CIP.002.026

ADJUSTMENT-IND

Data Element

DE Number

CIP026

System DE Number

CIP.002.026

File Name

CIP - CLAIM INPATIENT

File Segment Number

CIP00002

File Segment Name

CLAIM-HEADER-RECORD-IP

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	Indicates the type of adjustment record.
Size	X(1)
FLF Start Position	158
FLF Stop Position	158
Segment Key Field Identifier	4
Coding Requirements	1. Value must be in Adjustment Indicator List (VVL) 2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ] 3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ] 4. Value must be 1 character 5. Mandatory 6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated 7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated 8. Value must equal ‘1’, when associated Claim Status equals ‘686’

Valid Value Code Set	Valid Value Code	Valid Value Name	Valid Value Description	Effective Start Date	Effective End Date

RULE ID	RULE Definition
RULE-7647	If a segment is an IP claim header, and the type of claim is an encounter, the adjustment indicator must be populated.
RULE-7981	If a claim in a non-denied, original or adjustment FFS crossover claim from an IP file, and the MSIS ID is populated and the admission date is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'
RULE-7744	If a claim in a non-denied, original or adjustment Encounter crossover claimfrom an IP file, and the MSIS ID is populated and the admission date is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01','02', '04', '08'
RULE-7412	If a claim in a non-denied, original or adjustment FFS or Encounter crossover claim from an IP file, and the MSIS ID is populated and the admission date is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01','02', '04', '08'
RULE-7884	If the type of claim is a service tracking and adjustment indicator is populated on a claim header from an IP file, then the adjustment indicator value reported must be in the list of valid values for adjustment indicator.
RULE-7876	If the type of claim is a supplemental and adjustment indicator is populated on a claim header from an IP file, then the adjustment indicator value reported must be in the list of valid values for adjustment indicator.
RULE-7868	If the type of claim is a fee-for-service and adjustment indicator is populated on a claim header from an IP file, then the adjustment indicator value reported must be in the list of valid values for adjustment indicator.
RULE-7860	If a segment is an IP claim header, and the type of claim is a service tracking, the adjustment indicator must be populated.
RULE-7852	If a segment is an IP claim header, and the type of claim is a supplemental, the adjustment indicator must be populated.
RULE-7844	If a segment is an IP claim header, and the type of claim is a fee for service, the adjustment indicator must be populated.
RULE-7667	If the type of claim is an encounter and adjustment indicator is populated on a claim header from an IP file, then the adjustment indicator value reported must be in the list of valid values for adjustment indicator.
RULE-340	If the adjustment indicator is populated on a claim header from an IP file, then the adjustment indicator value reported must be in the list of valid values for adjustment indicator.
RULE-7633	All non-denied, paid IP claim header records must have a corresponding non-denied claim line record.
RULE-7570	All denied IP claim header records must have a corresponding claim line record.
RULE-7541	If a segment is an IP claim header, and claim status is equal to '686' (void claim), then adjustment indicator must be equal to '1' (void).
RULE-7464	If a segment is an IP claim header, adjustment indicator must be populated.
RULE-7431	All non-denied IP claim header records must have a corresponding claim line record.
RULE-7345	If a segment is an IP claim header and icn adj is populated, then adjustment indicator is a replacement or resubmission payment or a void, reversal or canceled payment.
RULE-7337	If a segment is an IP claim header and icn adj is not populated, then the adjustment indicator is an original claim/encounter payment, credit gross adjustment or a debit gross adjustment payment.
RULE-7183	If a claim header is from an IP file, then submitting state, original ICN, adjustment ICN, adjudication date, and adjustment indicator values reported must be unique across all IP claim headers.
RULE-6978	If a claim is from an IP file, then the adjustment indicator value reported must be compatible with the specified T-MSIS picture format: X(1).

Measure ID	Measure Name
MCR-54-002-2	# of plans with at least 100 enrollments or 100 capitations, 0 encounters
MCR-27-002-2	Encounters (by Claims file type) by Plan ID (non-PCCM)
MCR-27-001-1	Encounters (by Claim File Type)
EL-8-001-1	Enrollment, capitation payments, and encounters by Plan Type
RULE-7464	% of claim headers with a missing Adjustment Indicator
RULE-340	% of claim headers with an invalid Adjustment Indicator (ADJUSTMENT-IND is 2, 3, 9, other invalid value)
MCR-S-016-13	% of claim headers that are original
MCR-55-003-3	PACE capitation ratio
MCR-55-002-2	Enhanced PCCM capitation ratio
MCR-55-001-1	Traditional PCCM capitation ratio
MCR-54-010-10	# of plans where MC plan type does not match EL plan type
MCR-54-009-9	# of plans with at least 100 enrollments, capitations, or encounters, that do not have a managed care record
MCR-54-005-5	# of plans with at least 100 capitations or 100 encounters, 0 enrollments
MCR-54-004-4	# of plans with at least 100 enrollments and some capitations that have capitation ratios outside of the expected range (0.7 - 1.3)
MCR-54-003-3	# of plans with at least 100 enrollments or 100 encounters, 0 capitations
EL-8-002-2	Enrollment, capitation payments, capitation ratios, encounters (by claim file type) and encounter ratios (by claim file type) by plan ID with plan ID linking to MC file
MCR-54-001-1	# of plans with at least 100 enrollments, 0 capitations, 0 encounters
MCR-53-003-3	Total # of managed care encounters
MCR-53-002-2	Total # of managed care capitations
MCR-53-001-1	Total # of managed care enrollments
MCR-43-001-1	Adjustment Indicator values
MCR-33-001-1	Adjustment Indicator values
MCR-32-011-11	% of claim headers without a valid Adjustment Indicator (ADJ-IND is 2, 3, 9, other invalid value, or missing)
MCR-32-001-1	% of claim headers without a valid Adjustment Indicator (ADJ-IND is 2, 3, 9, other invalid value, or missing)
FFS-S-013-13	% of claim headers that are original
FFS-S-009-2	% of claim headers that are original
FFS-35-001-1	Adjustment Indicator values
FFS-27-001-1	Adjustment Indicator values
FFS-26-009-9	% of claim headers without a valid Adjustment Indicator (ADJ-IND is 2, 3, 9, other invalid value, or missing)

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
CLT025	CLT.002.025	ADJUSTMENT-IND	CLT00002	CLAIM-HEADER-RECORD-LT
COT025	COT.002.025	ADJUSTMENT-IND	COT00002	CLAIM-HEADER-RECORD-OT
CRX025	CRX.002.025	ADJUSTMENT-IND	CRX00002	CLAIM-HEADER-RECORD-RX

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
11/07/2023	3.16.0	CIP.002.026	UPDATE	Segment key field identifier	Not Applicable	4
11/07/2023	3.16.0	CIP.002.026	UPDATE	Coding requirement	Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’	1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’
08/15/2023	3.12.0	CIP.002.026	UPDATE	Coding requirement	1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory	Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’
08/07/2023	3.11.0	CIP.002.026	UPDATE	Coding requirement	1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim (CE) value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim (CE) value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory	1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory
03/01/2024	3.20.0	ADJUSTMENT-IND and LINE-ADJUSTMENT-IND CIP026	Update	Data Dictionary - Valid Values	Original Claim/Encounter	Original Claim/Encounter/Payment - Indicates that this is the first (and, when applicable, only) fully adjudicated transaction in a claim family (one or more claims with the related ICN-ORIG and/or ICN-ADJ and typically the same MSIS ID and provider ID(s) also).
03/01/2024	3.20.0	ADJUSTMENT-IND and LINE-ADJUSTMENT-IND CIP026	Update	Data Dictionary - Valid Values	Void of a prior submission	Void/Reversal/Cancel of a prior submission Use this code to convey that the purpose of the transaction is to void/reverse/cancel a previously paid/approved claim/encounter/payment where the claim/encounter/payment is not being replaced by a new paid/approved version of the claim/encounter/payment. Typically, this would be the last claim/encounter/payment that would ever be associated with a given claim family. These records must have the same ICN-ORIG or ICN-ADJ as the claim/encounter being voided. CMS expects a void transaction to also have the same MSIS ID and provider ID(s) as the claim/encounter/payment being voided/reversed/cancelled.
03/01/2024	3.20.0	ADJUSTMENT-IND and LINE-ADJUSTMENT-IND CIP026	Update	Data Dictionary - Valid Values	Debit Adjustment (positive supplemental)	Replacement/Resubmission of a previously paid/approved claim/encounter/payment - Use when the purpose of the transaction is to replace a previously paid/approved claim/encounter/payment with a new paid/approved version of the claim/encounter/payment. These records must have the same ICN-ORIG or ICN-ADJ as the claim/encounter being replaced. CMS expects a replacement transaction to also have the same MSIS ID and provider ID(s) as the claim/encounter/payment being replaced/resubmitted.
03/01/2024	3.20.0	ADJUSTMENT-IND and LINE-ADJUSTMENT-IND CIP026	Update	Data Dictionary - Valid Values	Credit Gross Adjustment	Credit Gross Adjustment - Use this code to indicate an aggregate provider-level recoupment of payments (e.g., not attributable to a single beneficiary). Amounts on these claims should be expressed as negative numbers. If a credit gross adjustment is reported with an ICN that is related to an ICN(s) of another gross adjustment (credit or debit) then CMS will interpret this to mean that the credit gross adjustment with the more recent adjudication date should completely replace the preceding related gross adjustment. If the ICNs of a credit gross adjustment are not related to any other gross adjustments (credit or debit) then the credit gross adjustment will always be treated as a distinct financial transaction.
03/01/2024	3.20.0	ADJUSTMENT-IND and LINE-ADJUSTMENT-IND CIP026	Update	Data Dictionary - Valid Values	Debit Gross Adjustment	Debit Gross Adjustment - Use this code to indicate an aggregate provider-level payment to a provider (e.g., not attributable to a single beneficiary). Amounts on these claims should be expressed as positive numbers. If a debit gross adjustment is reported with an ICN that is related to an ICN(s) of another gross adjustment (credit or debit) then CMS will interpret this to mean that the credit gross adjustment with the more recent adjudication date should completely replace the preceding related gross adjustment. If the ICNs of a debit gross adjustment are not related to any other gross adjustments (credit or debit) then the debit gross adjustment will always be treated as a distinct financial transaction.
10/02/2020	2.4.0	LINE-NUM-ADJ LINE-ADJUSTMENT-IND	UPDATE	Data Dictionary	\|DE No\|Data Element Name\|Coding Requirement\|CR No\| \|CIP238\|LINE-NUM-ADJ\|This field should be left blank or space-filled if the ADJUSTMENT-INDICATOR = 0. Otherwise, if there is a line adjustment indicator, then there should be a line adjustment number. \|Not Applicable\| \|CIP239\|LINE-ADJUSTMENT-IND\|If there is a line adjustment number, then there must be a line-adjustment indicator.\|CIP239-0002\| \|CLT191\|LINE-NUM-ADJ\|This field should be left blank or space-filled if the ADJUSTMENT-INDICATOR = 0. Otherwise, if there is a line adjustment indicator, then there should be a line adjustment number.\|CLT191-0002\| \|CLT192\|LINE-ADJUSTMENT-IND\|If there is a line adjustment number, then there must be a line-adjustment indicator.\|CLT192-0002\| \|CLT192\|LINE-ADJUSTMENT-IND\|If there is a line adjustment reason, then there must be a line adjustment indicator.\|CLT192-0003 \|COT161\|LINE-NUM-ADJ\|This field should be left blank or space-filled if the ADJUSTMENT-INDICATOR = 0. Otherwise, if there is a line adjustment indicator, then there should be a line adjustment number.\|COT161-0002\| \|COT162\|LINE-ADJUSTMENT-IND\|If there is a line adjustment number, then there must be a line-adjustment indicator.\|COT162-0002\| \|COT162\|LINE-ADJUSTMENT-IND\|If there is a line adjustment reason, then there must be a line adjustment indicator.\|COT162-003\| \|CRX115\|LINE-NUM-ADJ\|This field should be 8-filled, left blank or space-filled if the ADJUSTMENT-INDICATOR = 0. Otherwise, if there is a line adjustment indicator, then there should be a line adjustment number.\|CRX115-002\| \|CRX116\|LINE-ADJUSTMENT-IND\|If there is a line adjustment number, then there must be a line-adjustment indicator.\|CRX116-002\|	\|DE No\|Data Element Name\|Coding Requirement\|CR No\| \|CIP238\|LINE-NUM-ADJ\|This field should be left blank or space-filled if the ADJUSTMENT-INDICATOR = 0.\|Not Applicable\| \|CIP239\|LINE-ADJUSTMENT-IND\|Not Applicable.\|CIP239-0002\| \|CLT191\|LINE-NUM-ADJ\|This field should be left blank or space-filled if the ADJUSTMENT-INDICATOR = 0.\|CLT191-0002\| \|CLT192\|LINE-ADJUSTMENT-IND\|Not Applicable.\|CLT192-0002\| \|CLT192\|LINE-ADJUSTMENT-IND\|Not Applicable.\|CLT192-0003 \|COT161\|LINE-NUM-ADJ\|This field should be left blank or space-filled if the ADJUSTMENT-INDICATOR = 0.\|COT161-0002\| \|COT162\|LINE-ADJUSTMENT-IND\|Not Applicable.\|COT162-0002\| \|COT162\|LINE-ADJUSTMENT-IND\|Not Applicable.\|COT162-003\| \|CRX115\|LINE-NUM-ADJ\|This field should be 8-filled, left blank or space-filled if the ADJUSTMENT-INDICATOR = 0.\|CRX115-002\| \|CRX116\|LINE-ADJUSTMENT-IND\|Not Applicable.\|CRX116-002\|
11/23/2018	2.3.0	ADJUSTMENT-IND	UPDATE	Data Dictionary - Valid Values	N/A	Valid values for ADJUSTMENT-IND has been updated per T-MSIS DD 2.1. As per DD 2.1 the Valid values are: 0 Original Claim/Encounter/Payment 1 Void/Reversal/Cancel of a prior submission 4 Replacement/Resubmission of a previously paid/approved claim/encounter/payment 5 Credit Gross Adjustment 6 Debit Gross Adjustment