Primary Data Sources
- CMS Physician Fee Schedule (PFS): Published annually. Provides national and locality-adjusted reimbursement rates for all CPT codes. Our reimbursement projections are anchored to PFS rates.
- CMS Medicare Provider Utilization & Payment Data: Actual payment patterns and utilization volumes by procedure and geography.
- CMS OPPS (Outpatient Prospective Payment System): Facility reimbursement rates for hospital outpatient services.
- NCCI Correct Coding Initiative Edits: Official bundling and modifier validation rules maintained by CMS.
- OIG Work Plan: Annual enforcement priorities from the Office of Inspector General, informing our audit risk assessments.
Payer-Specific Sources
- Medicare: CMS national and local coverage determinations (NCDs/LCDs), MAC-specific policies
- UnitedHealthcare: Published Clinical Policy Bulletins and Medical Policy Updates
- Aetna: Clinical Policy Bulletins (CPBs) and Precertification Lists
- Blue Cross Blue Shield: State plan medical policies (varies by affiliate)
How We Use Sources
We map published payer criteria to specific CPT code and category combinations. Where exact payer+CPT data exists, we report it as "Exact match" with higher confidence. Where only category-level data exists, we flag it as "Category-derived" with appropriately reduced confidence scores.
Questions about our sources: editorial@builtfor.ai