URSA-CORE-921: Institutional Claims with Suspected Duplicate

Measure Description

Among institutional claim service line items, the percentage for which another record exists with identical patient, service start date, line number, and HCPCS code plus the first HCPCS modifier code or CMS revenue center code; the idea is that these duplicates will appear if the claims data have not been properly reconciled to final action.

Metadata

• Measure Type: Rate Measure
• Temporal Structure: Event
• Component Class: Normal-Form
• Denominator Case Field: Claim Service Line Item ID
• Target Direction: Down

Denominator Description

Institutional claim service line items.

Numerator Description

Denominator observations with at least one other institutional claim service line item with the same patient, service start date, service line number, and HCPCS code plus the first HCPCS modifier code or CMS revenue center code.

Published Fields

• Data Model Keys

  • Claim ID
  • Claim Service Line Item ID
  • Service Line Number
  • Patient ID
  • Service Provider ID
  • Source ID
  • Payor ID

• Date Fields

  • Claim Covered Start Date
  • Claim Covered End Date
  • Service Start Date
  • Service End Date
  • Segment Start Date -- The start date of the reporting segment. (See also [URSA-CORE] Reporting Segment)
  • Segment End Date -- The end date of the reporting segment. (See also [URSA-CORE] Reporting Segment)

• Clinical Services Fields

  • HCPCS Code
  • HCPCS Modifier 1 Code
  • CMS Revenue Center Code

• Financial Fields

  • Claim Service Line Item Allowed Amount
  • Claim Service Line Item Plan Paid Amount

• Numerator Fields

  • Count of Suspected Duplicate Records Using HCPCS
  • Count of Suspected Duplicate Records Using Revenue Center Code

• Measure Fields

  • Denominator
  • Numerator