Claims analyzed
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claims.csv
Total billed
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All submitted claims
Suspect Claims
Sorted by risk score (highest first)
Analyzing claims…
Detection Rules
CMS-aligned heuristics
Duplicate billing
Identical patient + CPT/HCPCS + DOS + NPI submitted multiple times.
Upcoding
High-complexity E/M (99215, 99223) billed against low-acuity ICD-10 (Z00.00, R51.9).
Impossible daily volume
A single NPI billing more than 30 encounters on one service date.
Phantom services
Date of service occurring after documented patient death.
Excessive units
More than 16 units of CPT 97110 (15-min therapeutic exercise) per day.
Opioid over-prescribing
Schedule II opioid NDC dispensed for non-specific low back pain (M54.50).