Missing and Invalid Diagnosis Codes in 2017 (Brief)

• In the T-MSIS Analytic File, diagnosis codes that denote beneficiaries’ medical conditions are on the header records in the medical claims files (IP, LT, and OT). In this analysis, we evaluated the extent to which each state’s claims were completely coded with at least one valid diagnosis code. We also calculated the mean number of valid diagnosis codes on claims in the IP and LT files to identify states with potentially incomplete diagnosis code data.
• The vast majority of IP claims had a valid ICD-10 primary diagnosis code. On average, states submitted six to eight diagnosis codes per IP claim. One state had unusable diagnosis code data in the IP file.
• Although there were a handful of exceptions, most states had a valid ICD-10 primary diagnosis code on the majority of their LT claims. States generally submitted two to four diagnosis codes per LT claim. Three states had unusable or highly concerning diagnosis code data.
• Valid ICD-10 primary diagnosis codes are available on most OT claims. It is noteworthy that valid ICD-10 primary diagnosis codes were frequently included on claims in the OT file submitted by providers who were not expected to have access to reliable diagnostic information about patients (for example, claims for medical supplies, prosthetic equipment, or non-emergency medical transportation services). Users of the T-MSIS Analytic File may want to exercise caution in using the diagnosis codes on these claims even if they appear to be valid ICD-10 codes. One state had unusable diagnosis code data in the OT file.

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