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TMSIS Dataguide Medicaid.gov
Version 3.27.0

RULE-405

Validation Rule
Last updated

No Updates

Tier 2.0
Tier Description Relational error
Error Category E2001
Error Category Message Values inconsistently specified (single record type, single record)
Rule Type One Record Type (Single Record)
File Segment Number CIP00002
Data Element Name CLAIM-HEADER-RECORD-IP.DIAGNOSIS-CODE-12 • CLAIM-HEADER-RECORD-IP.DIAGNOSIS-CODE-FLAG-12
Validation Logic 'if CLAIM-HEADER-RECORD-IP.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-IP has a valid, non-null value for DIAGNOSIS-CODE-12, then when CLAIM-HEADER-RECORD-IP.DIAGNOSIS-CODE-FLAG-12 is '1', CLAIM-HEADER-RECORD-IP.DIAGNOSIS-CODE-12 should be a valid value in 'ICD-9-DIAGNOSIS-CODE'. when CLAIM-HEADER-RECORD-IP.DIAGNOSIS-CODE-FLAG-12 is '2', CLAIM-HEADER-RECORD-IP.DIAGNOSIS-CODE-12 should be a valid value in 'ICD-10-DIAGNOSIS-CODE'.'
Rule Definition 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.
Denominator Logic # of IP claim headers with CLAIM-HEADER-RECORD-IP.CLAIM-STATUS-CATEGORY not equal to 'F2' AND with CLAIM-HEADER-RECORD-IP.DIAGNOSIS-CODE-12 equal to a valid, non-null value AND with CLAIM-HEADER-RECORD-IP.DIAGNOSIS-CODE-FLAG-12 in: '1', '2'