FFS-10-006-2

Data Quality Measure

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Key Information

Measure Name	% of claim lines with Procedure Code or Revenue Code (Medicaid Paid Amount > $0)
File Type	COT
Measure ID	FFS-10-006-2
Measure Type	Claims Percentage
Content area	FFS

Validation

Validation Type	Longitudinal and Inferential

Measure Priority

Measure Priority	Medium
Focus Area	N/A
Category	Utilization

Claim Information

Claim Type	Medicaid,FFS
Adjustment Type	Original
Crossover Type	Crossover

Thresholds

Minimum	0.99
Maximum	1
TA Minimun	0.99
TA Maximum	1
Longitudinal Threshold	0.1
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	MEDICAID-PAID-AMT • PROCEDURE-CODE • REVENUE-CODE
DD Data Element Number	COT178 • COT169 • COT168

Annotation	Calculate the percentage of Medicaid FFS: original, crossover, paid OT claim lines with Medicaid Paid Amount greater than 0, where Procedure Code or Revenue Code is not missing
Specification	STEP 1: Active non-duplicate paid OT claims during report month Define the OT claims universe at the line level by importing both headers and lines that satisfy the following criteria: For Headers: 1. Reporting Period from the filename = DQ report month 2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing 3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing 4. TYPE-OF-CLAIM is not equal to "Z" or is missing 5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585", "654") or is missing 6. No Header Duplicates: Duplicates are dropped at the header level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND. For Lines: 1. Reporting Period from the filename = DQ report month 2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing 3. No Line Duplicates: Duplicates are dropped at the line level if the following data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, LINE-NUM-ORIG, LINE-NUM-ADJ, and LINE-ADJSTMT-IND. 4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJSTMT-IND. STEP 2: Medicaid FFS: Original, Crossover, Paid Claims Of the claims that meet the criteria from STEP 1, further restrict them by the following criteria: 1. TYPE-OF-CLAIM = "1" 2. ADJUSTMENT-IND = "0" 3. CROSSOVER-INDICATOR = "1" STEP 3: Medicaid Paid Amount > 0 Of the claim lines that meet the criteria from STEP 2, further restrict them by the following criteria: 1. MEDICAID-PAID-AMT > 0 STEP 4: Procedure Code or Revenue Code Of the claim lines that meet the criteria from STEP 3, further restrict them by the following criteria: 1a. PROCEDURE-CODE is not missing OR 1b. REVENUE-CODE is not missing STEP 5: Calculate the percentage Divide the count of claim lines from STEP 4 by the count of claim lines for STEP 3

Annotation

Calculate the percentage of Medicaid FFS: original, crossover, paid OT claim lines with Medicaid Paid Amount greater than 0, where Procedure Code or Revenue Code is not missing

Specification

STEP 1: Active non-duplicate paid OT claims during report month

Define the OT claims universe at the line level by importing both headers and lines that satisfy the following criteria:

For Headers:

1. Reporting Period from the filename = DQ report month

2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing

3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing

4. TYPE-OF-CLAIM is not equal to "Z" or is missing

5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585", "654") or is missing

6. No Header Duplicates: Duplicates are dropped at the header level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND.

For Lines:

1. Reporting Period from the filename = DQ report month

2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing

3. No Line Duplicates: Duplicates are dropped at the line level if the following data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, LINE-NUM-ORIG, LINE-NUM-ADJ, and LINE-ADJSTMT-IND.

4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJSTMT-IND.

STEP 2: Medicaid FFS: Original, Crossover, Paid Claims

Of the claims that meet the criteria from STEP 1, further restrict them by the following criteria:

1. TYPE-OF-CLAIM = "1"

2. ADJUSTMENT-IND = "0"

3. CROSSOVER-INDICATOR = "1"

STEP 3: Medicaid Paid Amount > 0

Of the claim lines that meet the criteria from STEP 2, further restrict them by the following criteria:

1. MEDICAID-PAID-AMT > 0

STEP 4: Procedure Code or Revenue Code

Of the claim lines that meet the criteria from STEP 3, further restrict them by the following criteria:

1a. PROCEDURE-CODE is not missing

OR

1b. REVENUE-CODE is not missing

STEP 5: Calculate the percentage

Divide the count of claim lines from STEP 4 by the count of claim lines for STEP 3