ALL-35-004-4

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TMSIS Dataguide

Medicaid.gov

Version:

ALL-35-004-4

Data Quality Measure

Last updated

Key Information

Measure Name	% of claim lines with non-missing Tooth Number that do not have a Procedure Code format that indicates a CDT code
File Type	COT
Measure ID	ALL-35-004-4
Measure Type	Claims Percentage
Content area	ALL

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	Medium
Focus Area	N/A
Category	Utilization

Claim Information

Claim Type	CHIP,FFS or CHIP,Enc
Adjustment Type	Original and Replacement
Crossover Type	All Indicators

Thresholds

Minimum	0
Maximum	0.1
TA Minimun	0
TA Maximum	0.1
Longitudinal Threshold	N/A
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	PROCEDURE-CODE • TOOTH-NUM
DD Data Element Number	COT169 • COT196

Annotation

Calculate the percentage of S-CHIP FFS and Encounter: original and replacement, paid OT claim lines with non-missing tooth number that do not have a procedure code format indicating a CDT 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: S-CHIP FFS and Encounter: Original and Replacement Paid Claims

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

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

2. ADJUSTMENT-IND = "0" or "4"

STEP 3: Non-missing tooth number

Of the claims that meet criteria from STEP 2, keep those with non-missing TOOTH-NUM.

STEP 4: Procedure code format does not indicate a CDT code

Of the claims that meet the criteria from STEP 3, keep those that do NOT meet following criteria:

1. Length of PROCEDURE-CODE is 5

2. PROCEDURE-CODE begins with "D"

3. PROCEDURE-CODE only contains digits 0-9 in positions 2-5

STEP 5: Calculate percentage

Divide the count of claim lines from STEP 4 by the count of claim lines from STEP 3

Published Date	Data Guide Version	DQM	Action	Field	Before	After
08/13/2025	4.0.16	ALL-35-004-4	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: S-CHIP FFS and Encounter: Original and Replacement Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "A" or "C"2. ADJUSTMENT-IND = "0" or "4"STEP 3: Non-missing tooth numberOf the claims that meet criteria from STEP 2, keep those with non-missing TOOTH-NUM.STEP 4: Procedure code format does not indicate a CDT codeOf the claims that meet the criteria from STEP 3, keep those that do NOT meet following criteria:1. Length of PROCEDURE-CODE is 52. PROCEDURE-CODE begins with "D"3. PROCEDURE-CODE only contains digits 0-9 in positions 2-5STEP 5: Calculate percentageDivide the count of claim lines from STEP 4 by the count of claim lines 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: S-CHIP FFS and Encounter: Original and Replacement Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "A" or "C"2. ADJUSTMENT-IND = "0" or "4"STEP 3: Non-missing tooth numberOf the claims that meet criteria from STEP 2, keep those with non-missing TOOTH-NUM.STEP 4: Procedure code format does not indicate a CDT codeOf the claims that meet the criteria from STEP 3, keep those that do NOT meet following criteria:1. Length of PROCEDURE-CODE is 52. PROCEDURE-CODE begins with "D"3. PROCEDURE-CODE only contains digits 0-9 in positions 2-5STEP 5: Calculate percentageDivide the count of claim lines from STEP 4 by the count of claim lines from STEP 3
04/24/2025	4.0.7	ALL-35-004-4	ADD	N/A		Created