Overview

The Procedure Adjudication API serves as an intelligent, real-time gatekeeper for medical claims. It automatically evaluates procedure codes (CPT/CDT) against patient diagnoses (ICD-10) and historical data to ensure clinical accuracy and billing compliance.

By integrating this API, organizations can prevent denials, ensure medical necessity, and adhere to strict coding standards before a claim ever reaches a payer.

Use Cases

Data Sources

We ground our adjudication logic in industry-standard and authoritative sources:

Violation Types

We categorize claim issues into specific rule types. The API response returns these codes, allowing your system to route errors to the correct workflow.

1. Medical Necessity (PLE)

{
  "rule": "PLE",
  "level": "critical",
  "description": "Procedure not justified by diagnoses",
  "cpts": ["71045"],
  "detail": "Procedure 71045 is not justified by the provided diagnoses",
  "ref_ids": ["claim-line-1"]
}

2. Frequency Limits (MUE)

Medically Unlikely Edits (MUE) prevent over-billing by enforcing quantity limits based on anatomical or policy maximums.

Daily Limits (MUE1)

{
  "rule": "MUE1",
  "level": "critical",
  "description": "Procedure quantity exceeds daily limit",
  "cpts": ["44950"],
  "detail": "Total quantity of 3 exceeds limit of 1",
  "ref_ids": ["claim-line-2"]
}

Cross-Claim Daily Limits (MUE2)

{
  "rule": "MUE2",
  "level": "critical",
  "description": "Procedure quantity exceeds daily limit when considering current claim and historical claims",
  "cpts": ["44950"],
  "detail": "Total quantity of 2 (claim: 1, history: 1) exceeds limit of 1"
}

3. Bundling Integrity (PTP)

Procedure-to-Procedure (PTP) edits identify pairs of codes that should not be reported together. These rules, enforced by the National Correct Coding Initiative (NCCI), prevent improper payments by defining when a service is considered "integral" to or "mutually exclusive" with another more comprehensive service performed at the same site.

Hard Stops (PTP0)

{
  "rule": "PTP0",
  "level": "critical",
  "description": "Procedures cannot be billed together (modifier not allowed)",
  "cpts": ["99215", "99205"],
  "detail": "Procedures 99215 and 99205 can not be performed together on the same date of service",
  "ref_ids": ["claim-line-3", "claim-line-4"]
}

Soft Stops (PTP1)

{
  "rule": "PTP1",
  "level": "warning",
  "description": "Procedures cannot be billed together (modifier allowed with documentation)",
  "cpts": ["17000", "17003"],
  "detail": "Procedures 17000 and 17003 can not be performed together on the same date of service, except with valid documentation"
}

Missing Dates (Info)

{
  "rule": "PTP0",
  "level": "info",
  "description": "Procedures cannot be billed together (modifier not allowed)",
  "cpts": ["99215", "99205"],
  "detail": "Procedures 99215 and 99205 would not be accepted if performed on the same date",
  "ref_ids": ["claim-line-3", "claim-line-4"]
}

Criticality & Workflows

We categorize every violation into a severity level. This allows you to filter noise and route issues to the right person.

Endpoint

POST /adjudicate

Data Requirements

To maximize adjudication accuracy, ensure your request includes:

• Procedures: The CPT / CDT codes, dates, and units for the current claim.
• Diagnoses: The ICD-10-CM codes justifying the procedures.
• History: A list of past procedures. This is critical for MUE2 (cross-claim daily limit) checks. Without history, the API cannot detect if a patient has previously received procedures that would exceed daily limits when combined with the current claim.

Configuration

You can fine-tune the strictness of the API using the config object in your request.

Filter by Level

Control which violations are returned based on their severity. This is useful if you want to build different views for different users (e.g., showing only Critical errors to a physician).

Request Example:

{
  "procedures": [...],
  "diagnoses": [...],
  "config": {
    "level": "critical"
  }
}