ALL-15-001-1

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TMSIS Dataguide

Medicaid.gov

Version:

ALL-15-001-1

Data Quality Measure

Last updated

Key Information

Measure Name	% of claim lines with non-missing Place of Service that have missing Procedure Code
File Type	COT
Measure ID	ALL-15-001-1
Measure Type	Claims Percentage
Content area	ALL

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	N/A
Focus Area	N/A
Category	N/A

Claim Information

Claim Type	Medicaid,FFS or Medicaid,Enc or CHIP,FFS or CHIP,Enc
Adjustment Type	All Adjustment Types
Crossover Type	All Indicators

Thresholds

Minimum	0
Maximum	0.001
TA Minimun
TA Maximum
Longitudinal Threshold	N/A
For TA (for including in compliance training)	No
For TA (Longitudinal)	No

Data Elements

DD Data Element	PROCEDURE-CODE • PLACE-OF-SERVICE
DD Data Element Number	COT169 • COT123

Annotation

Calculate the percentage of Medicaid and S-CHIP FFS and Encounter: original and adjustment, paid OT claims with non-missing place-of-service that are missing a procedure-code

Specification

STEP 1: Active non-duplicate paid OT claims during report month

Define the OT claims universe at the line level by importing both headers and lines that satisfy the following criteria:

For Headers:

1. Reporting Period from the filename = DQ report month

2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing

3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing

4. TYPE-OF-CLAIM is not equal to "Z" or is missing

5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585", "654") or is missing

6. No Header Duplicates: Duplicates are dropped at the header level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND.

For Lines:

1. Reporting Period from the filename = DQ report month

2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing

3. No Line Duplicates: Duplicates are dropped at the line level if the following data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, LINE-NUM-ORIG, LINE-NUM-ADJ, and LINE-ADJUSTMENT-IND.

4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJUSTMENT-IND.

STEP 2: Medicaid and S-CHIP FFS and Encounter: Original and Adjustment, Paid Claims

Of the claims that meet the criteria from STEP 1, further restrict them by the following criteria:

1. TYPE-OF-CLAIM = "1" or "3" or "A" or "C"

STEP 3: Non-missing place of service

Of the claims that meet the criteria from STEP 2, restrict to non-missing PLACE-OF-SERVICE

STEP 4: Procedure code is missing

Of the claims that meet the criteria from STEP 3, restrict to claims that meet the following criteria:

1. PROCEDURE-CODE is missing

STEP 5: Calculate percentage

Divide the number of claims from STEP 4 by the number of claims from STEP 3

Published Date	Data Guide Version	DQM	Action	Field	Before	After
08/13/2025	4.0.16	ALL-15-001-1	UPDATE	Specification	STEP 1: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the line level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from the filename = DQ report month2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing4. TYPE-OF-CLAIM is not equal to "Z" or is missing5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585", "654") or is missing6. No Header Duplicates: Duplicates are dropped at the header level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND.For Lines:1. Reporting Period from the filename = DQ report month2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing3. No Line Duplicates: Duplicates are dropped at the line level if the following data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, LINE-NUM-ORIG, LINE-NUM-ADJ, and LINE-ADJSTMT-IND.4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJSTMT-IND.STEP 2: Medicaid and S-CHIP FFS and Encounter: Original and Adjustment, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "1" or "3" or "A" or "C"STEP 3: Non-missing place of serviceOf the claims that meet the criteria from STEP 2, restrict to non-missing PLACE-OF-SERVICESTEP 4: Procedure code is missingOf the claims that meet the criteria from STEP 3, restrict to claims that meet the following criteria: 1. PROCEDURE-CODE is missingSTEP 5: Calculate percentageDivide the number of claims from STEP 4 by the number of claims from STEP 3	STEP 1: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the line level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from the filename = DQ report month2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing4. TYPE-OF-CLAIM is not equal to "Z" or is missing5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585", "654") or is missing6. No Header Duplicates: Duplicates are dropped at the header level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND.For Lines:1. Reporting Period from the filename = DQ report month2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing3. No Line Duplicates: Duplicates are dropped at the line level if the following data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, LINE-NUM-ORIG, LINE-NUM-ADJ, and LINE-ADJUSTMENT-IND.4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJUSTMENT-IND.STEP 2: Medicaid and S-CHIP FFS and Encounter: Original and Adjustment, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "1" or "3" or "A" or "C"STEP 3: Non-missing place of serviceOf the claims that meet the criteria from STEP 2, restrict to non-missing PLACE-OF-SERVICESTEP 4: Procedure code is missingOf the claims that meet the criteria from STEP 3, restrict to claims that meet the following criteria: 1. PROCEDURE-CODE is missingSTEP 5: Calculate percentageDivide the number of claims from STEP 4 by the number of claims from STEP 3
04/24/2025	4.0.7	ALL-15-001-1	ADD	N/A		Created