CIP.002.065

DIAGNOSIS-CODE-12

Data Element

DE Number

CIP065

System DE Number

CIP.002.065

File Name

CIP - CLAIM INPATIENT

File Segment Number

CIP00002

File Segment Name

CLAIM-HEADER-RECORD-IP

Last updated

No Updates

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as "2105".
Size	X(7)
FLF Start Position	290
FLF Stop Position	296
Segment Key Field Identifier	Not Applicable
Coding Requirements	1. When populated, a Diagnosis Code Flag is required 2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 4. Value must be a minimum of 3 characters 5. Value must not contain a decimal point 6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters 7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters 8. When there is more than one diagnosis code on a claim, each value must be unique 9. Conditional 10. Value must not be populated when Diagnosis Code 11 (CIP.002.062) is not populated

This data element's valid value code set is maintained by a Code Set Maintenance Organization (CSMO), the official licensing organization for specific valid value code sets. The CSMO is the system of record for those specific valid value code sets. While T-MSIS endeavors to be in-sync with CMSO's updates, minor delays may occur but that shouldn't block T-MSIS data submissions using the CSMO's latest version.

Admitting Diagnosis Code List (ICD-9-CM Diagnosis and Procedure Codes)

Admitting Diagnosis Code List (ICD-10)

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

RULE ID	RULE Definition
RULE-353	If at least two of the 12 diagnosis codes are populated on a non-denied claim from an IP file, then the diagnosis code values reported must be unique values.
RULE-405	If the twelfth diagnosis code is populated on a non-denied claim from an IP file, then the value for the twelfth diagnosis code must be a valid value from the list of diagnosis code values corresponding to the twelfth diagnosis code flag.
RULE-408	If the eleventh diagnosis code is not populated on a non-denied claim from an IP file, the twelfth diagnosis code must not be populated.
RULE-6850	If a claim is a non-denied claim from an IP file, then the twelfth diagnosis code value reported must be compatible with specified T-MSIS picture format: X(7).

Measure ID	Measure Name
ALL-13-003-5	% of MSIS IDs with alien restricted benefits code status (RESTRICTED-BENEFITS-CODE = 2) with services that are not emergency room or pregnancy-related
FFS-1-004-28	Average # of diagnoses
FFS-1-005-22	% of claim headers with only 1 diagnosis code
FFS-3-004-16	Average # of diagnoses
FFS-3-005-10	% of claim headers with only 1 diagnosis code
MCR-1-004-16	Average # of diagnoses
MCR-1-005-10	% of claim headers with only 1 diagnosis code
MIS-2-016-16	% missing: DIAGNOSIS-CODE-12 (CIP00002)
RULE-405	% of claim headers with invalid Diagnosis Code 12
MIS-21-017-17	% missing: DIAGNOSIS-CODE-12 (CIP00002)
MIS-79-017-17	% missing: DIAGNOSIS-CODE-12 (CIP00002)

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name