Medical necessity, not just syntax.
30% of claims are denied on first submission — and most verification tools only check whether a code exists, not whether a payer will cover the combination. Skippy Medical Coding validates CPT+ICD-10 pairs against a clinical evidence base, surfaces medical necessity conflicts before submission, and generates appeal documentation when denials happen anyway.
What a response looks like
CPT code verification, CPT+ICD-10 medical necessity checking, and batch pre-submission audit — three capabilities, one API.
Office/outpatient visit, established patient, low complexity
Simulated output representative of real API responses. CPT and ICD-10 verification via clinical evidence base. ECE-calibrated confidence scores.
Six capabilities. One API.
CPT code verification
Validates a CPT procedure code against the CMS code database — returning status (VERIFIED / NOT_FOUND), description, category, section, effective date, and ECE-calibrated confidence score. Retired and superseded codes flagged.
ICD-10 code validation
Checks ICD-10-CM diagnosis codes for current validity, specificity requirements, and SNOMED CT alignment. Returns code metadata with documentation match status and ECE confidence. Flags codes insufficient for payer medical necessity review.
Medical necessity checking
Validates a CPT+ICD-10 pair against the clinical evidence base: is this procedure medically supported for this diagnosis? Returns VALID / REVIEW_REQUIRED / INVALID with supporting finding references and denial risk notes where applicable.
Batch verification
Submit multiple CPT+ICD-10 combinations in a single request. Returns per-combination status and a summary of VALID / REVIEW_REQUIRED / INVALID counts — built for pre-submission audits across full claim files.
Denial appeal generation
When a claim is denied, generate an evidence-grounded appeal letter citing specific NCD/LCD criteria, AMA CPT definitions, and ICD-10-CM Official Guidelines — with versioned effective dates. Estimated appeal success probability included.
NCD/LCD lookup
Retrieve Medicare National and Local Coverage Determinations for a CPT code — the exact criteria a payer will apply when evaluating medical necessity. Contractor-specific LCDs returned by MAC jurisdiction.
What each status means.
Every verification returns a structured verdict — not a free-text explanation. Downstream systems can act on VALID vs REVIEW_REQUIRED programmatically without parsing prose.
CPT or ICD-10 code exists in the current CMS code set, is not retired, and has not been superseded. Safe to submit.
Code does not exist or was retired in a prior year's update. Submission with this code will be rejected by the payer.
The CPT+ICD-10 pair is supported by the clinical evidence base — the procedure is documented as applicable to the diagnosis. Medical necessity criteria met.
Payer may question whether this procedure is indicated for this diagnosis. Modifier, additional documentation, or a different ICD-10 code may be required.
The CPT+ICD-10 combination is not clinically supported by the evidence base. High denial probability — combination should not be submitted without clinical review.
Expected Calibration Error score on each verification — measures how well model confidence tracks actual accuracy. ECE 0.05 = verified accuracy within 5% of stated confidence.
65% of denied claims are never reworked — the cost of the appeal process exceeds the expected recovery on low-value claims. The only economically rational intervention is catching denials before submission.
Most pre-submission tools verify code syntax — that 99213 is a real CPT code. Skippy Medical Coding goes further: does the clinical evidence base support this procedure for this diagnosis? Will Medicare NCD criteria or a MAC LCD flag this combination? REVIEW_REQUIRED verdicts surface before the claim goes out, not after the denial arrives.
“93000 (ECG) paired with Z00.00 (routine exam) passes every code-validity check — both codes exist and are active. But most commercial payers will deny it without a cardiac indication. Syntax is not medical necessity.”
The clinical evidence base validates the relationship between procedure and diagnosis — the same logic a payer's medical necessity review applies. REVIEW_REQUIRED surfaces these combinations before submission, with the specific NCD/LCD language that will drive the denial decision.
Billing teams and revenue cycle
CMS-cited, OIG-compliant documentation
All verifications reference CMS Medicare Billing Manual, NCD and LCD databases, AMA CPT definitions, and ICD-10-CM Official Guidelines — cited with version numbers and effective dates. HIPAA-compliant with PHI redaction options available.
CMS-0057-F aligned for prior authorization support use cases. OIG compliance guidelines followed for appeal documentation. FHIR R4 DiagnosticReport output for integration with billing and EHR systems.
MAC jurisdiction-specific LCD lookup returns the local coverage determination your claim will actually be evaluated against — not national NCD alone.
Often deployed together
Clinical documentation analysis that extracts structured diagnoses and procedures from notes — the upstream source of the ICD-10 and CPT codes Medical Coding then verifies.
Drug-drug interaction checking for pharmacy billing — when medication administration codes (HCPCS J-codes) appear alongside polypharmacy ICD-10 diagnoses, DDI flags interaction risk.
Adverse event reporting that starts from accurate coding — MedDRA term mapping from ICD-10 codes feeds FAERS and EudraVigilance submissions downstream.
Skippy Medical Coding is a decision-support tool for qualified medical coding and revenue cycle professionals. It does not replace coder review, physician attestation, or compliance officer oversight. All VALID verdicts should be confirmed against current institutional coding policies, applicable payer contracts, and patient-specific clinical documentation before claim submission. HIPAA-ready; BAA available.
See Medical Coding in your revenue cycle workflow
We work with hospital billing departments, RCM companies, and health systems. Let's talk about your denial prevention problem.