Billing guide

The /v1/knowledge/billing-guide endpoint consolidates billing rules from multiple knowledge layers into a single actionable guide. It tells you which form to use, what TOB codes apply, and flags potential billing issues before you submit a claim.

Request

curl -X POST https://api-dev.rcintell.com/v1/knowledge/billing-guide \
  -H "X-API-Key: $RCI_API_KEY" \
  -H "Content-Type: application/json" \
  -d '{
    "ccn": "170001",
    "cpt": "99213",
    "payer": "Medicare"
  }'

Parameters

Field	Type	Required	Description
`ccn`	string	Yes	6-digit Medicare Provider Number
`cpt`	string	Yes	CPT or HCPCS procedure code
`payer`	string	No	Payer name (defaults to Medicare)
`dx_codes`	string[]	No	ICD-10 codes for coverage context
`modifier`	string	No	CPT modifier to validate (e.g., `25`, `59`)

Response

{
  "ccn": "170001",
  "cpt": "99213",
  "guidelines": [
    {
      "source": "l2_facility_type",
      "billing_form": "UB-04 (CMS-1450) / 837I"
    },
    {
      "source": "l2_facility_type",
      "type_of_bill": "013x"
    }
  ],
  "warnings": []
}

What the billing guide resolves

Field	Source layer	Description
`billing_form`	L2	CMS-1500 (professional) or UB-04 (institutional)
`type_of_bill`	L2	3-4 digit TOB code (e.g., `013x` for outpatient hospital)
`warnings`	L2, L3	Consolidated billing flags, exceptions, modifier notes

Example: Home health agency

Home health agencies have specific consolidated billing rules that trigger warnings:

curl -X POST https://api-dev.rcintell.com/v1/knowledge/billing-guide \
  -H "X-API-Key: $RCI_API_KEY" \
  -H "Content-Type: application/json" \
  -d '{
    "ccn": "173001",
    "cpt": "99213",
    "payer": "Medicare"
  }'

{
  "ccn": "173001",
  "cpt": "99213",
  "guidelines": [
    {
      "source": "l2_facility_type",
      "billing_form": "UB-04 (CMS-1450) / 837I"
    },
    {
      "source": "l2_facility_type",
      "type_of_bill": "0329"
    }
  ],
  "warnings": [
    "Exceptions: 034x (osteoporosis drugs, dNPWT)",
    "Consolidated billing applies — check included services"
  ]
}

When the response includes a consolidated billing warning, the facility is responsible for all covered services during the episode. Separately billing Part B services that fall under consolidated billing will result in denials.

Common billing form rules

Facility type	Billing form	TOB (outpatient)	TOB (inpatient)
Short-term acute hospital	UB-04 / 837I	013x	011x
Critical Access Hospital	UB-04 / 837I	085x	011x
Home Health Agency	UB-04 / 837I	0329	—
Skilled Nursing Facility	UB-04 / 837I	—	021x
Hospice	UB-04 / 837I	—	081x
FQHC	UB-04 / 837I	077x	—

The x in TOB codes represents the frequency digit (e.g., 0 = non-payment/zero claim, 1 = admit through discharge, 7 = replacement, 8 = void/cancel).

Using with modifiers

Pass a modifier parameter to validate whether the modifier is appropriate for the service and setting:

curl -X POST https://api-dev.rcintell.com/v1/knowledge/billing-guide \
  -H "X-API-Key: $RCI_API_KEY" \
  -H "Content-Type: application/json" \
  -d '{
    "ccn": "170001",
    "cpt": "99213",
    "modifier": "25",
    "payer": "Medicare"
  }'

Modifier 25 (significant, separately identifiable E/M service) is one of the most common — and most audited — modifiers. The billing guide will include modifier-specific warnings when applicable.

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Platform

Request

Parameters

Response

What the billing guide resolves

Example: Home health agency

Common billing form rules

Using with modifiers

​Request

​Parameters

​Response

​What the billing guide resolves

​Example: Home health agency

​Common billing form rules

​Using with modifiers

Request

Parameters

Response

What the billing guide resolves

Example: Home health agency

Common billing form rules

Using with modifiers