Key Information

Measure Name	% difference between T-MSIS inpatient hospital expenditures and CMS-64 inpatient hospital expenditures (Medicaid FFS)
File Type	Multiple Files
Measure ID	EXP-46-001-1
Measure Type	Other percentage
Content area	EXP
Grace Period Expiration	05/07/2026

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	High
Focus Area	N/A
Category	Expenditures

Claim Information

Claim Type	N/A
Adjustment Type	All Adjustment Types
Crossover Type	N/A

Thresholds

Minimum	-0.2
Maximum	0.2
TA Minimun	-0.2
TA Maximum	0.2
Longitudinal Threshold	N/A
For TA (for including in compliance training)	TA- Inferental
For TA (Longitudinal)	No

Data Elements

DD Data Element	ADJUDICATION-DATE • MBESCBES-FORM-GROUP • MEDICAID-PAID-AMT • TOT-MEDICAID-PAID-AMT • PAYMENT-LEVEL-IND • MBESCBES-CATEGORY-OF-SERVICE
DD Data Element Number	CIP098 • CIP340 • CIP254 • CIP114 • CIP132 • CIP315

Annotation

Calculate the percent difference between the T-MSIS inpatient hospital expenditures and CMS-64 inpatient hospital expenditures

Specification

STEP 1: Define measurement period as the federal fiscal year for CMS-64 reporting 1. SET begin date of the federal fiscal year as the first day of the federal fiscal year 2. SET end date of the federal fiscal year as the last day of the federal fiscal year STEP 2: Total Annual Net Expenditure by Service Category from MBES report Retrieve the total expenditures by service category from the Medicaid Financial Management Report – Net Services. This is an external source. More information is available at: https://www.medicaid.gov/medicaid/financial-management/state-expenditure-reporting-for-medicaid-chip/expenditure-reports-mbescbes STEP 3: Denominator - Set Total Computable by Category of Service 1. Set the Denominator equal to the Total Computable column in the Medicaid Financial Management Report – Net Services file. Use the row “Inpatient Hospital – Reg. Payments” which is equivalent to MBESCBES-CATEGORY-OF-SERVICE = “1A” in T-MSIS where Valid Value Code List is 64.9COS. STEP 4: Define IP, LT, OT, and RX claim headers for measurement period Of original and adjustment claim headers, keep claim headers adjudicated in the current federal fiscal year or in the 2-years prior to the start of the current federal fiscal year. For example, 1. ADJUDICATION-DATE >= 2 years before the begin date of the federal fiscal year AND 2. ADJUDICATION-DATE <= end date of the federal fiscal year STEP 5: Keep up to two records per ICN-ORIG Of the claims from STEP 4, keep up to two records: 1. Latest claim in the current federal fiscal year 2. Latest claim from previous federal fiscal years STEP 6: Active non-duplicate IP, LT, OT, and RX records Of the claim headers from STEP 5, keep the IP, LT, OT, and RX records that satisfy the following criteria: 1. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing 2. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing 3. TYPE-OF-CLAIM is not equal to "Z" or is missing 4. CLAIM-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing 5. 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. STEP 7: Exclude Medicaid and S-CHIP encounters and sub-capitation encounters Of the IP, LT, OT, and RX claims that meet criteria from STEP 6, further restrict them by the following criteria: 1. TYPE-OF-CLAIM is not equal to (“3”, “C”, or “W”) 2. SOURCE-LOCATION is not equal to (“22” or “23”) STEP 8: Active non-duplicate IP, LT, OT, and RX claim lines 8a. Join Headers from STEP 7 and Lines Merge headers and lines using: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJUSTMENT-IND, and keep all claims, including orphan lines 8b. Keep lines where MBESCBES-FORM-GROUP = “1” STEP 9: Line-level Medicaid Paid Amount Of the claim headers and lines from STEP 8, further restrict lines by the following criteria: 9a. For IP and LT claim records, set MEDICAID-PAID-AMT equal to the TOTAL-MEDICAID-PAID-AMT on the claim line that satisfies the following criteria: 1. PAYMENT-LEVEL-IND = “1” or “3” AND 2.Maximum REVENUE-CHARGE. Remaining lines dropped. 9b. For OT and RX claim records, set MEDICAID-PAID-AMT equal to the TOTAL-MEDICAID-PAID-AMT on the claim line that satisfies the following criteria: 1. PAYMENT-LEVEL-IND = “1” or “3” AND 2. Maximum BILLED-AMT. Remaining lines dropped. 9c. For IP, LT, OT, and RX claim records where PAYMENT-LEVEL-IND = “2” keep all lines and keep the existing values in MEDICAID-PAID-AMT. STEP 10: Define financial transaction records for current federal fiscal year Define the FTX universe for the FTX00002, FTX00003, FTX00005, FTX00006, FTX00007, FTX00008, FTX00009, or FTX00095 tables respectively by keeping active records that satisfy the following criteria: 1a. PAYMENT-OR-RECOUPMENT-DATE >= 2 years prior to the begin date of the federal fiscal year AND 1b. PAYMENT-OR-RECOUPMENT-DATE <= end date of the federal fiscal year For claim records in FTX segment FTX0004, keep active records that satisfy the following criteria: 2a. PAYMENT-DATE >= 2 years prior to the begin date of the federal fiscal year AND 2b. PAYMENT-DATE <= end date of the federal fiscal year STEP 11: Keep up to two FTX claim records per ICN-ORIG Of the claims from STEP 10, keep up to two records: 1. Latest FTX record in the current federal fiscal year 2. Latest FTX record from previous federal fiscal years STEP 12: Active non-duplicate FTX claim records 12a. Of the FTX records from STEP 11, keep active records in FTX00002, FTX00003, FTX00004, FTX00005, FTX00006, FTX00007, FTX00095 tables that satisfy the following criteria: 1. PAYEE-ID-TYPE = “01” AND 2. MBESCBES-FORM-GROUP = “1” 12b. Of the FTX records from STEP 12a in the FTX00002 table, further restrict records that satisfy the following criteria: 1a. SUBCAPITATION-IND does not equal “2” 12c. Of the FTX records from STEP 12a and STEP 12b, keep the records in the FTX00002, FTX00003, FTX00005, FTX00006, FTX00007, and FTX00095 tables that satisfy the following criteria: No Financial Transaction Duplicates: Duplicates are dropped at the header-level, if the following data elements are the same: ICN-ORIG, ICN-ADJ, PAYMENT-OR-RECOUPMENT-DATE, ADJUSTMENT-IND 12d. Of the FTX records from STEP 12a, keep the records in the FTX00004 table that satisfy the following criteria: No Financial Transaction Duplicates: Duplicates are dropped at the header-level, if the following data elements are the same: ICN-ORIG, ICN-ADJ, PAYMENT-DATE, ADJUSTMENT-IND, MSIS-IDENTIFICATION-NUM, and SSN STEP 13: Total expenditures in current fiscal year and previous fiscal year by inpatient hospital category of service 13a. Calculate the total expenditures from the current federal fiscal year. Of the claim lines from STEP 9 and the financial transaction records from STEP 12 where ADJUDICATION-DATE, PAYMENT-OR-RECOUPMENT-DATE, or PAYMENT-DATE is on or after the begin date of the federal fiscal year, sum the total amount of paid dollar amounts where MBESCBES-CATEGORY-OF-SERVICE = “1A”. 13b. Calculate the total expenditures from the previous FFY. Of the claim lines from STEP 9 and the financial transaction records from STEP 12 where ADJUDICATION-DATE, PAYMENT-OR-RECOUPMENT-DATE, or PAYMENT-DATE is before the begin date of the FFY, sum the total amount of paid dollar amounts where MBESCBES-CATEGORY-OF-SERVICE = “1A”. STEP 14: Net expenditures in current fiscal year Calculate the difference between the expenditures calculated in STEP 13a and STEP 13b. STEP 15: Numerator Calculate the difference between net expenditures in current fiscal year from STEP 14 and CMS-64 reporting of expenditures by Category of Service from STEP 3. STEP 16: Percentage Divide the numerator calculated in STEP 15 by the Denominator from STEP 3 and round the current year’s statistic to 2 decimal places.