Calculate payment for a code
Compose payment for a code at a CCN.
Returns up to four blocks — physician (MPFS), outpatient_facility
(OPPS with wage index), lab (CLFS), and dme (DMEPOS) — populated
based on which fee schedules carry the code.
Logic for each block:
- physician —
allowed = ((work*pw_gpci) + (pe*pe_gpci) + (mp*mp_gpci)) * CFwhereCFis QPP (33.5675) or non-QPP (33.4009) for 2026 andpeis the facility or non-facility PE-RVU based on the CCN’s facility_type. - outpatient_facility —
allowed = (rate*0.6*wage_index) + (rate*0.4)using the FY26 wage index for the facility’s CBSA. - lab — flat CLFS rate (national, no geographic adjustment).
- dme — rural or non-rural rate based on the facility’s
is_ruralflag.
Authorizations
Path Parameters
Billing or terminology code value (CPT/HCPCS/NDC/etc depending on endpoint context).
Query Parameters
CCN — drives facility-aware composition
Optional HCPCS modifier (e.g. 26, TC, LT)
ISO date — reserved for future fee-schedule versioning
Use QPP conversion factor (True) or non-QPP (False)
0=non-QPP, 1=QPP — overrides qpp when supplied
GPCI locality override (legacy; ignored when ccn is set)
POS code (e.g. 11 office, 22 on-campus outpatient). Pins the facility vs non-facility PE-RVU choice; overrides facility_type/CCN defaults.
Legacy: use facility PE rate when no CCN is supplied
Response
Successful Response
Multi-block payment composition for a HCPCS / CPT code at a facility.
When ccn is provided, the response is composed against the facility's
geography (LOCCO → GPCI, CBSA → wage_index). When omitted, only the
physician block is populated using the supplied locality query
param (legacy GPCI-only behavior).
applicable_blocks lists which sub-blocks have data — drives display
on the consuming UI.
DMEPOS payment — picks rural vs non-rural rate by facility flag.
Facility context used to drive payment composition.
Clinical Lab Fee Schedule payment (national rate, no geographic adjustment).
OPPS / outpatient hospital facility payment block.
payment = (rate * 0.6 * wage_index) + (rate * 0.4)
MPFS payment block — work + PE + MP, GPCI-adjusted, then * conversion factor.
QPP-participating conversion factor used
User-visible reliability metadata for this payment composition.