Usability of Procedure Codes in 2017 (Brief)

Usability of Procedure Codes in 2017 (Brief)

T-MSIS Analytic Files Data Quality Brief #5202
Published: Oct 24, 2019
Publisher: Baltimore, MD: Centers for Medicare & Medicaid Services
Associated Project

Providing Business Analytics and Data Quality Development for Medicaid and CHIP Business Information Solutions (MACBIS)

Time frame: 2015-2019

Prepared for:

U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services


Kimberly Proctor

Jessie Parker

Key Findings
  • Procedure codes are used to document services rendered and to bill for medical procedures provided to a patient. These codes are critical to research on service utilization and access to care. This brief examines how often the procedure codes fields in the other services (OT) and inpatient files (IP) were missing, and how often the non-missing values were valid national or state-specific codes in 2017.
  • In the T-MSIS Analytic Files, states should have procedure codes in different fields depending on the claims file and type of claim. For professional claims in the OT file, the majority of states fell into the low-concern category because less than 10 percent of claim lines had a missing or invalid procedure code.
  • For outpatient institutional claims, which are found in the OT file, states should have procedure codes in the HCPCS rate field. Most states did not use the HCPCS rate field for procedure codes, but instead have valid procedure codes in the procedure codes field.
  • For inpatient institutional claims found in the IP file, nearly all states (46 states, the District of Columbia, and Puerto Rico) fell into the low-concern category; less than 10 percent of their claim headers with a procedure code were populated with an invalid value.

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