NCCI Edits

Query NCCI MUE limits, PTP bundling edits, and Add-On Code edits with optional AI summaries

The NCCI (National Correct Coding Initiative) endpoints resolve Medicare correct coding edits from CMS quarterly data. The sample dataset includes 56 MUE entries (across Practitioner, Hospital Outpatient, and DME settings), 42 PTP pairs (both Practitioner and Hospital tables), and 29 AOC relationships. Three edit types are supported:

Type	What it answers
MUE	”How many units of this code can I bill per encounter?”
PTP	”Can I bill these two codes together?”
AOC	”Which add-on codes are valid with this primary procedure?”

Every NCCI route is also available under the canonical knowledge namespace at /v1/knowledge/ncci/.... Both /v1/ncci/mue/practitioner/99213 and /v1/knowledge/ncci/mue/practitioner/99213 return identical results — pick whichever fits your URL conventions.

Pick a date_of_service to select the right NCCI version

Every endpoint accepts an optional date_of_service=YYYY-MM-DD query parameter (and validate/batch accepts date_of_service in the request body). The platform stores every quarterly NCCI release with its effective_date and (where applicable) deletion_date, then returns the row that was active on that date — not just the latest.

# What was the MUE for 99213 on a 2025-06-15 date of service?
curl "https://api-dev.rcintell.com/v1/ncci/mue/practitioner/99213?date_of_service=2025-06-15" \
  -H "X-API-Key: kp_test_..."

# Was 27447 + 27440 bundled on 2024-12-31?
curl "https://api-dev.rcintell.com/v1/ncci/validate?code1=27447&code2=27440&date_of_service=2024-12-31" \
  -H "X-API-Key: kp_test_..."

Behaviour:

Scenario	Response
date_of_service omitted	Latest active version (highest version_year / effective_date)
Date inside an active edit’s window	That edit’s row, with the version_*_dt fields telling you which CMS quarter it came from
Date before any version was effective	404 No NCCI edit found … on the given date
Date after a deleted edit’s deletion_date	404 (or the next active version, if one exists)

This means you can confidently reprice or re-validate an historical claim without worrying that the response reflects a later CMS revision.

MUE — Medically Unlikely Edits

MUE limits are split by clinical setting. Use the endpoint matching your claim type:

Practitioner

curl "https://api-dev.rcintell.com/v1/ncci/mue/practitioner/99213" \
  -H "X-API-Key: kp_test_..."

Response

{
  "proc_cd": "99213",
  "date_of_service": "2026-03-25",
  "mue_value": 3,
  "mue_adj_ind": "3 Date of Service Edit: Clinical",
  "mue_rationale": "Clinical: Data",
  "mue_type": "practitioner",
  "version_effective_dt": "2026-01-01",
  "version_posted_dt": null,
  "ai_summary": null
}

MAI (MUE Adjudication Indicator)

Value	Meaning	Appeal
1	Line Edit	Claim line adjudication
2	Date of Service Edit: Policy	Per-day limit based on statute/regulation — not appealable
3	Date of Service Edit: Clinical	Per-day limit based on clinical benchmarks — appealable with documentation

PTP — Procedure-to-Procedure Edits

PTP edits tell you whether two codes are bundled. Endpoints are split by claim type:

Practitioner

curl "https://api-dev.rcintell.com/v1/ncci/ptp/prac?col1_proc_cd=27447&col2_proc_cd=27440" \
  -H "X-API-Key: kp_test_..."

Response

{
  "col1_proc_cd": "27447",
  "col2_proc_cd": "27440",
  "date_of_service": "2026-03-25",
  "edit_effective_dt": "2020-01-01",
  "edit_delete_dt": "",
  "modifier": "0",
  "ptp_edit_rationale": "More extensive procedure",
  "version": "2026Q1",
  "version_effective_dt": "2020-01-01",
  "version_posted_dt": null,
  "ptp_type": "prac",
  "ai_summary": null
}

Modifier Indicator

Value	Meaning
0	Not Allowed — modifier cannot bypass the bundle
1	Allowed — modifier (e.g. -59, -XE) may unbundle the pair
9	Not Applicable

AOC — Add-On Code Edits

Look up which add-on codes are valid with a primary procedure (or vice versa). Provide at least one of add_on_code or primary_proc_cd:

# By primary procedure
curl "https://api-dev.rcintell.com/v1/ncci/aoc?primary_proc_cd=27447" \
  -H "X-API-Key: kp_test_..."

# By add-on code
curl "https://api-dev.rcintell.com/v1/ncci/aoc?add_on_code=22614" \
  -H "X-API-Key: kp_test_..."

# Specific pair
curl "https://api-dev.rcintell.com/v1/ncci/aoc?primary_proc_cd=27447&add_on_code=22614" \
  -H "X-API-Key: kp_test_..."

Response

{
  "code": "27447",
  "edit_count": 4,
  "results": [
    {
      "aoc_edit_type": "1",
      "add_on_code": "22614",
      "aoc_delete_dt": "",
      "primary_proc_cd": "27447",
      "primary_proc_cd_delete_dt": "",
      "aoc_edit_effect_dt": "2026-01-01",
      "aoc_edit_delete_dt": "",
      "special_instruct": null,
      "ai_summary": null
    }
  ],
  "ai_summary": null
}

AOC Edit Types

Type	Meaning
1	Limited number of specific primary codes listed by CMS
2	No specific primary code list — MACs define their own
3	Partial list — CPT Manual identifies some primaries, MACs may add more

Validate a Code Pair

Quick check whether two codes have a PTP bundling edit:

curl "https://api-dev.rcintell.com/v1/ncci/validate?code1=99214&code2=99213" \
  -H "X-API-Key: kp_test_..."

{
  "code1": "99214",
  "code2": "99213",
  "is_bundled": true,
  "modifier_allowed": false,
  "modifier_indicator": "0",
  "column1_code": "99214",
  "column2_code": "99213",
  "ptp_rationale": "Mutually exclusive procedures",
  "effective_date": "2022-01-01"
}

AI Summaries

Add ?include_summary=true to any MUE, PTP, or AOC request to get a plain-English explanation written for billing staff:

curl "https://api-dev.rcintell.com/v1/ncci/mue/practitioner/99213?include_summary=true" \
  -H "X-API-Key: kp_test_..."

Summaries are generated by the rcm-agents service using Claude. They explain:

• What the procedure code represents
• Why it appears on the edit list
• Practical billing impact
• A follow-up question to confirm interpretation

AI summaries require the rcm-agents service running at RCM_AGENTS_URL with a valid ANTHROPIC_API_KEY. Without it, ai_summary returns null — the structured data still works.

Sample data coverage

The bundled sample data covers these codes across all settings and claim types:

MUE (Practitioner)	MUE (Hospital OP)	MUE (DME)
99213, 99214, 99215	99213, 99214, 99215	E0601, E0470, E0471
99221-99223, 99231-99233	27447, 27440, 36415	K0823, K0824, K0856
27440, 27447, 36415	70553, 71046, 73610	A4253, A4259, A7027
70553-70554, 71046	80053, 85025, 93000	E1390, E0260, L3000
80053, 85025, 86900	92004, 99291	L3020, E0431, E0439

PTP Pairs (both tables)	AOC Pairs
27447/27440, 27447/29881	27447 + 22614, 22840, 20930, 27580
99213/99214, 99214/99215	99213 + 99354, 99417, 99358
70553/70554, 71046/71047	99291/99292, 96365/96366
80053/85025, 85025/86900	96374/96376, 36415/36416
10060/12001, 20610/20611	70553/70554, 93000/93042

Data freshness

NCCI data is sourced from CMS quarterly releases. Historical versions coexist so date_of_service selects the right quarter. Named dataset versions: GET /v1/data/snapshots?dataset=ncci.