openapi: 3.2.0
info:
  title: Optum Medicare Fee Schedule APIs API
  version: v1.0
  contact:
    name: Ken Kracker
    email: ken.kracker@optum.com
  description: 'Operations tagged Medicare Fee Schedule APIs across 2 of this provider''s published API definitions: optum-cms-common-physician-openapi.yml, optum-optum-common-physician-openapi.yml. Each path carries the servers of the definition it was published in.'
servers:
- url: /v1/cmscommonms
- url: /v1/optumcommonms
tags:
- name: Medicare Fee Schedule APIs
paths:
  /api/cms/physician/{code}/physician-time:
    get:
      tags:
      - Medicare Fee Schedule APIs
      summary: Fetches Physician time for particular CPT or HCPCS code
      operationId: getPhysicianTime
      parameters:
      - name: code
        in: path
        description: CPT or HCPCS code
        required: true
        schema:
          type: string
        example: 14000
      - name: yyyy-MM-dd
        in: header
        description: Date for which historical data is required
        required: false
        schema:
          type: string
          format: yyyy-MM-dd
      responses:
        '200':
          description: Fetch Physician Time
          content:
            application/json:
              example:
                physicianTime: 348
                unit: minutes
        '404':
          description: Not found
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Notification'
              example:
                timestamp: '2023-07-14T06:37:03.741+00:00'
                status: 404
                error: Not Found
                message: Not Found
                path: /cmscommonms/api/cms/physician/14000/physician-time1
        '500':
          description: Internal server error
          content:
            application/json:
              example:
                timestamp: '2023-07-13T06:36:22.518+00:00'
                path: /cmscommonms/api/cms/physician/14000/physician-time
                status: 500
                error: Internal Server Error
                requestId: e36d239e-324
      security:
      - bearerAuth: []
    servers:
    - url: /v1/cmscommonms
  /api/cms/physician/mpfs/status-codes:
    get:
      tags:
      - Medicare Fee Schedule APIs
      summary: Fetches MPFS Status codes
      operationId: getStatusCodes
      parameters:
      - name: yyyy-MM-dd
        in: header
        description: Date for which historical data is required
        required: false
        schema:
          type: string
          format: yyyy-MM-dd
      responses:
        '200':
          description: Fetches MPFS status codes
          content:
            application/json:
              example:
                content:
                - code: A
                  description: Active Code
                  definition: These codes are paid separately under the physician fee schedule, if covered.  There will be RVUs for codes with this status.  The presence of an "A" indicator does not mean that Medicare has made a national coverage determination regarding the service; carriers remain responsible for coverage decisions in the absence of a national Medicare policy.
                totalCount: 17
        '404':
          description: Not found
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Notification'
              example:
                timestamp: '2023-12-06T06:37:03.741+00:00'
                status: 404
                error: Not Found
                message: Not Found
                path: /cmscommonms/api/cms/physician/mpfs/status-codes1
        '500':
          description: Internal server error
          content:
            application/json:
              example:
                timestamp: '2023-07-13T06:36:22.518+00:00'
                path: /cmscommonms/api/cms/physician/mpfs/status-codes
                status: 500
                error: Internal Server Error
                requestId: e36d239e-324
      security:
      - bearerAuth: []
    servers:
    - url: /v1/cmscommonms
  /api/cms/physician/mpfs/payment-indicators/{ruletype}:
    get:
      tags:
      - Medicare Fee Schedule APIs
      summary: Fetches MPFS payment indicators and its definitions for particular medicare rule type
      operationId: getPaymentIndicatorList
      parameters:
      - name: ruletype
        in: path
        required: true
        schema:
          type: string
          enum:
          - PCTC
          - MULT_PROC
          - ASST_SURG
          - BILAT_SURG
          - CO_SURG
          - PHYS_SUP
          - TEAM_SURG
      - name: yyyy-MM-dd
        in: header
        description: Date for which historical data is required
        required: false
        schema:
          type: string
          format: yyyy-MM-dd
      responses:
        '200':
          description: MPFS payment indicators and its definitions for particular medicare rule type
          content:
            application/json:
              example:
                content:
                - paymentIndicator: '0'
                  definition: Team surgeons are not permitted for this procedure.
                - paymentIndicator: '1'
                  definition: Team surgeons may be allowed with supporting documentation to establish medical necessity.
                - paymentIndicator: '2'
                  definition: 'Team surgeons permitted, pay by report. '
                - paymentIndicator: '9'
                  definition: Team surgery concept does not apply
                totalCount: 4
        '404':
          description: Not found
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Notification'
              example:
                timestamp: '2023-07-14T06:37:03.741+00:00'
                status: 404
                error: Not Found
                message: Not Found
                path: /cmscommonms/api/cms/physician/mpfs/payment-indicators/AAA
        '500':
          description: Internal server error
          content:
            application/json:
              example:
                timestamp: '2023-07-13T06:36:22.518+00:00'
                path: /cmscommonms/api/cms/physician/mpfs/payment-indicators/TEAM_SURG
                status: 500
                error: Internal Server Error
                requestId: e36d239e-324
      security:
      - bearerAuth: []
    servers:
    - url: /v1/cmscommonms
  /api/cms/physician/mpfs/payment-indicator-status/{code}:
    get:
      tags:
      - Medicare Fee Schedule APIs
      summary: Fetches payment indicator and status information for CPT or HCPCS codes
      operationId: fetchPaymentIndicatorAndStatusFees
      parameters:
      - name: code
        in: path
        required: true
        schema:
          type: string
        example: 99213
      - name: yyyy-MM-dd
        in: header
        description: Date for which historical data is required
        required: false
        schema:
          type: string
          format: yyyy-MM-dd
      responses:
        '200':
          description: Fetches payment indicator and status information for CPT or HCPCS codes
          content:
            application/json:
              example: "  {{\n       \"Global\": {\n         \"pctc\": 0,\n         \"multProc\": 0,\n         \"bilatSurg\": 0,\n         \"asstSurg\": 0,\n         \"coSurg\": 0,\n         \"teamSurg\": 0,\n         \"status\": \"A\",\n         \"physSup\": \"09\",\n         \"modifier\": \" \",\n         \"statusDesc\": \"Active Code.  These codes are paid separately under the physician fee schedule, if covered.  There will be RVUs for codes with this status.  The presence of an \\\"A\\\" indicator does not mean that Medicare has made a national coverage determination regarding the service; carriers remain responsible for coverage decisions in the absence of a national Medicare policy.\",\n         \"pctcDesc\": \"PC/TC Indicator|Physician service codes: This indicator identifies codes that describe physician services\",\n         \"multProcDesc\": \"Multiple Procedures|No payment adjustment rules apply. If the procedure is reported on the same day as another procedure, the procedure is paid at the lower of the actual charge or the fee schedule amount for the procedure\",\n         \"bilatSurgDesc\": null,\n         \"asstSurgDesc\": \"Surgical Assistant|Payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity.\",\n         \"teamSurgDesc\": \"Team Surgery|Team surgeons are not permitted for this procedure.\",\n         \"physSurgDesc\": \"Physician Supervision of Diagnostic Procedures|Concept does not apply\",\n         \"coSurgDesc\": \"Co-surgeons|Co-surgeons are not permitted for this procedure.\"\n       }\n     }\n  }\n"
        '404':
          description: Not found
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Notification'
              example:
                timestamp: '2023-07-14T06:37:03.741+00:00'
                status: 404
                error: Not Found
                message: Not Found
                path: /cmscommonms/api/cms/physician/mpfs/payment-indicator-status1/99213
        '500':
          description: Internal server error
          content:
            application/json:
              example:
                timestamp: '2023-07-13T06:36:22.518+00:00'
                path: /cmscommonms/api/cms/physician/mpfs/payment-indicator-status/99213
                status: 500
                error: Internal Server Error
                requestId: e36d239e-324
      security:
      - bearerAuth: []
    servers:
    - url: /v1/cmscommonms
  /api/cms/physician/mpfs/national-physician-relative-file:
    get:
      tags:
      - Medicare Fee Schedule APIs
      summary: Fetches MPFS file content particular medicare rule type
      operationId: getRelativeFile
      parameters:
      - name: yyyy-MM-dd
        in: header
        description: Date for which historical data is required
        required: false
        schema:
          type: string
          format: yyyy-MM-dd
      responses:
        '200':
          description: Fetches the file content in the form of byte array, response headers and media type as fileType
          content:
            application/pdf:
              schema:
                $ref: '#/components/schemas/Notification'
              example: " access-control-expose-headers: Content-Disposition \n cache-control: no-cache,no-store,max-age=0,must-revalidate \n connection: keep-alive \n content-disposition: attachment; filename=RVU3C.pdf \n content-length: 178521 \n content-type: application/pdf \n date: Fri,28 Jul 2023 12:03:02 GMT \n expires: 0 \n pragma: no-cache \n vary: Origin,Access-Control-Request-Method,Access-Control-Request-Headers \n x-content-type-options: nosniff \n x-frame-options: DENY \n x-xss-protection: 0 \n"
        '404':
          description: 'Not found: Sub terms not found'
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Notification'
              example:
                timestamp: '2023-07-28T06:19:48.666+00:00'
                status: 404
                error: Not Found
                message: Not Found
                path: /cmscommonms/api/cms/mpfs/national-physician-relative-file
        '500':
          description: Internal server error
          content:
            application/json:
              example:
                timestamp: '2023-07-28T06:19:48.666+00:00'
                path: /cmscommonms/api/cms/mpfs/national-physician-relative-file
                status: 500
                error: Internal Server Error
                requestId: a4796cc7-1
      security:
      - bearerAuth: []
    servers:
    - url: /v1/cmscommonms
  /api/cms/physician/mpfs/global-days/{code}:
    get:
      tags:
      - Medicare Fee Schedule APIs
      summary: Fetches MPFS global days for CPT and HCPCS code
      operationId: getGlobalDays
      parameters:
      - name: code
        in: path
        required: true
        schema:
          type: string
        example: 99213
      - name: yyyy-MM-dd
        in: header
        description: Date for which historical data is required
        required: false
        schema:
          type: string
          format: yyyy-MM-dd
      responses:
        '200':
          description: Fetches MPFS global days for CPT and HCPCS code
          content:
            application/json:
              example:
                preop: 0
                intraop: 0
                postop: 0
                globalDays: '000'
        '400':
          description: Bad request
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Notification'
              example:
                error:
                - 'code : Invalid CPT or HCPCS value. Length should be 5'
                warning: null
                info: null
        '404':
          description: Not found
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Notification'
              example:
                timestamp: '2023-07-14T06:37:03.741+00:00'
                status: 404
                error: Not Found
                message: Not Found
                path: /cmscommonms/api/cms/physician/mpfs/global-day/99213
        '500':
          description: Internal server error
          content:
            application/json:
              example:
                timestamp: '2024-01-13T06:36:22.518+00:00'
                path: /cmscommonms/api/cms/physician/mpfs/global-days/99213
                status: 500
                error: Internal Server Error
                requestId: e36d239e-324
      security:
      - bearerAuth: []
    servers:
    - url: /v1/cmscommonms
  /api/cms/physician/mpfs/fee-schedule/{codetype}/{code}/{carrier}/{locality}:
    get:
      tags:
      - Medicare Fee Schedule APIs
      summary: Fetches MPFS fee schedule
      operationId: fetchMedicareFees
      parameters:
      - name: codetype
        in: path
        required: true
        schema:
          type: string
          enum:
          - hcpcs
          - cpt
      - name: code
        in: path
        required: true
        schema:
          type: string
        example: 99213
      - name: carrier
        in: path
        description: Carrier value
        required: true
        schema:
          type: string
        example: '00000'
      - name: locality
        in: path
        description: Locality value
        required: true
        schema:
          type: string
        example: '00'
      - name: cf
        in: query
        required: false
        schema:
          type: number
      - name: yyyy-MM-dd
        in: header
        description: Date for which historical data is required
        required: false
        schema:
          type: string
          format: yyyy-MM-dd
      responses:
        '200':
          description: Fetches MPFS fee schedule for cpt codes
          content:
            application/json:
              example:
                medicareFeeValues:
                  RVU_FACILITY:
                    TC_FEE:
                    - fee: 0
                      feeLabel: WORK RVU
                    - fee: 0.7463
                      feeLabel: PE RVU
                    - fee: 0.00748
                      feeLabel: Malpractice RVU
                    - fee: 0.75378
                      feeLabel: Total RVU
                    PROF_FEE:
                    - fee: 0.23
                      feeLabel: WORK RVU
                    - fee: 0.07024
                      feeLabel: PE RVU
                    - fee: 0.00748
                      feeLabel: Malpractice RVU
                    - fee: 0.30772
                      feeLabel: Total RVU
                    NATIONAL:
                    - fee: 0.23
                      feeLabel: WORK RVU
                    - fee: 0.93
                      feeLabel: PE RVU
                    - fee: 0.02
                      feeLabel: Malpractice RVU
                    - fee: 1.18
                      feeLabel: Total RVU
                    LOCALITY:
                    - fee: 0.23
                      feeLabel: WORK RVU
                    - fee: 0.81654
                      feeLabel: PE RVU
                    - fee: 0.01496
                      feeLabel: Malpractice RVU
                    - fee: 1.0615
                      feeLabel: Total RVU
                  RVU_OPPS:
                    TC_FEE:
                    - fee: 0
                      feeLabel: WORK RVU
                    - fee: 2.73936
                      feeLabel: PE RVU
                    - fee: 0.02992
                      feeLabel: Malpractice RVU
                    - fee: 2.76928
                      feeLabel: Total RVU
                    PROF_FEE:
                    - fee: 0.23
                      feeLabel: WORK RVU
                    - fee: 0.07024
                      feeLabel: PE RVU
                    - fee: 0.00748
                      feeLabel: Malpractice RVU
                    - fee: 0.30772
                      feeLabel: Total RVU
                    NATIONAL:
                    - fee: 0.23
                      feeLabel: WORK RVU
                    - fee: 3.2
                      feeLabel: PE RVU
                    - fee: 0.05
                      feeLabel: Malpractice RVU
                    - fee: 3.48
                      feeLabel: Total RVU
                    LOCALITY:
                    - fee: 0.23
                      feeLabel: WORK RVU
                    - fee: 2.8096
                      feeLabel: PE RVU
                    - fee: 0.0374
                      feeLabel: Malpractice RVU
                    - fee: 3.077
                      feeLabel: Total RVU
                  RVU_NON_FACILITY:
                    TC_FEE:
                    - fee: 0
                      feeLabel: WORK RVU
                    - fee: 0.7463
                      feeLabel: PE RVU
                    - fee: 0.00748
                      feeLabel: Malpractice RVU
                    - fee: 0.75378
                      feeLabel: Total RVU
                    PROF_FEE:
                    - fee: 0.23
                      feeLabel: WORK RVU
                    - fee: 0.07024
                      feeLabel: PE RVU
                    - fee: 0.00748
                      feeLabel: Malpractice RVU
                    - fee: 0.30772
                      feeLabel: Total RVU
                    NATIONAL:
                    - fee: 0.23
                      feeLabel: WORK RVU
                    - fee: 0.93
                      feeLabel: PE RVU
                    - fee: 0.02
                      feeLabel: Malpractice RVU
                    - fee: 1.18
                      feeLabel: Total RVU
                    LOCALITY:
                    - fee: 0.23
                      feeLabel: WORK RVU
                    - fee: 0.81654
                      feeLabel: PE RVU
                    - fee: 0.01496
                      feeLabel: Malpractice RVU
                    - fee: 1.0615
                      feeLabel: Total RVU
                  TOTAL_FEES:
                    TC_FEE:
                    - fee: 25.543493616
                      feeLabel: Facility
                    - fee: 25.543493616
                      feeLabel: Non-Facility
                    - fee: 93.843145216
                      feeLabel: OPPS Global
                    PROF_FEE:
                    - fee: 10.427769184
                      feeLabel: Facility
                    - fee: 10.427769184
                      feeLabel: Non-Facility
                    - fee: 10.427769184
                      feeLabel: OPPS Global
                    NATIONAL:
                    - fee: 39.986896
                      feeLabel: Facility
                    - fee: 39.986896
                      feeLabel: Non-Facility
                    - fee: 117.927456
                      feeLabel: OPPS Global
                    LOCALITY:
                    - fee: 35.9712628
                      feeLabel: Facility
                    - fee: 35.9712628
                      feeLabel: Non-Facility
                    - fee: 104.2709144
                      feeLabel: OPPS Global
        '404':
          description: Not found
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Notification'
              example:
                timestamp: '2023-07-14T06:37:03.741+00:00'
                status: 404
                error: Not Found
                message: Not Found
                path: /cmscommonms/api/cms/physician/mpfs/fee-schedule/i9v1/A4562/10112/00
        '500':
          description: Interal server error
          content:
            application/json:
              example:
                timestamp: '2023-07-13T06:36:22.518+00:00'
                path: /cmscommonms/api/cms/physician/mpfs/fee-schedule/cpt/72072/10112/00
                status: 500
                error: Internal Server Error
                requestId: e36d239e-324
      security:
      - bearerAuth: []
    servers:
    - url: /v1/cmscommonms
  /api/cms/physician/mpfs/fee-schedule/mpfs-reduction-groups/hcpcs/{code}:
    get:
      tags:
      - Medicare Fee Schedule APIs
      summary: Fetches MPFS reduction groups applicable for particular code
      operationId: getHcpcsMedicareReductionGroups
      parameters:
      - name: code
        in: path
        required: true
        schema:
          type: string
        example: A4562
      - name: yyyy-MM-dd
        in: header
        description: Date for which historical data is required
        required: false
        schema:
          type: string
          format: yyyy-MM-dd
      responses:
        '200':
          description: Fetch Medicare Localities
          content:
            application/json:
              example:
              - reductionLabel: Sequestration
                mpfsReductionGroupId: 13
                nonFacTotalAdjFactor: 98.4
                facTotalAdjFactor: 98.4
        '404':
          description: Not found
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Notification'
              example:
                timestamp: '2023-07-14T06:37:03.741+00:00'
                status: 404
                error: Not Found
                message: Not Found
                path: /cmscommonms/api/cms/physician/mpfs/fee-schedule/mpfs-reduction-groups/i9v1/A4562
        '500':
          description: Internal server error
          content:
            application/json:
              example:
                timestamp: '2023-07-13T06:36:22.518+00:00'
                path: /cmscommonms/api/cms/physician/mpfs/fee-schedule/mpfs-reduction-groups/hcpcs/A4562
                status: 500
                error: Internal Server Error
                requestId: e36d239e-324
      security:
      - bearerAuth: []
    servers:
    - url: /v1/cmscommonms
  /api/cms/physician/mpfs/fee-schedule/mpfs-reduction-groups/cpt/{code}:
    get:
      tags:
      - Medicare Fee Schedule APIs
      summary: Fetches MPFS Reduction Groups applicable for particular code
      operationId: getCptMedicareReductionGroups
      parameters:
      - name: code
        in: path
        required: true
        schema:
          type: string
        example: 99213
      - name: yyyy-MM-dd
        in: header
        description: Date for which historical data is required
        required: false
        schema:
          type: string
          format: yyyy-MM-dd
      responses:
        '200':
          description: Fetches MPFS Reduction Groups applicable for cpt code
          content:
            application/json:
              example:
              - reductionLabel: FX Modifier Reduction
                mpfsReductionGroupId: 21
                nonFacTotalAdjFactor: 80
                facTotalAdjFactor: 80
              - reductionLabel: FY Modifier Reduction
                mpfsReductionGroupId: 22
                nonFacTotalAdjFactor: 93
                facTotalAdjFactor: 93
              - reductionLabel: Sequestration
                mpfsReductionGroupId: 13
                nonFacTotalAdjFactor: 98.4
                facTotalAdjFactor: 98.4
        '404':
          description: Not found
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Notification'
              example:
                timestamp: '2023-07-14T06:37:03.741+00:00'
                status: 404
                error: Not Found
                message: Not Found
                path: /cmscommonms/api/cms/physician/mpfs/fee-schedule/mpfs-reduction-groups/i9v1/A4562
        '500':
          description: Internal server error
          content:
            application/json:
              example:
                timestamp: '2023-07-13T06:36:22.518+00:00'
                path: /cmscommonms/api/cms/physician/mpfs/fee-schedule/mpfs-reduction-groups/hcpcs/A4562
                status: 500
                error: Internal Server Error
                requestId: e36d239e-324
      security:
      - bearerAuth: []
    servers:
    - url: /v1/cmscommonms
  /api/optum/physician/mpfs/locality-fee/{codetype}/{code}/{carrier}/{locality}:
    get:
      tags:
      - Medicare Fee Schedule APIs
      summary: Fetches MPFS fee scedule
      operationId: fetchMedicareLocalityFees
      parameters:
      - name: codetype
        in: path
        required: true
        schema:
          type: string
          enum:
          - hcpcs
          - cpt
      - name: code
        in: path
        required: true
        schema:
          type: string
        example: 99213
      - name: carrier
        in: path
        description: Carrier value
        required: true
        schema:
          type: string
        example: '00000'
      - name: locality
        in: path
        description: Locality value
        required: true
        schema:
          type: string
        example: '00'
      - name: cf
        in: query
        required: false
        schema:
          type: number
      - name: yyyy-MM-dd
        in: header
        description: Date for which historical data is required
        required: false
        schema:
          type: string
          format: yyyy-MM-dd
      responses:
        '200':
          description: Fetches MPFS fee schedule for cpt codes
          content:
            application/json:
              example:
                medicareFeeValues:
                  RVU_FACILITY:
                    Locality:
                    - fee: 1.3
                      feeLabel: Work
                    - fee: 1.97
                      feeLabel: Total
                  RVU_NON_FACILITY:
                    Locality:
                    - fee: 1.3
                      feeLabel: Work
                    - fee: 2.75
                      feeLabel: Total
                  TOTAL_FEES:
                    Locality:
                    - fee: 63.722605
                      feeLabel: Facility
                    - fee: 88.952875
                      feeLabel: Non-Facility
                conversionFactor: 32.3465
        '404':
          description: Not found
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Notification'
              example:
                timestamp: '2023-07-14T06:37:03.741+00:00'
                status: 404
                error: Not Found
                message: Not Found
                path: /cmscommonms/api/optum/physician/mpfs/locality-fee/i9v1/A4562/10112/00
        '500':
          description: Interal server error
          content:
            application/json:
              example:
                timestamp: '2023-07-13T06:36:22.518+00:00'
                path: /cmscommonms/api/optum/physician/mpfs/locality-fee/cpt/72072/10112/00
                status: 500
                error: Internal Server Error
                requestId: e36d239e-324
      security:
      - bearerAuth: []
    servers:
    - url: /v1/optumcommonms
components:
  schemas:
    Notification:
      type: object
      properties:
        error:
          type: array
          items:
            type: string
        warning:
          type: array
          items:
            type: string
        info:
          type: array
          items:
            type: string
  securitySchemes:
    bearerAuth:
      type: http
      scheme: bearer
      bearerFormat: JWT
x-refined-from:
- optum-cms-common-physician-openapi.yml
- optum-optum-common-physician-openapi.yml
x-readme:
  explorer-enabled: true
  proxy-enabled: true