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TMSIS Dataguide Medicaid.gov
Version 3.27.0

RULE-425

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.PROCEDURE-CODE-2 • CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-FLAG-2
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 PROCEDURE-CODE-2, then CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-2 is a valid value specified by CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-FLAG-2 or is a state valid value from 'PROCEDURE-CODE-STATE'. when CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-FLAG-2 is '01', CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-2 should be a valid value in 'CPT'. when CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-FLAG-2 is '02', CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-2 should be a valid value in 'ICD-9-PROCEDURE-CODE'. when CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-FLAG-2 is '06', CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-2 should be a valid value in 'HCPCS'. when CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-FLAG-2 is '07', CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-2 should be a valid value in 'ICD-10-PROCEDURE-CODE'.'
Rule Definition If the second procedure code is populated on a non-denied claim from an IP file, then the second procedure code must be a valid value from the list of procedure code values corresponding to the second procedure code flag.
Denominator Logic # of IP headers with CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-2 equal to a valid, non-null value AND with CLAIM-HEADER-RECORD-IP.CLAIM-STATUS-CATEGORY not equal to 'F2' AND with CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-FLAG-2 in: '01', '02', '06', '07'