Code Lookup

GET /codes/lookup

Look up coverage policies for a specific procedure or diagnosis code.

Request

GET /v1/codes/lookup?code=76942

Query Parameters

Parameter	Type	Required	Description
`code`	string	Yes	The procedure or diagnosis code
`code_system`	string	No	Filter by code system: `CPT`, `HCPCS`, `ICD10CM`, `ICD10PCS`, `NDC`
`include`	string	No	Additional data: `rvu`, `policies` (comma-separated)
`jurisdiction`	string	No	Filter policies by MAC jurisdiction
`fuzzy`	string	No	Enable fuzzy matching: `true` or `false` (default: `true`). When enabled, returns suggestions if exact code not found

Response

{
  "success": true,
  "data": {
    "code": "27447",
    "code_system": "CPT",
    "found": true,
    "description": "Total knee arthroplasty",
    "short_description": "Total knee replacement",
    "category": "Surgery",
    "betos_code": "P4D",
    "is_active": true,
    "rvu": {
      "work_rvu": "19.11",
      "pe_rvu_facility": "11.59",
      "pe_rvu_nonfacility": "11.59",
      "mp_rvu": "4.02",
      "total_rvu_facility": "34.72",
      "total_rvu_nonfacility": "34.72",
      "facility_price": "1159.68",
      "non_facility_price": "1159.68",
      "conversion_factor": "33.4009",
      "global_days": "090",
      "status_code": "A",
      "year": 2026
    },
    "policies": [
      {
        "policy_id": "A59811",
        "title": "Billing and Coding: Total Joint Arthroplasty",
        "policy_type": "Article",
        "jurisdiction": "J05",
        "disposition": "covered",
        "effective_date": "2024-01-01"
      }
    ]
  },
  "meta": {
    "request_id": "req_abc123",
    "includes": ["rvu", "policies"],
    "fuzzy_enabled": true
  }
}

Code Systems

Code System	Description
`CPT`	CPT procedure codes (numeric 5-digit codes like `99213`, `27447`)
`HCPCS`	HCPCS Level II codes (alphanumeric like `J0585`, `G0101`)
`ICD10CM`	ICD-10-CM diagnosis codes (like `E11.9`, `M17.11`)
`ICD10PCS`	ICD-10-PCS procedure codes
`NDC`	National Drug Codes (11-digit codes, with or without dashes)

RVU Data

When include=rvu is specified, the response includes Medicare fee schedule data:

Field	Description
`work_rvu`	Work Relative Value Units
`pe_rvu_facility`	Practice Expense RVU (facility setting)
`pe_rvu_nonfacility`	Practice Expense RVU (non-facility setting)
`mp_rvu`	Malpractice RVU
`facility_price`	Calculated Medicare payment (facility)
`non_facility_price`	Calculated Medicare payment (non-facility)
`conversion_factor`	Medicare conversion factor used
`global_days`	Global surgery period (`000`, `010`, `090`, `XXX`, etc.)
`status_code`	Medicare status indicator (`A`=Active, `I`=Invalid, etc.)
`year`	Fee schedule year

NDC Crosswalk

When looking up an NDC code, the response includes HCPCS crosswalk data:

Field	Description
`ndc`	The original NDC code
`hcpcs_code`	Mapped HCPCS code for billing
`hcpcs_description`	Description of the HCPCS code
`ndc_label`	Drug name/label
`route`	Route of administration
`billing_units`	Billing units for the drug
`conversion_factor`	NDC to HCPCS conversion factor

{
  "data": {
    "code": "J0585",
    "code_system": "NDC",
    "found": true,
    "description": "Botulinum toxin type A",
    "ndc_crosswalk": {
      "ndc": "00023114501",
      "hcpcs_code": "J0585",
      "hcpcs_description": "Injection, onabotulinumtoxina",
      "ndc_label": "Botox",
      "route": "Injection",
      "billing_units": "1 unit",
      "conversion_factor": "1"
    }
  }
}

Code Examples

import requests

response = requests.get(
    'https://api.verity.health/v1/codes/lookup',
    params={'code': '27447', 'include': 'rvu,policies'},
    headers={'Authorization': 'Bearer YOUR_API_KEY'}
)

data = response.json()
code_info = data['data']
print(f"Code: {code_info['code']} ({code_info['code_system']})")
print(f"Description: {code_info['description']}")
if code_info.get('rvu'):
    print(f"Work RVU: {code_info['rvu']['work_rvu']}")
    print(f"Medicare Payment: ${code_info['rvu']['facility_price']}")

const params = new URLSearchParams({
  code: '27447',
  include: 'rvu,policies'
});

const response = await fetch(
  `https://api.verity.health/v1/codes/lookup?${params}`,
  {
    headers: {
      'Authorization': 'Bearer YOUR_API_KEY'
    }
  }
);

const { data } = await response.json();
console.log(`Code: ${data.code} (${data.code_system})`);
console.log(`Description: ${data.description}`);
if (data.rvu) {
  console.log(`Work RVU: ${data.rvu.work_rvu}`);
  console.log(`Medicare Payment: $${data.rvu.facility_price}`);
}

curl -X GET "https://api.verity.health/v1/codes/lookup?code=27447&include=rvu,policies" \
  -H "Authorization: Bearer YOUR_API_KEY"

Coverage Dispositions

Disposition	Description
`covered`	Code is covered under the policy
`not_covered`	Code is not covered
`conditional`	Coverage depends on specific criteria
`requires_pa`	Prior authorization required

Fuzzy Matching

When fuzzy=true (the default), the API will attempt to find similar codes if an exact match isn't found. This is useful for handling typos or partial codes.

GET /v1/codes/lookup?code=7694&fuzzy=true

If the exact code isn't found, the response includes suggestions:

{
  "success": true,
  "data": {
    "code": "7694",
    "code_system": "unknown",
    "found": false,
    "description": null,
    "suggestions": [
      {
        "code": "76942",
        "code_system": "HCPCS",
        "description": "Ultrasonic guidance for needle placement",
        "score": 0.95,
        "match_type": "code"
      },
      {
        "code": "76940",
        "code_system": "HCPCS",
        "description": "Ultrasound guidance ablation",
        "score": 0.90,
        "match_type": "code"
      }
    ]
  },
  "meta": {
    "includes": [],
    "fuzzy_enabled": true
  }
}

To disable fuzzy matching and only return exact matches:

GET /v1/codes/lookup?code=76942&fuzzy=false

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