MCR-10-005-21

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TMSIS Dataguide

Medicaid.gov

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MCR-10-005-21

Data Quality Measure

Last updated

Key Information

Measure Name	% of claim lines with TYPE-OF-SERVICE = 12, 2, 61, 28, 41 with diagnosis codes
File Type	COT
Measure ID	MCR-10-005-21
Measure Type	Claims Percentage
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	0.95
Maximum	1
TA Minimun	0.95
TA Maximum	1
Longitudinal Threshold	0.15
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	TYPE-OF-SERVICE • DIAGNOSIS-CODE
DD Data Element Number	COT186 • COT284

Annotation

Percentage of unique Medicaid Encounter: original, non-crossover, paid OT claims with TYPE-OF-SERVICE = 12, 2, 61, 28, 41 with DX Codes

Specification

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

Define the OT claims universe at the line level by importing headers, lines, and DX segments 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.

DX Segments:

1. 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 2: Medicaid Encounter: Original, Non-Crossover, Paid Claims

Of 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 missing

STEP 3: Type of service

Of the claim lines that meet the criteria from STEP 2, further restrict them by the following criteria:

1. TYPE-OF-SERVICE = “012” or “002” or “061” or "028" or "041"

STEP 4: Diagnosis code

Of the claims that meet the criteria from STEP 4, select records where

1. There is at least one CLAIM-DX-OT (COT00004) segment where DIAGNOSIS-CODE is not missing

STEP 5: Link claim lines to claim DX records

Merge the lines from STEP 3 with the DX records from STEP 4 by header.

STEP 6: Drop lines without diagnosis codes

Of the claim lines from STEP 5, keep only lines linked to a DX record from STEP 4

STEP 7: Calculate the percentage for the measure

Divide the count of claim lines from STEP 6 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	MCR-10-005-21	UPDATE	Specification	STEP 1: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the line level by importing headers, lines, and DX segments 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.DX Segments:1. 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-NUMBERSTEP 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: Type of serviceOf the claim lines that meet the criteria from STEP 2, further restrict them by the following criteria: 1. TYPE-OF-SERVICE = “012” or “002” or “061” or "028" or "041"STEP 4: Diagnosis codeOf the claims that meet the criteria from STEP 4, select records where1. There is at least one CLAIM-DX-OT (COT00004) segment where DIAGNOSIS-CODE is not missingSTEP 5: Link claim lines to claim DX recordsMerge the lines from STEP 3 with the DX records from STEP 4 by header.STEP 6: Drop lines without diagnosis codesOf the claim lines from STEP 5, keep only lines linked to a DX record from STEP 4STEP 7: Calculate the percentage for the measureDivide the count of claim lines from STEP 6 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 headers, lines, and DX segments 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.DX Segments:1. 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-NUMBERSTEP 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: Type of serviceOf the claim lines that meet the criteria from STEP 2, further restrict them by the following criteria: 1. TYPE-OF-SERVICE = “012” or “002” or “061” or "028" or "041"STEP 4: Diagnosis codeOf the claims that meet the criteria from STEP 4, select records where1. There is at least one CLAIM-DX-OT (COT00004) segment where DIAGNOSIS-CODE is not missingSTEP 5: Link claim lines to claim DX recordsMerge the lines from STEP 3 with the DX records from STEP 4 by header.STEP 6: Drop lines without diagnosis codesOf the claim lines from STEP 5, keep only lines linked to a DX record from STEP 4STEP 7: Calculate the percentage for the measureDivide the count of claim lines from STEP 6 by the count of claim lines from STEP 3
04/24/2025	4.0.7	MCR-10-005-21	ADD	N/A		Created