CRX.003.143

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TMSIS Dataguide

Medicaid.gov

Version 3.36.0

DRUG-UTILIZATION-CODE

Data Element

DE Number

CRX143

System DE Number

CRX.003.143

File Name

CRX - CLAIM PHARMACY

File Segment Number

File Segment Name

CLAIM-LINE-RECORD-RX

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	A code indicating the conflict, intervention and outcome of a prescription presented for fulfillment. The T-MSIS Drug Utilization Code data element is composite field comprised of three distinct NCPDP data elements: "Reason for Service Code" (439-E4); "Professional Service Code" (440-E5); and "Result of Service Code" (441-E6). All 3 of these NCPDP fields are situationally required and independent of one another. Pharmacists may report none, one, two or all three. NCPDP situational rules call for one or more of these values in situations where the field(s) could result in different coverage, pricing, patient financial responsibility, drug utilization review outcome, or if the information affects payment for, or documentation of, professional pharmacy service. The NCPDP "Reasons of Service Code" (bytes 1 & 2 of the T-MSIS DRUG-UTILIZATION-CODE) explains whether the pharmacist filled the prescription, filled part of the prescription, etc. The NCPDP "Professional Service Code" (bytes 3 & 4 of the T-MSIS Drug Utilization Code) describes what the pharmacist did for the patient. The NCPDP "Result of Service Code" (bytes 5 & 6 of the T-MSIS Drug Utilization Code) describes the action the pharmacist took in response to a conflict or the result of a pharmacist"s professional service. Because the T-MSIS Drug Utilization Code data element is a composite field, it is necessary for the state to populate all six bytes if any of the three NCPDP fields has a value. In such situations, use "spaces" as placeholders for not applicable codes.
Size	X(6)
FLF Start Position	354
FLF Stop Position	359
Segment Key Field Identifier	Not Applicable
Coding Requirements	1. Value must be 6 characters or less 2. Characters 1 and 2 (2-character string) must be in Drug Utilization Reason for Service Code List (VVL) 3. Characters 3 and 4 (2-character string) must be in Drug Utilization Professional Service Code List (VVL) 4. Characters 5 and 6 (2-character string) must be in Drug Utilization Result of Service Code List (VVL) 5. Mandatory

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

RULE ID	RULE Definition
RULE-1948	If the drug utilization code is populated on a non-denied claim from an RX file, then the substring drug utilization code (0,2) value reported must be in the list of valid values for E4 drug utilization codes.
RULE-7049	If a claim line is a non-denied claim line from an RX file, then the drug utilization code value reported must be compatible with specified T-MSIS picture format: X(6).
RULE-7202	If the drug utilization code is populated on a non-denied claim from an RX file, then the substring drug utilization code (2,2) value reported must be in the list of valid values for E5 drug utilization codes.
RULE-7203	If the drug utilization code is populated on a non-denied claim from an RX file, then the substring drug utilization code (4,2) value reported must be in the list of valid values for E6 drug utilization codes.

Measure ID	Measure Name
RULE-1948	% of claim lines with invalid Reason for Service component of the Drug Utilization Code

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

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
09/12/2024	3.29.0	CRX.003.143	UPDATE	Definition	A code indicating the conflict, intervention and outcome of a prescription presented for fulfillment. The T-MSIS Drug Utilization Code data element is composite field comprised of three distinct NCPDP data elements: "Reason for Service Code" (439-E4); "Professional Service Code" (440-E5); and "Result of Service Code" (441-E6). All 3 of these NCPDP fields are situationally required and independent of one another. Pharmacists may report none, one, two or all three. NCPDP situational rules call for one or more of these values in situations where the field(s) could result in different coverage, pricing, patient financial responsibility, drug utilization review outcome, or if the information affects payment for, or documentation of, professional pharmacy service. The NCPDP "Reasons of Service Code" (bytes 1 & 2 of the T-MSIS DRUG-UTILIZATION-CODE) explains whether the pharmacist filled the prescription, filled part of the prescription, etc. The NCPDP "Professional Service Code" (bytes 3 & 4 of the T-MSIS Drug Utilization Code) describes what the pharmacist did for the patient. The NCPDP "Result of Service Code" (bytes 5 & 6 of the T-MSIS Drug Utilization Code) describes the action the pharmacist took in response to a conflict or the result of a pharmacist's professional service. Because the T-MSIS Drug Utilization Code data element is a composite field, it is necessary for the state to populate all six bytes if any of the three NCPDP fields has a value. In such situations, use 'spaces' as placeholders for not applicable codes.	A code indicating the conflict, intervention and outcome of a prescription presented for fulfillment. The T-MSIS Drug Utilization Code data element is composite field comprised of three distinct NCPDP data elements: "Reason for Service Code" (439-E4); "Professional Service Code" (440-E5); and "Result of Service Code" (441-E6). All 3 of these NCPDP fields are situationally required and independent of one another. Pharmacists may report none, one, two or all three. NCPDP situational rules call for one or more of these values in situations where the field(s) could result in different coverage, pricing, patient financial responsibility, drug utilization review outcome, or if the information affects payment for, or documentation of, professional pharmacy service. The NCPDP "Reasons of Service Code" (bytes 1 & 2 of the T-MSIS DRUG-UTILIZATION-CODE) explains whether the pharmacist filled the prescription, filled part of the prescription, etc. The NCPDP "Professional Service Code" (bytes 3 & 4 of the T-MSIS Drug Utilization Code) describes what the pharmacist did for the patient. The NCPDP "Result of Service Code" (bytes 5 & 6 of the T-MSIS Drug Utilization Code) describes the action the pharmacist took in response to a conflict or the result of a pharmacist"s professional service. Because the T-MSIS Drug Utilization Code data element is a composite field, it is necessary for the state to populate all six bytes if any of the three NCPDP fields has a value. In such situations, use "spaces" as placeholders for not applicable codes.
04/30/2021	3.0.0	DRUG-UTILIZATION-CODE	ADD	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION\| DRUG-UTILIZATION-CODE-E4\|00010101\|99991231\|SC\|Suboptimal Compliance\| DRUG-UTILIZATION-CODE-E4\|00010101\|99991231\|SD\|Suboptimal Drug/Indication\| DRUG-UTILIZATION-CODE-E4\|00010101\|99991231\|SE\|Side Effect\| DRUG-UTILIZATION-CODE-E4\|00010101\|99991231\|SF\|Suboptimal Dosage Form\| DRUG-UTILIZATION-CODE-E4\|00010101\|99991231\|SX\|Drug-Gender\| DRUG-UTILIZATION-CODE-E4\|00010101\|99991231\|TN\|Laboratory Test Needed\| DRUG-UTILIZATION-CODE-E4\|00010101\|99991231\|TP\|Payer/Processor Question\|
06/24/2022	3.0.0	DRUG-UTILIZATION-CODE	UPDATE	Data Dictionary	DE No\|Data Element Name\|CODING REQUIREMENT\| CRX143\|DRUG-UTILIZATION-CODE\| 1.(S) value must be 6 characters or less 2.(S) characters 1 and 2 (2-character string) may be in Drug Utilization Result of Service Code List (VVL), or spaces in cases where code is unused or not available 3.(S) characters 3 and 4 (2-character string) may be in Drug Utilization Professional Service Code List (VVL), or spaces in cases where code is unused or not available 4.(S) characters 5 and 6 (2-character string) may be in Drug Utilization Reason For Service Code List (VVL), or not populated in cases where code is unused or not available 5.(N) mandatory\|	DE No\|Data Element Name\|CODING REQUIREMENT\| CRX143\|DRUG-UTILIZATION-CODE\| 1.(S) value must be 6 characters or less 2.(S) characters 1 and 2 (2-character string) must be in Drug Utilization Reason of Service Code List (VVL) 3.(S) characters 3 and 4 (2-character string) must be in Drug Utilization Professional Service Code List (VVL) 4.(S) characters 5 and 6 (2-character string) must be in Drug Utilization Result For Service Code List (VVL) 5.(N) mandatory\|
05/13/2022	3.0.0	CRX143	UPDATE	Data Dictionary	DE NO\| DATA ELEMENT NAME\|DEFINITION\| CRX143\|DRUG-UTILIZATION-CODE\|A code indicating the conflict, intervention and outcome of a prescription presented for fulfillment. The T-MSIS Drug Utilization Code data element is composite field comprised of three distinct NCPDP data elements: "Reason for Service Code" (439-E4); "Professional Service Code" (44-E5); and "Result of Service Code" (441-E6). All 3 of these NCPDP fields are situationally required and independent of one another. Pharmacists may report none, one, two or all three. NCPDP situational rules call for one or more of these values in situations where the field(s) could result in different coverage, pricing, patient financial responsibility, drug utilization review outcome, or if the information affects payment for, or documentation of, professional pharmacy service. The NCPDP "Results of Service Code" (bytes 1 & 2 of the T-MSIS Drug Utilization Code) explains whether the pharmacist filled the prescription, filled part of the prescription, etc. The NCPDP "Professional Service Code" (bytes 3 & 4 of the T-MSIS Drug Utilization Code) describes what the pharmacist did for the patient. The NCPDP "Result of Service Code" (bytes 5 & 6 of the T-MSIS Drug Utilization Code) describes the action the pharmacist took in response to a conflict or the result of a pharmacist's professional service. Because the T-MSIS Drug Utilization Code data element is a composite field, it is necessary for the state to populate all six bytes if any of the three NCPDP fields has a value. In such situations, use 'spaces' as placeholders for not applicable codes.\|	DE NO\| DATA ELEMENT NAME\|DEFINITION\| CRX143\|DRUG-UTILIZATION-CODE\|A code indicating the conflict, intervention and outcome of a prescription presented for fulfillment. The T-MSIS Drug Utilization Code data element is composite field comprised of three distinct NCPDP data elements: "Reason for Service Code" (439-E4); "Professional Service Code" (440-E5); and "Result of Service Code" (441-E6). All 3 of these NCPDP fields are situationally required and independent of one another. Pharmacists may report none, one, two or all three. NCPDP situational rules call for one or more of these values in situations where the field(s) could result in different coverage, pricing, patient financial responsibility, drug utilization review outcome, or if the information affects payment for, or documentation of, professional pharmacy service.The NCPDP "Reason for Service Code" (bytes 1 & 2 of the T-MSIS Drug Utilization Code) explains whether the pharmacist filled the prescription, filled part of the prescription, etc. The NCPDP "Professional Service Code" (bytes 3 & 4 of the T-MSIS Drug Utilization Code) describes what the pharmacist did for the patient. The NCPDP "Result of Service Code" (bytes 5 & 6 of the T-MSIS Drug Utilization Code) describes the action the pharmacist took in response to a conflict or the result of a pharmacist's professional service. Because the T-MSIS Drug Utilization Code data element is a composite field, it is necessary for the state to populate all six bytes if any of the three NCPDP fields has a value. In such situations, use 'spaces' as placeholders for not applicable codes.\|