Denial Risk Calculator

Enter a CPT code and ICD-10 diagnosis to get a pre-billing denial risk score. Reviews bundling conflicts, modifier gaps, diagnosis-procedure fit, MUE limits, and documentation requirements.

CPT Code

ICD-10 Diagnosis

Modifiers (optional — select any that apply)

How It Works

This tool applies six heuristic rules to the code pair and aggregates a denial risk score from 0–100. It is designed for pre-submission review, not patient-facing adjudication.

Low (0–34)

Low probability of denial based on known patterns. Standard documentation review recommended.

Medium (35–69)

Elevated risk from one or more rules. Review triggered rules and ensure documentation supports each service.

High (70–100)

High probability of denial. Address all triggered rules before submission. Consider escalating to coding supervisor.

This tool uses heuristic rules, not a live payer adjudication engine. Results are educational and informational only.