MCR-1-004-16

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TMSIS Dataguide

Medicaid.gov

Version:

MCR-1-004-16

Data Quality Measure

Last updated

Key Information

Measure Name	Average # of diagnoses
File Type	CIP
Measure ID	MCR-1-004-16
Measure Type	Average # Occurrences
Content area	MCR

Validation

Validation Type	Longitudinal and Inferential

Measure Priority

Measure Priority	High
Focus Area	Managed care
Category	Utilization

Claim Information

Claim Type	Medicaid,Enc
Adjustment Type	Original
Crossover Type	Non-Crossover

Thresholds

Minimum	2
Maximum	37
TA Minimun	2
TA Maximum	37
Longitudinal Threshold	0.15
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	DIAGNOSIS-CODE
DD Data Element Number	CIP332

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
11/20/2025	4.0.22	MCR-1-004-16	UPDATE	Annotation	Average number of diagnosis codes for Medicaid Encounter: original, non-crossover, paid IP claims	N/A
11/20/2025	4.0.22	MCR-1-004-16	UPDATE	Specification	STEP 1: Active non-duplicate paid IP claims during report monthDefine the IP claims universe at the header level that satisfy the following criteria: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.STEP 2: Medicaid Encounter: Original, Non-Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: DX Segments1. DX segments merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND.2. No DX Duplicates: Duplicates are dropped at the diagnosis level, if the following seven data elements are the same: SUBMITTING-STATE, ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, ADJUSTMENT-IND, DIAGNOSIS-CODE, and DIAGNOSIS-SEQUENCE-NUMBER.STEP 4: Non-missing diagnosis codesOf the DX segments that meet the criteria from STEP 3, set Count_Elements equal to the total number of DX segments in STEP 3 where 1. DIAGNOSIS-CODE is not missing2a. DIAGNOSIS-TYPE is not missingAND2b. DIAGNOSIS-TYPE is not equal to ("A")STEP 5: Total number of diagnosesSum Count_Elements for all claims in STEP 4 STEP 6: Calculate the average for measureDivide the sum from STEP 5 by the count of claims from STEP 2	N/A
08/13/2025	4.0.16	MCR-1-004-16	UPDATE	Specification	STEP 1: Active non-duplicate paid IP claims during report monthDefine the IP claims universe at the header level that satisfy the following criteria: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.STEP 2: Medicaid Encounter: Original, Non-Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: DX Segments1. DX segments merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND.2. No DX Duplicates: Duplicates are dropped at the diagnosis level, if the following seven data elements are the same: SUBMITTING-STATE, ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, ADJUSTMENT-IND, DIAGNOSIS-TYPE-CODE, and DIAGNOSIS-SEQUENCE-NUMBER.STEP 4: Non-missing diagnosis codesOf the DX segments that meet the criteria from STEP 3, set Count_Elements equal to the total number of DX segments in STEP 3 where 1. DIAGNOSIS-CODE is not missing2a. DIAGNOSIS-TYPE is not missingAND2b. DIAGNOSIS-TYPE is not equal to ("A")STEP 5: Total number of diagnosesSum Count_Elements for all claims in STEP 4 STEP 6: Calculate the average for measureDivide the sum from STEP 5 by the count of claims from STEP 2	STEP 1: Active non-duplicate paid IP claims during report monthDefine the IP claims universe at the header level that satisfy the following criteria: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.STEP 2: Medicaid Encounter: Original, Non-Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: DX Segments1. DX segments merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND.2. No DX Duplicates: Duplicates are dropped at the diagnosis level, if the following seven data elements are the same: SUBMITTING-STATE, ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, ADJUSTMENT-IND, DIAGNOSIS-CODE, and DIAGNOSIS-SEQUENCE-NUMBER.STEP 4: Non-missing diagnosis codesOf the DX segments that meet the criteria from STEP 3, set Count_Elements equal to the total number of DX segments in STEP 3 where 1. DIAGNOSIS-CODE is not missing2a. DIAGNOSIS-TYPE is not missingAND2b. DIAGNOSIS-TYPE is not equal to ("A")STEP 5: Total number of diagnosesSum Count_Elements for all claims in STEP 4 STEP 6: Calculate the average for measureDivide the sum from STEP 5 by the count of claims from STEP 2
05/27/2025	4.0.9	MCR-1-004-16	UPDATE	Ta max	12	37
05/27/2025	4.0.9	MCR-1-004-16	UPDATE	Threshold maximum	12	37
04/24/2025	4.0.7	MCR-1-004-16	ADD	N/A		Created