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Synthetic Clinical Demonstration Cases

Explore how HealthyClaim processes realistic, synthetic clinical documentation. Review the extracted clinical facts, deterministic NCCI/MUE adjudication, and resulting draft claim artifacts.

Notice: All case studies below use synthetic, de-identified patient data. This demonstration platform is intended for technical evaluation and research.
Case 01: Office Visit & Chronic Management Synthetic: 62yo F • Established

CHIEF COMPLAINT: Follow-up for Type 2 Diabetes and Hypertension; new symptom of foot numbness.

HISTORY: 62yo female with poorly controlled T2DM (HbA1c 9.2%) and hypertension. Complains of progressive bilateral stocking-distribution paresthesias over past 3 months.

EXAM: Reduced vibration sense bilaterally at 1st MTP joints. Monofilament exam abnormal in 4/10 sites bilaterally. BP 148/92 mmHg.

ASSESSMENT & PLAN: T2DM with diabetic polyneuropathy, uncontrolled. Started on Gabapentin 300mg QHS. Lisinopril increased to 20mg daily. Total encounter time: 38 minutes.

Extracted Facts: T2DM with polyneuropathy (E11.40), Essential HTN (I10), Moderate MDM / 38 min (99214).
Adjudication & Evaluation EVALUATED
E/M Code: 99214 (Level 4 Established)
MDM Level: Moderate (1 chronic with progression + prescription drug mgmt)
Time Verification: 38 min supports 99214 (30-39 min band)
Diagnosis Linking: E11.40 (Primary), I10 (Secondary)
Draft Artifacts:
Draft CMS-1500 Draft EDI 837P
Case 02: Knee Injection with E/M Synthetic: 67yo M • Medicare Part B

CHIEF COMPLAINT: Acute flare of right knee pain after fall; scheduled procedure review.

EXAM & EVALUATION: Evaluated acute exacerbation, reviewed new X-rays showing severe tricompartmental OA without fracture. High complexity MDM.

PROCEDURE: Arthrocentesis with intermediate joint injection, right knee. Under sterile prep, 1% lidocaine local, aspirated 12ml cloudy fluid, injected Depo-Medrol 80mg (J1040).

Extracted Facts: Arthrocentesis major joint (20610-RT), Separate E/M (99214-25), Depo-Medrol 80mg (J1040 x2).
Adjudication & Evaluation EVALUATED
Modifier 25: Applied to 99214 (Separate acute evaluation documented)
Anatomy Modifier: 20610-RT (Right knee verified)
Drug Units: J1040 (2 units = 80mg; billing unit = 40mg)
NCCI Edit: 20610 / 99214 bypass supported with Modifier 25
Draft Artifacts:
Draft CMS-1500 Draft EDI 837P
Case 03: Complex Wound Debridement Synthetic: 74yo F • Outpatient Clinic

PROCEDURE: Selective wound debridement including removal of non-viable tissue.

LOCATION & DEPTH: Left lower extremity venous ulcer. Subcutaneous tissue depth. Wound area measured: 36 sq cm.

TECHNIQUE: Sharp excision using scalpel down to viable subcutaneous tissue. Hemostasis achieved.

Extracted Facts: Debridement subcu first 20 sq cm (11042), Each additional 20 sq cm (11045 x1).
Adjudication & Evaluation EVALUATED
Primary Code: 11042 (First 20 sq cm debridement)
Add-On Code: 11045 (1 unit for remaining 16 sq cm)
MUE Unit Cap: 11045 unit count within CMS practitioner cap
LCD Check: Venous ulcer etiology documented (I87.2)
Draft Artifacts:
Draft CMS-1500 Draft EDI 837P
Case 04: Colonoscopy with Lesion Excision Synthetic: 55yo M • Screening converted to Diagnostic

INDICATION: Screening colonoscopy in average-risk 55yo male.

FINDINGS: 8mm sessile polyp in ascending colon removed by snare polypectomy. 4mm hyperplastic-appearing polyp in sigmoid removed by cold biopsy forceps.

TECHNIQUE: Cecum reached. Complete visualization. Two distinct techniques at two distinct anatomical sites.

Extracted Facts: Snare polypectomy (45385), Biopsy separate site (45380-59), Screening modifier (PT/33).
Adjudication & Evaluation EVALUATED
Primary Procedure: 45385 (Snare removal ascending colon)
Secondary Procedure: 45380-XS / 59 (Biopsy at distinct site: sigmoid)
NCCI Conflict Check: 45385 / 45380 PTP edit unbundled via documented separate site
Screening Waiver: Modifier PT applied for Medicare cost-sharing waiver
Draft Artifacts:
Draft CMS-1500 Draft EDI 837P
Case 05: Bilateral Dermatology Destruction Synthetic: 68yo F • Dermatology Clinic

INDICATION: Multiple premalignant actinic keratoses.

PROCEDURE: Liquid nitrogen cryosurgery destruction of 4 discrete actinic keratoses on left dorsal forearm and 3 on right dorsal forearm (total 7 lesions).

POST-PROCEDURE: Wound care instructions given. Sun protection advised.

Extracted Facts: Premalignant destruction first lesion (17000), Additional 2-14 lesions (17003 x6).
Adjudication & Evaluation EVALUATED
Base Code: 17000 (First lesion destruction)
Add-On Code: 17003 (6 units for lesions 2 through 7)
Bilateral Evaluation: 17000/17003 evaluated per lesion count, not bilateral modifier
Diagnosis Linking: L57.0 (Actinic keratosis)
Draft Artifacts:
Draft CMS-1500 Draft EDI 837P