procedure-coverage

For a diagnosis and one or more CPT/HCPCS codes, report what CMS Local Coverage Articles record for each code, which ICD-10 diagnoses those articles list as covered or non-covered, and the CMS Physician Fee Schedule PROFESSIONAL amount where a national rate exists. Setting matters and is stated: codes performed only in a facility return not_applicable_in_this_setting rather than an invented office price, and codes CMS does not pay under the PFS (status I, X, N, E, B, P) return not_payable_under_pfs rather than a figure computed from published RVUs. Coverage is contractor-specific. Does NOT compare clinical effectiveness or recommend treatment, and a missing national rate is never treated as non-coverage. The amount is the clinician fee only — not the facility fee, device or imaging.

{'type': 'object', 'required': [], 'properties': {'codes': {'type': 'string', 'description': 'Comma-separated CPT/HCPCS codes, e.g. "27447,20610"'}, 'diagnosis': {'type': 'string', 'description': 'ICD-10 code or prefix, e.g. "M17" (knee osteoarthritis)'}}}