Technical Instruction History
| Date | Description of Change |
|---|---|
| 09/16/19 | Original technical instructions issued |
| 11/11/19 |
1. Removed 442-E7 (for prescription) (quantity dispensed) from the list of source fields for DTL-METRIC-DEC-QTY (CRX144) 2. Changed terminology in the Source Field column of Table 1 from “prescription” to “non-compound" |
| 06/24/2022 |
Technical instructions updated in correspondence with V3.0.0 data dictionary update:
|
Brief Issue Description
This technical instruction document outlines the challenges states have faced when reporting quantity and unit of measure fields in the IP, LT, OT, and RX files and provides technical instructions to states on this topic.
Background Discussion
Context
Providers use a variety of formats to submit claims to state Medicaid (or CHIP) agencies or their managed care plans (such as UB-04 or the 837 forms). All types of claim formats have a field in the detailed claim lines where providers submit the quantity of procedure, service, or drug provided. Mapping the quantity of service from the claims forms to the detailed claim line fields is relatively straightforward in the IP and LT claims files, but mapping the quantity of service from the claim forms to the claim lines of the OT and RX files is not as clear. The unit of measure, which expresses the unit of measure for each corresponding value reported by the quantity data elements, can be populated on all claim types and should be populated when a given claim line also contains an NDC code. All claim lines that contain NDC codes, including all RX claim lines, should contain a unit of measure.
Challenges
Many states are not mapping quantity of service from claims forms to T-MSIS claims files correctly because there are misunderstandings regarding the conditions under which the various variables listed in Table 1 should be populated. Some of these misunderstandings result from the various claim forms used to populate the claims files.
- Claims data in the T-MSIS IP and LT files come from the 837I/UB-04 claim formats.
- Claims data in the T-MSIS OT file come from the 837I/UB-04, the 837P/CMS-1500, the 837D/ADA 2012, and possibly other claim formats.
- Claims data in the T-MSIS RX files come from the NCPDP claim format.
In some situations, a single data element in the T-MSIS claims file will be mapped differently depending on the claim form being used to populate the claim record. For example, there are six or more fields from different claim formats that could be used to populate the same T-MSIS OT variable (SERVICE-QUANTITY-ACTUAL, formerly known as OT-RX-CLAIM-QUANTITY-ACTUAL).
Additionally, it was not always clear how data elements should be populated. For example, the OT-RX-CLAIM-QUANTITY-ACTUAL field meant different things depending on whether it was in the OT file or the RX file. In the RX file, the OT-RX-CLAIM-QUANTITY-ACTUAL data element mapped to the drug quantity when the drug is a prescription with an NDC, while in the OT file the same data element mapped to the service quantity. In addition, when the claim reported in the OT file is for a drug with an NDC code, the drug quantity should map to the NDC-QUANTITY data element and not to OT-RX-CLAIM-QUANTITY-ACTUAL.
Technical Instruction
Reporting Quantity
All claims forms have a field used for reporting quantity in the detailed claim line segment in T-MSIS. In addition to the standard quantity values on the IP, LT, and OT files, when a NATIONAL-DRUG-CODE data element (CIP284, CLT228, COT217) is populated, then the corresponding NDC-QUANTITY data element (CIP278, CLT230, COT225) should be populated. The T-MSIS quantity and metric values which are populated will depend on whether the quantity value corresponds to a drug or a service.
- Procedures/Services
- REVENUE-CENTER-QUANTITY-ACTUAL (formerly known as IP-LT-QUANTITY-OF-SERVICE-ACTUAL) (IP and LT files)
- SERVICE-QUANTITY-ACTUAL (formerly known as OT-RX-CLAIM-QUANTITY-ACTUAL) (when in the OT file)
- Drugs
- NDC-QUANTITY (IP, LT, OT files when there is an NDC on a claim line)
- PRESCRIPTION-QUANTITY-ACTUAL (formerly known as OT-RX-CLAIM-QUANTITY-ACTUAL) (RX)
- DTL-METRIC-DEC-QTY (RX)
- NDC-UNIT-OF-MEASURE (IP, LT, OT files when there is an NDC on a claim line)
- UNIT-OF-MEASURE (RX)
The quantity of service or procedure reported by providers on their claims should be mapped to the “actual” quantity fields in the T-MSIS IP, LT, and OT files. When a claim includes an NDC, regardless of the claim file, the quantity value reported with the NDC on the claim should map to the NDC-QUANTITY fields in the T-MSIS IP, LT, and OT files and the PRESCRIPTION-QUANTITY-ACTUAL (formerly known as OT-RX-CLAIM-QUANTITY-ACTUAL) or DTL-METRIC-DEC-QTY in the RX file.
As mentioned earlier, before T-MSIS Data Dictionary V3.0.0 the OT-RX-CLAIM-QUANTITY-ACTUAL data element meant different things depending on if it is in the OT file or if it is in the RX file. In V3.0.0, OT-RX-CLAIM-QUANTITY-ACTUAL was replaced by SERVICE-QUANTITY-ACTUAL in the OT file and PRESCRIPTION-QUANTITY-ACTUAL in the RX file. In the OT file, SERVICE-QUANTITY-ACTUAL should capture the “Units of Service/Days” (837I/UB-04) or “Units” (837P/CMS-1500, 837D/ADA 2012) fields, representing both revenue codes and procedure codes. In the RX file PRESCRIPTION-QUANTITY-ACTUAL should capture the amount dispensed (“quantity dispensed” [NCDPD 442-E7] or “compound ingredient quantity” [NCDPD 448-ED]).
The T-MSIS data element DTL-METRIC-DEC-QTY captures quantity of compounds reported on an RX claim. The source of DTL-METRIC-DEC-QTY and PRESCRIPTION-QUANTITY-ACTUAL (formerly known as OT-RX-QUANTITY-ACTUAL) from a provider’s claim depends on whether the claim is for a compound drug or a non-compound drug. If an RX claim is for a non-compound drug then DTL-METRIC-DEC-QTY is not applicable but PRESCRIPTION-QUANTITY-ACTUAL (formerly known as OT-RX-QUANTITY-ACTUAL) is applicable. If states report both PRESCRIPTION-QUANTITY-ACTUAL (formerly known as OT-RX-CLAIM-QUANTITY-ACTUAL) and DTL-METRIC-DEC-QTY on the RX file, they should capture the same information.
The way that claims data are mapped from the source claim formats to T-MSIS should follow the conventions in Table 1.
Table 1. Claim form source fields for populating quantity and unit of measure related data elements to the T-MSIS IP, LT, OT, and RX files
| DE NO | DATA ELEMENT NAME | SOURCE FIELD[a] |
|---|---|---|
| CIP249 | REVENUE-CENTER-QUANTITY-ACTUAL[b] | 837I: Loop 2400 SV205 (Quantity) UB04: FL 46 (Service units) |
| CIP250 | REVENUE-CENTER-QUANTITY-ALLOWED[c] | 837I: Loop 2400 HCP12 (Approved service units or inpatient days) |
| CIP285 | NDC-UNIT-OF-MEASURE | 837I: Loop 2410 CTP05 (Composite unit of measure) UB04: FL 43 (Description) |
| CIP278 | NDC-QUANTITY | 837I: Loop 2410 CTP04 (Quantity) UB04: FL 43 (Description) |
| CLT202 | REVENUE-CENTER-QUANTITY-ACTUAL[b] | 837I: Loop 2400 SV205 (Quantity) UB04: FL 46 (Service units) |
| CLT203 | EVENUE-CENTER-QUANTITY-ALLOWED[c] | 837I: Loop 2400 HCP12 (Approved service units) |
| CLT229 | NDC-UNIT-OF-MEASURE | 837I: Loop 2410 CTP05 (Composite unit of measure) UB04: FL 43 (Description) |
| CLT230 | NDC-QUANTITY | 837I: Loop 2410 CTP04 (Quantity) UB04: FL 43 (Description) |
| COT183 | SERVICE-QUANTITY-ACTUAL[d] | 837I: Loop 2400 SV205 (Quantity) 837P: Loop 2400 SV104 (Quantity) 837D: Loop 2400 SV306 (Number of procedures) UB04: FL 46 (Service units) CMS-1500: 24G (Days or units) ADA2012: 29b (Quantity) |
| COT184 | SERVICE-QUANTITY-ALLOWED[e] | 837I: Loop 2400 HCP12 (Approved service units) 837P: Loop 2400 HCP12 (Approved service units) 837D: Loop 2400 HCP12 (Approved service units) 835: Loop 2110 QTY02 (Quantity) |
| COT224 | NDC-UNIT-OF-MEASURE | 837I: Loop 2410 CTP05 (Composite unit of measure) 837P: Loop 2410 CTP05 (Composite unit of measure) UB04: FL 43 (Description) CMS-1500: 24D (Procedures, services, or supplies) |
| COT225 | NDC-QUANTITY | 837I: Loop 2410 CTP04 (Quantity) 837P: Loop 2410 CTP04 (Quantity) UB04: FL 43 (Description) CMS-1500: 24D (Procedures, services, or supplies) |
| CRX131 | PRESCRIPTION-QUANTITY-ALLOWED[e] | N/A |
| CRX132 | PRESCRIPTION-QUANTITY-ACTUAL[d] |
NCDPD: 442-E7 (for non-compound) (quantity dispensed) |
| CRX133 | UNIT-OF-MEASURE |
NDCPDP: 600-28 (for non-compound) (unit of measures) |
| CRX144 | DTL-METRIC-DEC-QTY |
NCDPD:448-ED (for compound drugs only) (Compound ingredient quantity) |
[a] The Source Field column provides the claim form type, field number, and field name for each data element.
[b] This data element was formerly known as IP-LT-QUANTITY-OF-SERVICE-ACTUAL.
[c] This data element was formerly known as IP-LT-QUANTITY-OF-SERVICE-ALLOWED.
[d] This data element was formerly known as OT-RX-CLAIM-QUANTITY-ACTUAL.
[e] This data element was formerly known as OT-RX-CLAIM-QUANTITY-ACTUAL.
Reporting Unit of Measure
The T-MSIS data element UNIT-OF-MEASURE (CRX133) should be reported on all claim lines on the RX file, corresponding to the quantities reported by PRESCRIPTION-QUANTITY-ACTUAL (formerly known as OT-RX-CLAIM-QUANTITY-ACTUAL) or DTL-METRIC-DEC-QTY. This element is mapped from two fields on the NCPDP claim form: field 600-28 UNIT OF MEASURE and field 451-EG COMPOUND DISPENSING UNIT FORM INDICATOR. Valid values for these two source fields use different codes to report the same underlying meaning, so they can be mapped to the common T-MSIS code set. States should report values populated in the two NCPDP fields using the corresponding T-MSIS valid values. When a claim is a standard pharmacy claim, unit of measure should be reported from field 600-28 UNIT OF MEASURE. When a claim is a compound, unit of measure should be reported from field 451-EG COMPOUND DISPENSING UNIT FORM INDICATOR.
T-MSIS data elements NDC-UNIT-OF-MEASURE (CIP285, CLT229, or COT224) and NDC-QUANTITY (CIP278, CLT230, or COT225) are only applicable to and therefore reported in the IP, LT, and OT files when a value is reported to the NATIONAL-DRUG-CODE data element (CIP284, CLT228, or COT217). The data element NDC-UNIT-OF-MEASURE uses the same valid values and coding rules as UNIT-OF-MEASURE.
Valid values for units of measure
| T-MSIS UNIT-OF-MEASURE | NCDPD UNIT OF MEASUREa | NCPDP COMPOUND DISPENSING UNIT FORM INDICATORa |
|---|---|---|
|
UN Unit |
EA = each |
1 = each |
[a] See the NCPDP Billing Unit Standard Implementation Guide.
Populating related variables for “ALLOWED” quantities
The data elements REVENUE-CENTER-QUANTITY-ALLOWED (formerly known as IP-LT-CLAIM-QUANTITY-ALLOWED), SERVICE-QUANTITY-ALLOWED, and PRESCRIPTION-QUANTITY-ALLOWED (both formerly known as OT-RX-CLAIM-QUANTITY-ALLOWED) reports the maximum quantity of service covered by Medicaid, CHIP, or the managed care plan that may be provided per day of service or per month. Unlike REVENUE-CENTER-QUANTITY-ACTUAL (formerly known as IP-LT-CLAIM-QUANTITY-ACTUAL), SERVICE-QUANTITY-ACTUAL, and PRESCRIPTION-QUANTITY-ACTUAL (both formerly known as OT-RX-CLAIM-QUANTITY-ACTUAL), which should be passed through directly from the providers claim to T-MSIS, REVENUE-CENTER-QUANTITY-ALLOWED (formerly known as IP-LT-CLAIM-QUANTITY-ALLOWED), SERVICE-QUANTITY-ALLOWED, and PRESCRIPTION-QUANTITY-ALLOWED (both formerly known as OT-RX-CLAIM-QUANTITY-ALLOWED) are expected to be calculated/assigned by the state or their managed care plans during claim adjudication. On the RX file only, it is expected that PRESCRIPTION-QUANTITY-ALLOWED (formerly known as OT-RX-CLAIM-QUANTITY-ALLOWED) may not be frequently populated due to point-of-sale claim systems. In this case, it is recommended that PRESCRIPTION-QUANTITY-ALLOWED (formerly known as OT-RX-CLAIM-QUANTITY-ALLOWED) is either not populated or is populated with the same value as PRESCRIPTION-QUANTITY-ACTUAL (formerly known as OT-RX-CLAIM-QUANTITY-ACTUAL).
Proposed updates to the data dictionary
As of June 24, 2022, with the release of the V3.0.0 of the Data Dictionary, the names of IP-LT-QUANTITY-OF-SERVICE-ACTUAL (CIP249 and CLT202) and IP-LT-QUANTITY-OF-SERVICE-ALLOWED (CIP250 and CLT203) were changed to REVENUE-CENTER-QUANTITY-ACTUAL and REVENUE-CENTER-QUANTITY-ALLOWED, and OT-RX-CLAIM-QUANTITY-ACTUAL (COT183, CRX132) and OT-RX-CLAIM-QUANTITY-ALLOWED (COT184, CRX131) changed to SERVICE-QUANTITY-ACTUAL and SERVICE-QUANTITY-ALLOWED on the OT file and PRESCRIPTION-QUANTITY-ACTUAL and PRESCRIPTION-QUANTITY-ALLOWED on the RX file. The technical instructions in this document apply regardless of any changes in name to the data elements used to capture quantity. The changes to the data dictionary also align valid values of UNIT-OF-MEASURE (CRX133) with valid values from the source NCPDP claim form.