MCR-5-004-19

An official website of the United States government

Official websites use .gov
A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS
A lock () or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites.

TMSIS Dataguide

Medicaid.gov

Version:

MCR-5-004-19

Data Quality Measure

Last updated

Key Information

Measure Name	Average # of diagnoses
File Type	CLT
Measure ID	MCR-5-004-19
Measure Type	Average # Occurrences
Content area	MCR

Validation

Validation Type	Longitudinal

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	1
Maximum	37
TA Minimun	1
TA Maximum	37
Longitudinal Threshold	0.25
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	DIAGNOSIS-CODE
DD Data Element Number	CLT278

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
11/20/2025	4.0.22	MCR-5-004-19	UPDATE	Annotation	Average number of diagnosis codes for Medicaid Encounter original, non-crossover, paid LT claims	N/A
11/20/2025	4.0.22	MCR-5-004-19	UPDATE	Specification	STEP 1: Active non-duplicate paid LT claims during report monthDefine the LT 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 FFS: 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-NUMBERSTEP 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 4STEP 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-5-004-19	UPDATE	Specification	STEP 1: Active non-duplicate paid LT claims during report monthDefine the LT 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 FFS: 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-NUMBERSTEP 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 4STEP 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 LT claims during report monthDefine the LT 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 FFS: 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-NUMBERSTEP 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 4STEP 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-5-004-19	UPDATE	Ta max	5	37
05/27/2025	4.0.9	MCR-5-004-19	UPDATE	Threshold maximum	5	37
04/24/2025	4.0.7	MCR-5-004-19	ADD	N/A		Created