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TMSIS Dataguide Medicaid.gov
Version 3.27.0

RULE-451

Validation Rule
Last updated

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-4 • CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-FLAG-4
Validation Logic 'if CLAIM-HEADER-RECORD-IP.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-IP.CLAIM-DENIED-INDICATOR does not equal '0' and CLAIM-HEADER-RECORD-IP.ADJUSTMENT-IND does not equal '1' and CLAIM-HEADER-RECORD-IP.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654', '686' and CLAIM-HEADER-RECORD-IP has a valid, non-null value for PROCEDURE-CODE-4, then CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-4 is a valid value specified by CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-FLAG-4 or is a state valid value from 'PROCEDURE-CODE-STATE'. when CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-FLAG-4 is '01', CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-4 should be a valid value in 'CPT'. when CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-FLAG-4 is '02', CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-4 should be a valid value in 'ICD-9-PROCEDURE-CODE'. when CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-FLAG-4 is '06', CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-4 should be a valid value in 'HCPCS'. when CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-FLAG-4 is '07', CLAIM-HEADER-RECORD-IP.PROCEDURE-CODE-4 should be a valid value in 'ICD-10-PROCEDURE-CODE'.'
Rule Definition If a claim is a non-denied, non-void claim from an IP file, and the procedure code 4 is populated, then the procedure code flag 4 is a valid value from the procedure code state, when the procedure code flag is 1, procedure code 4 is a CPT code, when the procedure code flag is 2, the procedure code 4 is a ICD-9 procedure code, when the procedure code flag is 6, the procedure code 4 is a HCPCS code, when the procedure code flag is 7, the procedure code 4 is a ICD-10 procedure code.
Denominator Logic # of IP claim headers with CLAIM-HEADER-RECORD-IP.CLAIM-STATUS-CATEGORY does not equal 'F2' and with CLAIM-HEADER-RECORD-IP.CLAIM-DENIED-INDICATOR does not equal '0' and with CLAIM-HEADER-RECORD-IP.ADJUSTMENT-IND is not equal to '1' and with CLAIM-HEADER-RECORD-IP.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654', '686' and with CLAIM-HEADER-RECORD-IP has a valid, non-null value for PROCEDURE-CODE-4