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TMSIS Dataguide Medicaid.gov
Version 3.27.0

MCR-10-022-17

Data Quality Measure
Last updated

Key Information

Measure Name % of claim lines with TYPE-OF-SERVICE = 12, 25, 26 with local service code indicator (PROCEDURE-CODE-FLAG = 10 - 87)
File Type COT
Measure ID MCR-10-022-17
Measure Type Claims Percentage
Content area MCR

Validation

Validation Type Longitudinal and Inferential

Measure Priority

Measure Priority Medium
Focus Area Managed care
Category Utilization

Claim Information

Claim Type Medicaid,Enc
Adjustment Type Original
Crossover Type Non-Crossover

Thresholds

Minimum 0
Maximum 0.5
TA Minimun 0
TA Maximum 0.5
Longitudinal Threshold 0.15
For TA
(for including in compliance training) 		TA- Inferential
For TA
(Longitudinal) 		No

Data Elements

DD Data Element TYPE-OF-SERVICE • PROCEDURE-CODE-FLAG
DD Data Element Number COT186 • COT171

Annotation Percentage of unique Medicaid Encounter: original, non-crossover, paid OT claims with TYPE-OF-SERVICE = 12, 25, 26 with Local Service Code Ind.
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 Encounter: 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 = "3"

2. ADJUSTMENT-IND = "0"

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



STEP 3: Type of service

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

1. TYPE-OF-SERVICE = "012" or "025" or "026"



STEP 4: Procedure code

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

PROCEDURE-CODE-FLAG = "10" through "87"



STEP 5: Calculate the percentage for the measure

Divide the count of claims from STEP 4 by the count of claims from STEP 3