CMS Technical Instructions: Reporting Quantity fields in the Claims files, Revised

This technical instruction document outlines the challenges states have faced when reporting quantity and unit of measure fields in the IP, LT, OT, and RX files and provides technical instructions to states on this topic.

Providers use a variety of formats to submit claims to state Medicaid (or CHIP) agencies or their managed care plans (such as UB-04 or the 837 forms). All types of claim formats have a field in the detailed claim lines where providers submit the quantity of procedure, service, or drug provided. Mapping the quantity of service from the claims forms to the detailed claim line fields is relatively straightforward in the IP and LT claims files, but mapping the quantity of service from the claim forms to the claim lines of the OT and RX files is not as clear. The unit of measure, which expresses the unit of measure for each corresponding value reported by the quantity data elements, can be populated on all claim types and should be populated when a given claim line also contains an NDC code. All claim lines that contain NDC codes, including all RX claim lines, should contain a unit of measure.

Many states are not mapping quantity of service from claims forms to T-MSIS claims files correctly because there are misunderstandings regarding the conditions under which the various variables listed in Table 1 should be populated. Some of these misunderstandings result from the various claim forms used to populate the claims files.

• Claims data in the T-MSIS IP and LT files come from the 837I/UB-04 claim formats.
• Claims data in the T-MSIS OT file come from the 837I/UB-04, the 837P/CMS-1500, the 837D/ADA 2012, and possibly other claim formats.
• Claims data in the T-MSIS RX files come from the NCPDP claim format.

In some situations, a single data element in the T-MSIS claims file will be mapped differently depending on the claim form being used to populate the claim record. For example, there are six or more fields from different claim formats that could be used to populate the same T-MSIS OT variable (SERVICE-QUANTITY-ACTUAL).

All claims forms have a field used for reporting quantity in the detailed claim line segment in T-MSIS. In addition to the standard quantity values on the IP, LT, and OT files, when a NATIONAL-DRUG-CODE data element (CIP284, CLT228, COT217) is populated, then the corresponding NDC-QUANTITY data element (CIP278, CLT230, COT225) should be populated. The T-MSIS quantity and metric values which are populated will depend on whether the quantity value corresponds to a drug or a service.

• Procedures/Services
  • REVENUE-CENTER-QUANTITY-ACTUAL (IP and LT files)
  • SERVICE-QUANTITY-ACTUAL (when in the OT file)
• Drugs
  • NDC-QUANTITY (IP, LT, OT files when there is an NDC on a claim line)
  • PRESCRIPTION-QUANTITY-ACTUAL (RX)
  • DTL-METRIC-DEC-QTY (RX)
  • NDC-UNIT-OF-MEASURE (IP, LT, OT files when there is an NDC on a claim line)
  • UNIT-OF-MEASURE (RX)

The quantity of service or procedure reported by providers on their claims should be mapped to the “actual” quantity fields in the T-MSIS IP, LT, and OT files. When a claim includes an NDC, regardless of the claim file, the quantity value reported with the NDC on the claim should map to the NDC-QUANTITY fields in the T-MSIS IP, LT, and OT files and the PRESCRIPTION-QUANTITY-ACTUAL or DTL-METRIC-DEC-QTY in the RX file.

In V3.0.0, SERVICE-QUANTITY-ACTUAL (OT File) and PRESCRIPTION-QUANTITY-ACTUAL (RX File) replaced OT-RX-CLAIM-QUANTITY-ACTUAL. In the OT file, SERVICE-QUANTITY-ACTUAL should capture the “Units of Service/Days” (837I/UB-04) or “Units” (837P/CMS-1500, 837D/ADA 2012) fields, representing both revenue codes and procedure codes. In the RX file PRESCRIPTION-QUANTITY-ACTUAL should capture the amount dispensed (“quantity dispensed” [NCDPD 442-E7] or “compound ingredient quantity” [NCDPD 448-ED]). The SERVICE-QUANTITY-ACTUAL or PRESCRIPTION-QUANTITY-ACTUAL fields are expected to be populated and the corresponding UNIT-OF-MEASURE must also be populated.

The T-MSIS data element DTL-METRIC-DEC-QTY captures quantity of compounds reported on an RX claim. The source of DTL-METRIC-DEC-QTY and PRESCRIPTION-QUANTITY-ACTUAL from a provider’s claim depends on whether the claim is for a compound drug or a non-compound drug. If an RX claim is for a non-compound drug, then DTL-METRIC-DEC-QTY is not applicable but PRESCRIPTION-QUANTITY-ACTUAL (is applicable. If states report both PRESCRIPTION-QUANTITY-ACTUAL and DTL-METRIC-DEC-QTY on the RX file, they should capture the same information.

The way that claims data are mapped from the source claim formats to T-MSIS should follow the conventions in Table 1.

Table 1. Claim form source fields for populating quantity and unit of measure related data elements to the T-MSIS IP, LT, OT, and RX files.

The T-MSIS data element UNIT-OF-MEASURE (CRX133) should be reported on all claim lines on the RX file, corresponding to the quantities reported by PRESCRIPTION-QUANTITY-ACTUAL or DTL-METRIC-DEC-QTY. This element is mapped from two fields on the NCPDP claim form: field 600-28 UNIT OF MEASURE and field 451-EG COMPOUND DISPENSING UNIT FORM INDICATOR. Valid values for these two source fields use different codes to report the same underlying meaning, so they can be mapped to the common T-MSIS code set. States should report values populated in the two NCPDP fields using the corresponding T-MSIS valid values. When a claim is a standard pharmacy claim, unit of measure should be reported from field 600-28 UNIT OF MEASURE. When a claim is a compound, unit of measure should be reported from field 451-EG COMPOUND DISPENSING UNIT FORM INDICATOR.

T-MSIS data elements NDC-UNIT-OF-MEASURE (CIP285, CLT229, or COT224) and NDC-QUANTITY (CIP278, CLT230, or COT225) are only applicable to and therefore reported in the IP, LT, and OT files when a value is reported to the NATIONAL-DRUG-CODE data element (CIP284, CLT228, or COT217). The data element NDC-UNIT-OF-MEASURE uses the same valid values and coding rules as UNIT-OF-MEASURE.

Table 2. Valid values for units of measure

The data elements REVENUE-CENTER-QUANTITY-ALLOWED, SERVICE-QUANTITY-ALLOWED, and PRESCRIPTION-QUANTITY-ALLOWED reports the maximum quantity of service covered by Medicaid, CHIP, or the managed care plan that may be provided per day of service or per month. Unlike REVENUE-CENTER-QUANTITY-ACTUAL, SERVICE-QUANTITY-ACTUAL, and PRESCRIPTION-QUANTITY-ACTUAL, which should be passed through directly from the providers claim to T-MSIS, REVENUE-CENTER-QUANTITY-ALLOWED, SERVICE-QUANTITY-ALLOWED, and PRESCRIPTION-QUANTITY-ALLOWED) are expected to be calculated/assigned by the state or their managed care plans during claim adjudication. On the RX file only, it is expected that PRESCRIPTION-QUANTITY-ALLOWED may not be frequently populated due to point-of-sale claim systems. In this case, it is recommended that PRESCRIPTION-QUANTITY-ALLOWED is either not populated or is populated with the same value as PRESCRIPTION-QUANTITY-ACTUAL.