CMS Pub. 100-04, ch. 24, § 50.3.4

Sets Requirements

(Rev. 13105; Issued- 04-10-25; Effective: 05-12-25; Implementation: 05-12-25)

The functionality of the CCEM is dependent on the standard system maintainers (SSM)

providing current code sets for inbound claims and claim status inquiries to be edited

against. This requires the CCEM maintainer to update the following code sets on a

quarterly release basis in order to align with industry:

• Country Codes (ISO 3166-1)

• Country Subdivision Codes (ISO 3166-2)

• State Codes (United States, Canada, Mexico)

• Not Otherwise Classified (NOC) Procedure Codes (as defined by CMS)

• National Uniform Billing Committee (NUBC) Condition Codes (that are valid

for use on the 837 Professional claim per the National Uniform Claim

Committee (NUCC))

• Ambulance Modifiers

• Health Insurance Prospective Payment System (HIPPS) (as updated and

maintained by CMS)

A/B MACs are required to validate the incoming codes listed above against the most

recent codes sets provided by the SSM. CMS will notify the shared system maintainers

(via Recurring Update Notification) to load the most recent code sets into the CCEM

environment for download to the A/B MAC local data center (LDC) in conjunction with

the quarterly release.

The CCEM maintainer also updates the following code sets on a frequency basis other

than quarterly in order to align with industry:

• ZIP codes

• Claim Adjustment Reason Codes (CARC)

• Anesthesia Modifiers

• Diagnosis Related Groups (DRG) codes

• Healthcare Common Procedure Coding System (HCPCS) codes

• Health Insurance Premium Payment System (HIPPS) codes

• International Classification of Diseases, (ICD) codes

• National Drug Codes (NDC) (as published by the Federal Drug Administration

(FDA))

• National Provider Identifier (NPI)

• Remittance Advice Remark Codes (RARC)

• Taxonomy Codes

• Procedure Code Modifier Codes

• Admission Source Codes

• Admission Type Codes

• Patient Status Codes

• Condition Codes

• Occurrence Codes

• Occurrence Span Codes

• Value Codes

• Revenue Codes

• Uniform Bill Type codes

• Provider Control File (PCF) - Part B only

A/B MACs are required to validate the incoming codes listed above against the most

recent codes sets provided by the SSM. When the above listed reference code sets are

updated, they are sent to the A/B MAC (LDC) as part of nightly code updates.