Editorial Policy

Data Sourcing

MedicalClaim.ai is built on official U.S. government datasets. Every billing code, bundling rule, unit limit, and coverage determination traces back to a published CMS or CDC source file.

• CMS Physician Fee Schedule: 9,685 CPT codes with work, practice expense, and malpractice RVUs. Updated annually with quarterly corrections.
• CDC ICD-10-CM: 74,719 diagnosis codes. Updated each October.
• CMS HCPCS Level II: 8,685 supply, DME, and drug administration codes.
• CMS NCCI Edits: 442,646 procedure-to-procedure bundling rules and 15,095 medically unlikely edit limits. Updated quarterly.
• CMS LCD/NCD: Coverage determination data mapping procedures to covered and non-covered diagnoses.
• CMS MS-DRG: 770 inpatient payment groups with relative weights and mean length of stay.
• X12 CARC Codes: 283 claim adjustment reason codes for denial decoding.

Validation Process

Data is imported from official source files, deduplicated against primary keys, and verified with spot checks against known values (e.g., 99213 RVUs, standard MUE thresholds). Payer-specific denial risk models are calibrated against published denial rate data from KFF, AMA, and CMS reports.

Limitations

Denial risk scores are probabilistic estimates, not guarantees. Reimbursement figures use CMS conversion factors and may not reflect your specific contracted rates. LCD coverage data is partial; a "supported" result does not guarantee payment.

For methodology questions: Contact the editorial team