NCCI PTP Edit Validation

Validate whether two CPT/HCPCS codes can be billed together on the same claim.

Overview

The National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits identify pairs of codes that should not normally be billed together. CMS publishes these edits quarterly for both practitioner and hospital outpatient settings.

When a code pair has an active edit, the column 2 code is typically denied unless a valid modifier is appended. The modifier_indicator field tells you whether modifier use is allowed.

Endpoint

Method	Path	Description
GET	`/v1/ncci/validate`	Validate a code pair

Validate a Code Pair

Check if arthroscopy codes can be billed together

Request

Node.js

const response = await fetch(
  "https://api.fhirfly.io/v1/ncci/validate?code1=29881&code2=29880",
  {
    method: "GET",
    headers: {
    "x-api-key": "YOUR_API_KEY",
  }
  }
);

const data = await response.json();
console.log(data);

Response

JSON

{
  "data": {
    "code1": "29881",
    "code2": "29880",
    "can_bill_together": false,
    "edits": [
      {
        "claim_type": "hospital",
        "modifier_indicator": "1",
        "modifier_allowed": true,
        "effective_date": "2004-01-01",
        "is_active": true,
        "rationale": "Standards of medical/surgical practice"
      },
      {
        "claim_type": "practitioner",
        "modifier_indicator": "1",
        "modifier_allowed": true,
        "effective_date": "1996-01-01",
        "is_active": true,
        "rationale": "Standards of medical/surgical practice"
      }
    ],
    "summary": "These codes cannot be billed together. Modifier use is allowed for both claim types."
  },
  "meta": {
    "source": {
      "name": "CMS NCCI PTP Edits",
      "quarter": "2026-Q1"
    },
    "legal": {
      "license": "public_domain",
      "attribution_required": false,
      "source_name": "CMS National Correct Coding Initiative",
      "citation": "CMS National Correct Coding Initiative PTP Edits. Accessed via FHIRfly."
    }
  }
}

A clean pair (no edit found) returns can_bill_together: true with an empty edits array:

Check an office visit + venipuncture pair

Request

Node.js

const response = await fetch(
  "https://api.fhirfly.io/v1/ncci/validate?code1=99213&code2=36415",
  {
    method: "GET",
    headers: {
    "x-api-key": "YOUR_API_KEY",
  }
  }
);

const data = await response.json();
console.log(data);

Response

JSON

{
  "data": {
    "code1": "99213",
    "code2": "36415",
    "can_bill_together": true,
    "edits": [],
    "summary": "No NCCI PTP edit found for this code pair. These codes can be billed together."
  },
  "meta": {
    "source": {
      "name": "CMS NCCI PTP Edits",
      "quarter": "2026-Q1"
    },
    "legal": {
      "license": "public_domain",
      "attribution_required": false,
      "source_name": "CMS National Correct Coding Initiative",
      "citation": "CMS National Correct Coding Initiative PTP Edits. Accessed via FHIRfly."
    }
  }
}

Parameters

Parameter	Required	Description
`code1`	Yes	First CPT/HCPCS code (4-5 alphanumeric characters)
`code2`	Yes	Second CPT/HCPCS code (4-5 alphanumeric characters)
`claim_type`	No	Filter by `"practitioner"` or `"hospital"`. Returns both if omitted.

Understanding the Response

`can_bill_together`

true — No active NCCI edit exists for this pair. Safe to bill together.
false — An active edit exists. The column 2 code will typically be denied unless a modifier is used.

`edits[]`

Each edit in the array represents a PTP edit rule for a specific claim type.

Field	Type	Description
`claim_type`	string	`"practitioner"` or `"hospital"`
`modifier_indicator`	string	`"0"` = no modifier allowed, `"1"` = modifier allowed, `"9"` = not applicable
`modifier_allowed`	boolean	Whether appending a modifier can override the edit
`effective_date`	string \| null	When the edit took effect (ISO date)
`is_active`	boolean	Whether the edit is currently active
`rationale`	string	CMS rationale for the edit

Modifier Indicators

Value	Meaning
`0`	No modifier allowed — the code pair cannot be unbundled
`1`	Modifier allowed — append modifier 59 (or XE/XP/XS/XU) to override
`9`	Not applicable

SDK Usage

Node.js

import { Fhirfly } from "@fhirfly-io/terminology";

const client = new Fhirfly({ apiKey: "your-api-key" });

// Check if two codes can be billed together
const result = await client.claims.validateNcci("29881", "29880");

if (!result.data.can_bill_together) {
  console.log("NCCI edit found — these codes conflict");
  for (const edit of result.data.edits) {
    console.log(`  ${edit.claim_type}: modifier ${edit.modifier_allowed ? "allowed" : "not allowed"}`);
  }
}

// Filter by claim type
const practitioner = await client.claims.validateNcci("29881", "29880", {
  claim_type: "practitioner",
});

Required Scopes

claims.read — NCCI PTP edit validation

NCCI PTP Edit Validation

Overview

Endpoint

Validate a Code Pair

Check if arthroscopy codes can be billed together

Check an office visit + venipuncture pair

Parameters

Understanding the Response

can_bill_together

edits[]

Modifier Indicators

SDK Usage

Required Scopes

See Also

Cookie Preferences

`can_bill_together`

`edits[]`