MCR-3-005-10

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TMSIS Dataguide

Medicaid.gov

Version:

MCR-3-005-10

Data Quality Measure

Last updated

Key Information

Measure Name	% of claim headers with only 1 diagnosis code
File Type	CIP
Measure ID	MCR-3-005-10
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	CHIP,Enc
Adjustment Type	Original
Crossover Type	Non-Crossover

Thresholds

Minimum	0
Maximum	0.25
TA Minimun	0
TA Maximum	0.25
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-3-005-10	UPDATE	Annotation	Percentage of S-CHIP Encounter: original, non-crossover, paid IP claims with only 1 diagnosis	N/A
11/20/2025	4.0.22	MCR-3-005-10	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: S-CHIP 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 = "C"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: DX Segments1. Merge DX segments to claims from STEP 2 by 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: Diagnosis codeOf the claims that meet the criteria from STEP 3, select records where:1. There is only one CLAIM-DX-IP (CIP00004) segment where DIAGNOSIS-CODE is not missing STEP 5: Calculate the percentage for the measureDivide the count of claims from STEP 4 by the count of claims from STEP 2.	N/A
08/13/2025	4.0.16	MCR-3-005-10	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: S-CHIP 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 = "C"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: DX Segments1. Merge DX segments to claims from STEP 2 by 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: Diagnosis codeOf the claims that meet the criteria from STEP 3, select records where:1. There is only one CLAIM-DX-IP (CIP00004) segment where DIAGNOSIS-CODE is not missing STEP 5: Calculate the percentage for the measureDivide the count of claims from STEP 4 by the count of header 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: S-CHIP 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 = "C"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: DX Segments1. Merge DX segments to claims from STEP 2 by 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: Diagnosis codeOf the claims that meet the criteria from STEP 3, select records where:1. There is only one CLAIM-DX-IP (CIP00004) segment where DIAGNOSIS-CODE is not missing STEP 5: Calculate the percentage for the measureDivide the count of claims from STEP 4 by the count of claims from STEP 2.
04/24/2025	4.0.7	MCR-3-005-10	ADD	N/A		Created