Data Sources

Primary Data Sources

• CMS Physician Fee Schedule (CY 2026 Q1): 9,685 CPT codes with work RVUs, practice expense RVUs, malpractice RVUs, facility and non-facility rates. Conversion factor: $33.5675.
• CDC ICD-10-CM (FY 2026): 74,719 active diagnosis codes. Used for code validation, medical necessity checks, and LCD/NCD coverage mapping.
• CMS HCPCS Level II (2026): 8,685 codes covering DME, supplies, drug administration (J-codes), and temporary codes.
• CMS NCCI PTP Edits (Q1 2026): 442,646 procedure-to-procedure bundling rules with modifier indicators.
• CMS NCCI MUE (Q1 2026): 15,095 medically unlikely edit limits with adjudication type indicators.
• CMS MS-DRG (FY 2026): 770 inpatient payment groups with relative weights and geometric/arithmetic mean lengths of stay.

Regulatory and Coverage Sources

• CMS LCD/NCD: Local and National Coverage Determination data mapping CPT procedures to covered and non-covered ICD-10 diagnoses. 379,816 covered and 45,341 non-covered code pairs imported.
• X12/WPC CARC Codes: 283 Claim Adjustment Reason Codes for denial decoding and appeal strategy mapping.
• CMS Place of Service Codes: 50 facility type codes for POS validation.
• CMS RARC Codes: 399 Remittance Advice Remark Codes for supplemental denial information.

Methodology

Medicare rates are calculated from PFS RVUs multiplied by the CY 2026 conversion factor ($33.5675). Commercial estimates apply payer-specific multipliers derived from published data. Denial risk is modeled per payer using a 4-tier engine: exact match lookups, category-based rules, code-type heuristics, and baseline payer profiles calibrated against KFF and AMA denial rate studies.

Questions about our sources: Contact the editorial team