CCI/MUE API

Overview 

• CCI/MUE API accepts procedure codes with optional modifiers and returns potential billing conflicts and whether the modifier(s) passed resolved the conflict.

Walkthrough : CCI/MUE API Request

CCI API request uses the following objects :  

{
 
    "entityId": 1, 
    "effectiveDate": "2017-01-01",
    "providerType": "H",
    "items": [
      {
        "code": "42700"
      },
      {
        "code": "94002"
      }
    ]
}

For more details on the information contained in the request see CCI API Request below.

Interpreting the CCI/MUE API Response

The response below contains details and validation results for each of the codes passed, along with additional information such as RVUs and MUEs.

{
  "items": [
    {
      "code": "42700",
      "codeId": 307394,
      "status": "OK",
      "shortDescription": "DRAINAGE OF TONSIL ABSCESS",
      "longDescription": "Incision and drainage abscess; peritonsillar",
      "codeType": "CPT",
      "isValid": true,
      "statusIndicator": "T",
      "statusIndicatorDescription": "Procedure or Service, Multiple Procedure 
        Reduction Applies",
      statusIndicatorExplanation": "Paid under OPPS; separate APC payment.",
      "workRvu": 1.67,
      "mpRvu": 0.24,
      "tranFacPeRvu": 2,
      "tranNonFacPeRvu": 3.53,
      "fullImpFacTotal": 3.91,
      "fullImpNonFacTotal": 5.44,
      "mueValue": 2,
      "mueAdjudicationIndicator": "3 Date of Service Edit: Clinical"
    },
    {
      "code": "94002",
      "codeId": 312425,
      "status": "Warning",
      "issues": [
        {
          "status": 2,
          "message": "Cannot be billed with 42700 unless documentation supports 
            adding NCCI-appropriate modifier."
        }
      ],
      "shortDescription": "VENT MGMT INPAT INIT DAY",
      "longDescription": "Ventilation assist and management, initiation of  
        pressure or volume preset ventilators for assisted or controlled  
        breathing; hospital inpatient/observation, initial day",
      "codeType": "CPT",
      "isValid": true,
      "statusIndicator": "Q3",
      "statusIndicatorDescription": "Codes That May Be Paid Through a Composite 
        APC",
      "statusIndicatorExplanation": "Paid under OPPS; Addendum B displays APC 
        assignments when services are separately payable.Addendum M displays 
        composite APC assignments when codes are paid through a composite APC.(1)  
        Composite APC payment based on OPPS composite-specific payment criteria.  
        Payment is packaged into a single payment for specific combinations of 
        services.(2)  In other circumstances, payment is made through a separate 
        APC payment or packaged into payment for other services.",
      "workRvu": 1.99,
      "mpRvu": 0.16,
      "tranFacPeRvu": 0.48,
      "tranNonFacPeRvu": 0.48,
      "fullImpFacTotal": 2.63,
      "fullImpNonFacTotal": 2.63,
      "mueValue": 1,
      "mueAdjudicationIndicator": "2 Date of Service Edit: Policy"
    }
  ],
  ...
}

In the example above, code 94002 contains an issue because it cannot be billed with 42700.   After adding the appropriate modifier, this should now look like the following:

{
    "entityId": 1, 
    "effectiveDate": "2017-01-01",
    "providerType": "H",
    "items": {
      {
        "code": "42700"
      },
      {
        "code": "94002",
        "modCodes": [ "T3" ]
      }
    }
}

Result Response :

{
  "items": [
    ...
    {
      "code": "94002",
      "modifiers": [
        {
          "modCode": "T3",
          "status": "Warning",
          "message": "Vitalware does not consider use of this modifier to be best 
            practice"
        }
      ],
      "codeId": 312425,
      "status": "OK",
      "issues": [
        {
          "status": 4,
          "message": "PTP CCI Issue Has Been Resolved By Use of NCCI-Eligible 
            Modifier"
        }
      ],
      ...
    }
  ],
  ...
}

Notice the issue has turned into an informational one. In this case, we have used a modifier that, although is NCCI eligible, it is not considered a best practice by VitalWare.

For more details on the information returned in the response see the CCI API Response below.

Request Objects

Response Objects

A CCI API response contains an array of objects called items. The properties in each, include: