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                         Vitalware assigned entity identifier
payer optional payer
effectiveDate date of effective service
providerType type of provider
items list of procedure codes
{
 
    "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

Property Data type Description
entityId int A specific value assigned by VitalWare. Note that although this is currently required, this parameter will be deprecated and removed from future releases.
payer string Optional payer. Valid values include:
  • "Medicare" (Default value if omitted)
  • "Medicaid"
effectiveDate Date Date of service
providerType string Type of provider. Valid values include:
  • "H" - Hospital/Facility
  • "P" - Physician
items CciInputItem[] Array of objects, each containing procedure codes and optional modifiers:
Parameter Data type Description
code string CPT/HCPCS code
modCodes string[] Optional list of modifiers to apply to this procedure.

Response Objects

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

code string Procedure code
modifiers CciModifierItem[] Array of details for each modifier passed in with this code. Properties include:
Property Data type Description
modCode string The modifier code
status string Status associated with modifier. Possible values include:
  • "OK"
  • "Warning"
  • "Error"
message string Message for modifier, usually associated with status.
codeId int VitalWare internal code identifier
status string Status value returned for validation of procedure code Values include:
  • "OK"
  • "Warning"
  • "Error"
issues CciIssue[] Array of issues encountered validating code. Properties for each issue include:
  • 1 - OK
  • 2 - Warning
  • 3 - Error
  • 4 - An issue that was resolved by usage of a compatible modifier
Property Data type Description
status int Numeric representation of status value. Note that this will be normalized to the other values for status used elsewhere in a future version. Possible values include:
message string Message associated with issue
shortDescription string Short code description
longDescription string Long code description
codeType string Type of code
isValid bool Whether or not the code was found and is valid
invalidReason string Reason code was not valid. Valid values include:
  • "NotFound"
  • "Deleted"
  • "Invalid"
statusIndicator string Status indicator associated with code
statusIndicatorDescription string Description for status indicator
statusIndicatorExplanation string Additional information for status indicator
workRvu decimal Work RVU
mpRvu decimal MP RVU
tranFacPeRvu decimal Facility PE RVU
tranNonFacPeRvu decimal Non Facility PE RVU
fullImpFacTotal decimal Total Facility RVU
fullImpNonFacTotal decimal Total Non Facility RVU
mueValue int MUE Value
mueAdjudicationIndicator string MUE adjudication indicator with description