FFS-3-005-10

Data Quality Measure

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Key Information

Measure Name	% of claim headers with only 1 diagnosis code
File Type	CIP
Measure ID	FFS-3-005-10
Measure Type	Claims Percentage
Content area	FFS

Validation

Validation Type	Longitudinal and Inferential

Measure Priority

Measure Priority	High
Focus Area	N/A
Category	Utilization

Claim Information

Claim Type	CHIP,FFS
Adjustment Type	Original
Crossover Type	Non-Crossover

Thresholds

Minimum	0
Maximum	0.25
TA Minimun	0
TA Maximum	0.25
Longitudinal Threshold	0.15
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	DIAGNOSIS-CODE-1 • DIAGNOSIS-CODE-2 • DIAGNOSIS-CODE-3 • DIAGNOSIS-CODE-12
DD Data Element Number	CIP032 • CIP035 • CIP038 • CIP065

Annotation	Percentage of S-CHIP FFS: original, non-crossover, paid IP claims with only 1 diagnosis
Specification	STEP 1: Active non-duplicate paid IP claims during report month Define the IP claims universe at the header level that satisfy the following criteria: 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. STEP 2: S-CHIP FFS: Original, Non-Crossover, Paid Claims Of the claims that meet the criteria from STEP 1, further restrict them by the following criteria: 1. TYPE-OF-CLAIM = "A" 2. ADJUSTMENT-IND = "0" 3. CROSSOVER-INDICATOR = "0" or is missing STEP 3: Diagnosis code Of the claims that meet the criteria from STEP 2, select records where 1. DIAGNOSIS-CODE-1 is not missing 2. DIAGNOSIS-CODE-2 through DIAGNOSIS-CODE-12 is missing STEP 4: Calculate the percentage for the measure Divide the count of claims from STEP 3 by the count of claims from STEP 2

Annotation

Percentage of S-CHIP FFS: original, non-crossover, paid IP claims with only 1 diagnosis

Specification

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

Define the IP claims universe at the header level that satisfy the following criteria:

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.

STEP 2: S-CHIP FFS: Original, Non-Crossover, Paid Claims

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

1. TYPE-OF-CLAIM = "A"

2. ADJUSTMENT-IND = "0"

3. CROSSOVER-INDICATOR = "0" or is missing

STEP 3: Diagnosis code

Of the claims that meet the criteria from STEP 2, select records where

1. DIAGNOSIS-CODE-1 is not missing

2. DIAGNOSIS-CODE-2 through DIAGNOSIS-CODE-12 is missing

STEP 4: Calculate the percentage for the measure

Divide the count of claims from STEP 3 by the count of claims from STEP 2