echocardiography (without Doppler). This is a component study that is already included within 93306 (complete TTE). Billing 93307 on the same claim as 93306 for the same date of service is a NCCI PTP (Procedure-to-Procedure) edit violation representing unbundling.",96 "ncci_conflicts": ["93306"]97 },98 "93308": {99 "description": "Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study",100 "gender_restriction": null,101 "note": "Follow-up or limited transthoracic echocardiography. Cannot be billed with 93306 on the same date of service - NCCI PTP edit applies.",102 "ncci_conflicts": ["93306"]103 }104 },105 "ncci_edits": [106 {107 "column1": "93306",108 "column2": "93307",109 "conflict_type": "mutually_exclusive",110 "modifier_allowed": false,111 "note": "NCCI PTP Edit: CPT 93306 (complete TTE) and CPT 93307 (limited TTE without Doppler) are mutually exclusive. A complete echocardiographic study inherently includes all elements of a limited study. Billing both represents unbundling. No modifier is allowed to bypass this edit. Effective since CMS NCCI inception."112 },113 {114 "column1": "93306",115 "column2": "93308",116 "conflict_type": "mutually_exclusive",117 "modifier_allowed": false,118 "note": "NCCI PTP Edit: CPT 93306 (complete TTE) and CPT 93308 (follow-up/limited TTE) cannot be billed together on the same date of service for the same patient. The complete study subsumes the limited/follow-up study."119 },120 {121 "column1": "99213",122 "column2": "99214",123 "conflict_type": "mutually_exclusive",124 "modifier_allowed": false,125 "note": "NCCI Edit: Two different levels of E/M office visit codes (99213 and 99214) cannot be billed for the same patient on the same date of service. Only the code that best represents the complexity of services rendered should be reported."126 }127 ],128 "tasks": [129 {130 "task_id": "easy_demographic",131 "difficulty": "easy",132 "description": "Identify a demographic applicability mismatch in the proposed ICD-10 codes for a male patient.",133 "scenario": "A 34-year-old male patient's chart contains a maternity-specific ICD-10 code that is clinically impossible for male patients.",134 "patient": {135 "age": 34,136 "sex": "male",137 "mrn": "MRN-2024-001",138 "insurance": "Blue Cross PPO"139 },140 "clinical_note": "REASON FOR VISIT: Annual physical examination.\n\nHISTORY OF PRESENT ILLNESS: Mr. J.T. is a 34-year-old male presenting for his routine annual wellness examination. He has a 5-year history of type 2 diabetes mellitus, well-controlled with metformin 1000mg twice daily. He denies polyuria, polydipsia, or blurred vision. No acute complaints today.\n\nPAST MEDICAL HISTORY: Type 2 diabetes mellitus (diagnosed 2019), mild hypertension.\n\nSOCIAL HISTORY: Non-smoker, occasional alcohol use, employed as software engineer.\n\nREVIEW OF SYSTEMS: Negative for chest pain, dyspnea, GI complaints, or urinary symptoms.\n\nPHYSICAL EXAM: Vitals: BP 128/82, HR 72, Wt 185 lbs, Ht 5'10\". General: Alert and oriented male in no acute distress. Cardiovascular: Regular rate and rhythm. Respiratory: Clear to auscultation bilaterally. Abdomen: Soft, non-tender.\n\nASSESSMENT AND PLAN: 1. Type 2 diabetes mellitus — well controlled, continue current regimen, recheck HbA1c in 3 months. 2. Routine health maintenance — ordered age-appropriate cancer screenings.",141 "proposed_codes": {142 "E11.9": {143 "description": "Type 2 diabetes mellitus without complications",144 "code_type": "ICD-10-CM"145 },146 "Z00.00": {147 "description": "Encounter for general adult medical examination without abnormal findings",148 "code_type": "ICD-10-CM"149 },150 "O80": {151 "description": "Encounter for full-term uncomplicated delivery",152 "code_type": "ICD-10-CM"153 }154 },155 "expected_errors": [156 {157 "code": "O80",158 "error_type": "demographic_mismatch",159 "description": "O80 (Encounter for full-term uncomplicated delivery) is a maternity code from the Pregnancy, Childbirth and the Puerperium chapter (O00-O9A), which by definition applies only to female patients. This code is clinically impossible for Mr. J.T., a 34-year-old male patient. Assigning this code to a male patient represents a severe demographic-sex applicability error.",160 "key_terms": ["female", "male", "maternity", "obstetric", "delivery", "sex", "gender", "demographic"],161 "evidence_spans": ["34-year-old male", "Mr. J.T.", "Alert and oriented male"]162 }163 ],164 "max_steps": 10,165 "hints": [166 "Check each proposed code against the patient's demographic information",167 "Pay attention to the chapter classification of each ICD-10 code",168 "O-codes (O00-O9A) are the Obstetrics chapter — they apply exclusively to female patients"169 ],170 "clarification_pool": [171 {172 "triggers": ["sex", "gender", "male", "female", "patient sex", "patient gender", "o80", "obstetric", "maternity", "delivery"],173 "response": "The patient is a 34-year-old male. He has never been pregnant. Code O80 was added in error — it is not clinically applicable to this patient."174 }175 ]176 },177 {178 "task_id": "medium_ncci_conflict",179 "difficulty": "medium",180 "description": "Identify a CMS NCCI Procedure-to-Procedure (PTP) bundling violation in the proposed CPT codes.",181 "scenario": "A 67-year-old female patient's cardiology encounter has two echocardiography CPT codes billed together that constitute a NCCI PTP edit (unbundling violation).",182 "patient": {183 "age": 67,184 "sex": "female",185 "mrn": "MRN-2024-002",186 "insurance": "Medicare Part B"187 },188 "clinical_note": "REASON FOR VISIT: Cardiology evaluation for known coronary artery disease and assessment of left ventricular function.\n\nHISTORY OF PRESENT ILLNESS: Mrs. E.R. is a 67-year-old female with a history of coronary artery disease (status post PCI in 2021), hypertension, and hyperlipidemia. She presents for follow-up and cardiac function monitoring. She reports mild dyspnea on exertion but denies chest pain at rest, orthopnea, or paroxysmal nocturnal dyspnea.\n\nSERVICES RENDERED: A complete transthoracic echocardiogram was performed today with 2D imaging, M-mode recording, spectral Doppler, and color flow Doppler to provide comprehensive assessment of valvular function and left ventricular ejection fraction (LVEF estimated at 50-55%). Additionally, a limited echocardiographic study was documented to assess regional wall motion abnormality in the anterolateral territory.\n\nASSESSMENT: LVEF mildly reduced at 50-55%. Mild mitral regurgitation. No new wall motion abnormalities.\n\nPLAN: Continue current cardiac medications. Repeat echo in 12 months. Return to clinic in 3 months or sooner if symptoms worsen.",189 "proposed_codes": {190 "93306": {191 "description": "Echocardiography, transthoracic, complete study with spectral and color flow Doppler",192 "code_type": "CPT"193 },194 "93307": {195 "description": "Echocardiography, transthoracic, limited study without spectral or color Doppler",196 "code_type": "CPT"197 },198 "99213": {199 "description": "Office visit, established patient, low-moderate complexity",200 "code_type": "CPT"201 }202 },203 "expected_errors": [204 {205 "code": "93306",206 "error_type": "ncci_edit",207 "conflicting_code": "93307",208 "description": "CPT 93306 (complete transthoracic echocardiography with Doppler) and CPT 93307 (limited TTE without Doppler) are subject to a CMS NCCI Procedure-to-Procedure (PTP) edit. A complete echocardiographic study (93306) inherently includes all components of a limited study (93307). Billing both codes on the same date of service for the same patient constitutes unbundling. No modifier is permitted to override this edit. Only 93306 should be reported.",209 "key_terms": ["bundling", "unbundling", "NCCI", "PTP", "complete", "limited", "component", "comprehensive", "93307"],210 "evidence_spans": ["complete transthoracic echocardiogram was performed today", "limited echocardiographic study was documented"]211 }212 ],213 "max_steps": 15,214 "hints": [215 "Use CheckNCCIEdits to verify whether any CPT code pair has a bundling conflict",216 "The complete echo (93306) includes all elements of the limited echo (93307) by definition",217 "NCCI PTP edits prevent unbundling of component services from their comprehensive code"218 ]219 },220 {221 "task_id": "hard_specificity_untraceable",222 "difficulty": "hard",223 "description": "Identify a 7th character specificity error (wrong encounter type) and an untraceable ICD-10 code in a complex fracture follow-up encounter.",224 "scenario": "A 28-year-old male presents for a follow-up visit for a healing radius fracture. The proposed codes include the wrong 7th character extension (initial encounter used instead of subsequent encounter) and an invalid ICD-10 code that cannot be traced to any official code set.",225 "patient": {226 "age": 28,227 "sex": "male",228 "mrn": "MRN-2024-003",229 "insurance": "Aetna HMO"230 },231 "clinical_note": "REASON FOR VISIT: Follow-up visit, 6 weeks post closed fracture of distal right radius.\n\nHISTORY OF PRESENT ILLNESS: Mr. A.K. is a 28-year-old male presenting for routine follow-up 6 weeks after sustaining a closed fracture of the distal right radius during a bicycle fall. He was initially treated in the emergency department where the fracture was reduced and a short-arm cast was applied. Today, the cast has been removed. He reports significant improvement in pain and function.\n\nEXAMINATION: Right wrist: mild residual swelling, tenderness to palpation over the distal radius. Grip strength 60% compared to contralateral side. ROM: flexion/extension 40 degrees (limited), improving.\n\nIMAGING: Repeat X-ray of the right wrist demonstrates appropriate callus formation with no evidence of nonunion or malunion. Alignment maintained.\n\nASSESSMENT AND PLAN:\n1. Closed fracture distal right radius — healing well with routine progress. Cast removed today. Begin formal physical therapy for range of motion and strengthening.\n2. Right upper arm pain — mild, consistent with disuse atrophy and guarding after cast immobilization.\n3. Continue NSAIDs for pain as needed.\n4. Return to clinic in 4 weeks for final follow-up X-ray.\n\nNote: Fracture originally sustained 6 weeks ago. This is a SUBSEQUENT ENCOUNTER for a healing fracture, not an initial encounter.",232 "proposed_codes": {233 "S52.501A": {234 "description": "Unspecified fracture of lower end of right radius, initial encounter for closed fracture",235 "code_type": "ICD-10-CM"236 },237 "M79.621": {238 "description": "Pain in right upper arm",239 "code_type": "ICD-10-CM"240 },241 "Z99.999": {242 "description": "Unspecified dependence on enabling machine (placeholder)",243 "code_type": "ICD-10-CM"244 }245 },246 "expected_errors": [247 {248 "code": "S52.501A",249 "error_type": "specificity_error",250 "description": "The 7th character 'A' (initial encounter for closed fracture) is incorrect for this visit. Per ICD-10-CM guidelines, the 7th character 'A' should be used only during the active/definitive treatment phase. The clinical note explicitly documents that this is a follow-up visit 6 weeks after the original injury, at which point active/definitive treatment has concluded. The correct code is S52.501D (subsequent encounter for fracture with routine healing). Using 'A' on a follow-up visit misrepresents the phase of care and is a compliance violation.",251 "key_terms": ["7th character", "subsequent", "initial", "follow-up", "healing", "S52.501D", "encounter type", "phase of care"],252 "evidence_spans": ["Follow-up visit, 6 weeks post closed fracture", "SUBSEQUENT ENCOUNTER for a healing fracture, not an initial encounter", "routine follow-up 6 weeks after"]253 },254 {255 "code": "Z99.999",256 "error_type": "untraceable_code",257 "description": "Z99.999 does not exist in the official ICD-10-CM tabular list. The Z99 category (Dependence on enabling machines and devices, NEC) contains valid codes only through Z99.89. Z99.999 is not a recognized, billable ICD-10-CM code. This code cannot be validated against any official coding reference and must be flagged as untraceable. Submitting an untraceable code to a payer will result in claim denial.",258 "key_terms": ["invalid", "untraceable", "not exist", "Z99", "not found", "official", "billable"],259 "evidence_spans": ["Unspecified dependence on enabling machine (placeholder)"]260 }261 ],262 "max_steps": 20,263 "hints": [264 "Read the clinical note carefully for clues about the visit type (initial vs. follow-up)",265 "7th character extensions for fracture codes indicate the phase of care, not just the fracture type",266 "For codes that cannot be found in the guideline database, flag them as untraceable",267 "ICD-10-CM Z99 category only has valid codes through Z99.89 — verify each code exists"268 ],269 "clarification_pool": [270 {271 "triggers": ["initial", "subsequent", "follow-up", "encounter type", "7th character", "first visit", "fracture treatment", "active treatment"],272 "response": "This is a follow-up visit. The fracture was first treated 6 weeks ago in the emergency department. Today's visit is for routine monitoring of healing — the patient is no longer in the active/definitive treatment phase."273 },274 {275 "triggers": ["z99", "z99.999", "untraceable", "invalid code", "not exist", "dependence"],276 "response": "Z99.999 was added by a transcription error. It does not correspond to any active diagnosis for this patient. The Z99 category only has valid codes through Z99.89."277 }278 ]279 },280 {281 "task_id": "medium_excludes1",282 "difficulty": "medium",283 "description": "Identify an ICD-10-CM Excludes1 (mutually exclusive) conflict between COPD and asthma codes billed on the same encounter.",284 "scenario": "A 58-year-old female presents to pulmonary clinic with an acute COPD exacerbation. The coder has listed both J44.1 (COPD with exacerbation) and J45.20 (mild intermittent asthma) on the same claim, violating the Excludes1 relationship between these two categories.",285 "patient": {286 "age": 58,287 "sex": "female",288 "mrn": "MRN-2024-004",289 "insurance": "United Healthcare PPO"290 },291 "clinical_note": "REASON FOR VISIT: Acute exacerbation of chronic obstructive pulmonary disease.\n\nHISTORY OF PRESENT ILLNESS: Ms. D.L. is a 58-year-old female with a 20-year history of COPD (GOLD stage II) presenting with worsening dyspnea, increased sputum production, and purulent sputum over the past 4 days. She is a former smoker (35 pack-year history, quit 3 years ago). She has been using her albuterol rescue inhaler 6-8 times daily, up from her baseline of 1-2 times daily.\n\nPAST MEDICAL HISTORY: COPD diagnosed 2004. Note: Patient was previously given a working diagnosis of 'mild intermittent asthma' by her PCP in 2002, but pulmonary function testing in 2004 confirmed irreversible airflow obstruction consistent with COPD. The asthma diagnosis was superseded by the COPD diagnosis. She does NOT carry a concurrent asthma diagnosis.\n\nMEDICATIONS: Tiotropium 18mcg daily, fluticasone/salmeterol 250/50 BID, albuterol PRN.\n\nPHYSICAL EXAM: Vitals: BP 138/86, HR 92, RR 22, SpO2 91% on room air, Temp 99.1F. Respiratory: Diffuse expiratory wheezes bilaterally, prolonged expiratory phase, decreased breath sounds at bases. Using accessory muscles of respiration.\n\nSPIROMETRY (in-office): FEV1 45% predicted (baseline 58%), FEV1/FVC ratio 0.62. Post-bronchodilator FEV1 improvement <10% (consistent with COPD, not asthma).\n\nASSESSMENT AND PLAN:\n1. COPD with acute exacerbation — start prednisone 40mg daily x 5 days, azithromycin 500mg day 1 then 250mg days 2-5. Increase tiotropium. Oxygen supplementation as needed.\n2. The prior 'asthma' label from 2002 is no longer an active diagnosis. PFTs confirm irreversible obstruction. Do NOT code asthma concurrently with COPD per Excludes1 guidelines.",292 "proposed_codes": {293 "J44.1": {294 "description": "Chronic obstructive pulmonary disease with acute exacerbation",295 "code_type": "ICD-10-CM"296 },297 "J45.20": {298 "description": "Mild intermittent asthma, uncomplicated",299 "code_type": "ICD-10-CM"300 },301 "Z87.891": {302 "description": "Personal history of other specified conditions",303 "code_type": "ICD-10-CM"304 }305 },306 "expected_errors": [307 {308 "code": "J44.1",309 "error_type": "excludes1_conflict",310 "conflicting_code": "J45.20",311 "description": "ICD-10-CM code J44.1 (COPD with acute exacerbation) has an Excludes1 note for J45.- (Asthma). This means J44.1 and J45.20 (Mild intermittent asthma) are mutually exclusive and cannot be reported on the same encounter. The clinical note confirms the patient's diagnosis is COPD with irreversible obstruction; the prior asthma label was superseded. Only J44.1 should be coded.",312 "key_terms": ["Excludes1", "mutually exclusive", "asthma", "COPD", "J45", "J44", "cannot be coded together", "superseded"],313 "evidence_spans": ["asthma diagnosis was superseded by the COPD diagnosis", "Do NOT code asthma concurrently with COPD per Excludes1 guidelines", "She does NOT carry a concurrent asthma diagnosis"]314 }315 ],316 "max_steps": 15,317 "hints": [318 "Query the guidelines for J44.1 and check its Excludes1 list",319 "Excludes1 means the two conditions cannot coexist on the same claim — they are mutually exclusive",320 "Look at the clinical note for evidence about whether both diagnoses are currently active",321 "Z87.891 (personal history) is a valid code and does not conflict with the other codes"322 ]323 },324 {325 "task_id": "expert_multi_error",326 "difficulty": "expert",327 "description": "Identify multiple coding errors (Excludes1 conflict + NCCI bundling violation) in a complex multi-system encounter with valid codes acting as false-positive traps.",328 "scenario": "A 65-year-old male is seen for a comprehensive cardiology and endocrinology evaluation. The proposed codes contain two distinct errors: an Excludes1 conflict between Type 1 and Type 2 diabetes codes, and an NCCI PTP edit between echocardiography codes. Two additional codes are valid and should NOT be flagged.",329 "patient": {330 "age": 65,331 "sex": "male",332 "mrn": "MRN-2024-005",333 "insurance": "Medicare Part B"334 },335 "clinical_note": "REASON FOR VISIT: Comprehensive cardiology follow-up with concurrent endocrinology management.\n\nHISTORY OF PRESENT ILLNESS: Mr. R.P. is a 65-year-old male with a history of Type 2 diabetes mellitus (diagnosed 2010, managed with metformin 1000mg BID and glipizide 5mg daily), coronary artery disease (status post 2-vessel CABG in 2019), hypertension, and chronic right upper arm pain from a rotator cuff repair 6 months ago.\n\nHe presents for his annual comprehensive cardiac evaluation and diabetes management review. His HbA1c has been stable at 7.2%. He reports occasional exertional dyspnea (NYHA class II) but no chest pain, syncope, or lower extremity edema. His right arm pain is improving with physical therapy.\n\nENDOCRINOLOGY ASSESSMENT: Patient has Type 2 diabetes mellitus. He has NEVER been diagnosed with Type 1 diabetes. C-peptide levels are within normal range (2.1 ng/mL), confirming endogenous insulin production. Autoantibody panel (GAD65, IA-2, ZnT8) was negative in 2010, ruling out autoimmune/Type 1 diabetes. The patient's diabetes is definitively classified as Type 2.\n\nCARDIOLOGY ASSESSMENT: A complete transthoracic echocardiogram was performed today with 2D imaging, M-mode, spectral Doppler, and color flow Doppler. LVEF 45-50% (mildly reduced, stable from prior). Mild aortic stenosis. No pericardial effusion. A follow-up limited echocardiogram was also documented for focused assessment of the aortic valve gradient.\n\nRIGHT ARM: Chronic pain in right upper arm, improving. ROM 80% of normal. No new imaging needed.\n\nASSESSMENT AND PLAN:\n1. Type 2 diabetes mellitus — stable, continue current regimen. Recheck HbA1c in 3 months.\n2. Coronary artery disease — stable post-CABG. LVEF mildly reduced but unchanged.\n3. Right upper arm pain — continue PT, reassess in 3 months.\n4. Schedule follow-up in 6 months.",336 "proposed_codes": {337 "E10.9": {338 "description": "Type 1 diabetes mellitus without complications",339 "code_type": "ICD-10-CM"340 },341 "E11.9": {342 "description": "Type 2 diabetes mellitus without complications",343 "code_type": "ICD-10-CM"344 },345 "93306": {346 "description": "Echocardiography, transthoracic, complete study with spectral and color flow Doppler",347 "code_type": "CPT"348 },349 "93308": {350 "description": "Echocardiography, transthoracic, follow-up or limited study",351 "code_type": "CPT"352 },353 "99214": {354 "description": "Office visit, established patient, moderate-high complexity",355 "code_type": "CPT"356 },357 "M79.621": {358 "description": "Pain in right upper arm",359 "code_type": "ICD-10-CM"360 }361 },362 "expected_errors": [363 {364 "code": "E10.9",365 "error_type": "excludes1_conflict",366 "conflicting_code": "E11.9",367 "description": "ICD-10-CM code E10.9 (Type 1 diabetes mellitus) has an Excludes1 note for E11.- (Type 2 diabetes mellitus). These codes are mutually exclusive and cannot appear on the same claim. The clinical note explicitly states the patient has Type 2 diabetes only, with negative autoantibody panel and normal C-peptide ruling out Type 1. E10.9 should be removed.",368 "key_terms": ["Excludes1", "mutually exclusive", "Type 1", "Type 2", "E11", "E10", "diabetes", "cannot be coded together"],369 "evidence_spans": ["He has NEVER been diagnosed with Type 1 diabetes", "C-peptide levels are within normal range", "Autoantibody panel (GAD65, IA-2, ZnT8) was negative"]370 },371 {372 "code": "93306",373 "error_type": "ncci_edit",374 "conflicting_code": "93308",375 "description": "CPT 93306 (complete TTE with Doppler) and CPT 93308 (follow-up/limited TTE) are subject to a CMS NCCI PTP edit. The complete echocardiographic study inherently includes all components of a follow-up/limited study. Billing both on the same date of service constitutes unbundling. Only 93306 should be reported.",376 "key_terms": ["bundling", "unbundling", "NCCI", "PTP", "complete", "limited", "follow-up", "93308", "comprehensive"],377 "evidence_spans": ["complete transthoracic echocardiogram was performed today", "A follow-up limited echocardiogram was also documented for focused assessment"]378 }379 ],380 "max_steps": 25,381 "hints": [382 "This encounter has multiple distinct errors — do not stop after finding the first one",383 "Check ICD-10 guidelines for Excludes1 relationships between diabetes codes",384 "Use check_ncci_edits on all CPT code pairs to find bundling violations",385 "Not every code has an error — M79.621 and 99214 are valid for this encounter",386 "The clinical note contains explicit evidence ruling out Type 1 diabetes"387 ]388 }389 ]390}391