NCCI Edits

The NCCI (National Correct Coding Initiative) endpoints resolve Medicare correct coding edits from CMS quarterly data. The separate CMS Medicaid NCCI edit set is served under /v1/ncci/medicaid/* (see below). 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://sandbox.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://sandbox.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.

Payer and state

NCCI files are CMS national tables. Pass payer + state so the response is labeled for that claim and so Medicaid uses the Medicaid file (not Medicare).

Query	File used	What `state` means
`payer=medicare_ffs&state=KS`	CMS Medicare NCCI	Claim geography. Edits are national.
`payer=masshealth&state=MA` or `plan_type=medicaid&state=KS`	CMS Medicaid NCCI	That state’s Medicaid program applying the CMS Medicaid floor.
Commercial slug (`uhc`)	CMS Medicare NCCI	We do not publish a commercial-payer NCCI file.

# Kansas Medicaid — CMS Medicaid MUE floor, stamped state=KS
curl "https://sandbox.rcintell.com/v1/ncci/medicaid/mue/practitioner/99213?state=KS&payer=medicaid" \
  -H "X-API-Key: kp_test_..."

# Same pair check via the Medicare path (routes to Medicaid when payer is Medicaid)
curl "https://sandbox.rcintell.com/v1/ncci/validate?code1=27447&code2=99213&payer=masshealth&state=MA" \
  -H "X-API-Key: kp_test_..."

edit_scope is cms_medicare_national or cms_medicaid_national. state_overlay=not_ingested means extra state SMA / Medi-Cal add-on edits are not merged yet — the CMS Medicaid floor is what we return. POST /v1/encounter/check with plan_type=medicaid (or a Medicaid payer slug) uses the Medicaid PTP file.

MUE — Medically Unlikely Edits

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

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

curl "https://sandbox.rcintell.com/v1/ncci/mue/hosp-op/99213" \
  -H "X-API-Key: kp_test_..."

curl "https://sandbox.rcintell.com/v1/ncci/mue/dme/E0601" \
  -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:

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

curl "https://sandbox.rcintell.com/v1/ncci/ptp/hosp?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://sandbox.rcintell.com/v1/ncci/aoc?primary_proc_cd=27447" \
  -H "X-API-Key: kp_test_..."

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

# Specific pair
curl "https://sandbox.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://sandbox.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"
}

Medicaid NCCI (separate edit set)

CMS publishes a separate NCCI edit set for Medicaid each quarter. It is not the Medicare table with a different label: pairs, modifier indicators, and MUE values differ, and Medicaid MUEs carry no adjudication indicator (MAI). The platform serves it under /v1/ncci/medicaid/* so a Medicaid claim is never checked against Medicare edits by accident.

Medicare	Medicaid	Notes
`/v1/ncci/mue/{setting}/{code}`	`/v1/ncci/medicaid/mue/{setting}/{code}`	Same settings: `practitioner`, `hosp-op`, `dme`
—	`/v1/ncci/medicaid/mue/{code}`	All settings for one code
`/v1/ncci/ptp/prac`, `/v1/ncci/ptp/hosp`	`/v1/ncci/medicaid/ptp?claim_type=prac\|hosp\|dme`	Medicaid also publishes a DME PTP table
`/v1/ncci/validate`	`/v1/ncci/medicaid/validate`	Same response shape plus `program: "medicaid"`
`/v1/data/snapshots?dataset=ncci`	`/v1/ncci/medicaid/status`	Row counts and load time of the Medicaid tables

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

{
  "program": "medicaid",
  "proc_cd": "99213",
  "mue_type": "practitioner",
  "mue_value": 1,
  "mue_rationale": "Clinical: Data",
  "mue_adj_ind": null,
  "note": "CMS publishes no MUE adjudication indicator (MAI) for Medicaid; each state Medicaid program decides line-level vs date-of-service adjudication.",
  "medicare_mue_value": 3,
  "source_file": "MCD-MUE-PractitionerServices-...txt",
  "loaded_at": "2026-09-10T04:12:07Z"
}

medicare_mue_value is the Medicare limit for the same code and setting so billing staff can see both numbers side by side.

Medicaid NCCI is the national edit set states must adopt at minimum; states may add their own edits and choose how to adjudicate MUEs. Medicaid PTP rows in the platform are the currently active edits (CMS deletions are dropped at ingest) and MUEs are the current quarter, so date_of_service selects among effective dates rather than replaying prior quarters. If the tables have not been loaded yet the endpoints return 503 with the ingest to run.

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://sandbox.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.

Get Started

Who is RCIntel for?

Policies

Knowledge Resolution

AI Agents

MCP Server

Facilities

Integrations

Free Tools

Healthcare Essentials

Platform

Pick a `date_of_service` to select the right NCCI version

Payer and state

MUE — Medically Unlikely Edits

Response

MAI (MUE Adjudication Indicator)

PTP — Procedure-to-Procedure Edits

Response

Modifier Indicator

AOC — Add-On Code Edits

Response

AOC Edit Types

Validate a Code Pair

Medicaid NCCI (separate edit set)

AI Summaries

Sample data coverage

Data freshness

​Pick a date_of_service to select the right NCCI version

​Payer and state

​MUE — Medically Unlikely Edits

​Response

​MAI (MUE Adjudication Indicator)

​PTP — Procedure-to-Procedure Edits

​Response

​Modifier Indicator

​AOC — Add-On Code Edits

​Response

​AOC Edit Types

​Validate a Code Pair

​Medicaid NCCI (separate edit set)

​AI Summaries

​Sample data coverage

​Data freshness

Pick a `date_of_service` to select the right NCCI version

Payer and state

MUE — Medically Unlikely Edits

Response

MAI (MUE Adjudication Indicator)

PTP — Procedure-to-Procedure Edits

Response

Modifier Indicator

AOC — Add-On Code Edits

Response

AOC Edit Types

Validate a Code Pair

Medicaid NCCI (separate edit set)

AI Summaries

Sample data coverage

Data freshness