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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-3 • CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-FLAG-3 |
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-3, then CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-3 is a valid value specified by CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-FLAG-3 or is a state valid value from 'PROCEDURE-CODE-STATE'. when CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-FLAG-3 is '01', CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-3 should be a valid value in 'CPT'. when CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-FLAG-3 is '02', CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-3 should be a valid value in 'ICD-9-PROCEDURE-CODE'. when CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-FLAG-3 is '06', CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-3 should be a valid value in 'HCPCS'. when CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-FLAG-3 is '07', CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-3 should be a valid value in 'ICD-10-PROCEDURE-CODE'.' |
Rule Definition | If the third procedure code is populated on a non-denied claim from an IP file, then the value for the third procedure code must be a valid value from the list of values for procedure codes corresponding to the third procedure code flag or the third procedure code must be a valid value from a list of values for state-defined procedure codes. |
Denominator Logic | # of IP claim headers with CLAIM-HEADER-RECORD-IP.CLAIM-STATUS-CATEGORY not equal to 'F2' AND with CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-3 equal to a valid, non-null value |