2014 Physician Quality Reporting System

Webinar 2 – PQRS Ready To Start Claims Reporting

Presented by: Marcy Le

Prior to attending this session you should have some basic understanding of PQRS and be sure that your office wants to report PQRS data through Medicare claims submission. In order for this session to be successful for everyone involved you should complete the “homework” below. 1. Please save the 2 attached documents to your desktop. (do not print this 600+ page

document) 2. Open the 2014 PQRS Individual Measure Spec Manual (print pages 9-15)3. Review the 358 measures with the provider you are reporting PQRS data for.4. Highlight a minimum of 5-10 measures that your provider thinks they want to report.5. Look at the reporting options and make sure there is a “C” in the column (this means you can report via claims)6. The far right column will tell you the page number within the manual so you can review

the measure details EXTRA CREDIT The attached 2014 National Quality Strategy Domains document is what we reviewed in the previous webinar. Reminder: The measures you choose should be from at LEAST 3 National Quality Strategy Domains. (we will review this together during the next webinar)

Homework Assignment

HOMEWORK ASSIGNMENT

Attachments: 2014 QDC Measure List & 2014 Claims/Registry Measure Specifications Manual

3 measures to avoid the penalty 9 measures to receive the incentive

Be sure that your measures cover AT LEAST 3 domains

Measure must have a “C” for claims based reporting in the reporting options list

(use the QDC document to verify this)

When using the claims-based reporting option, each eligible professional (EP) must satisfactorily report on at least 50 percent of eligible instances to qualify for the incentive.

The 2014 Physician Quality Reporting System (PQRS) Measure Specifications contain ICD-9-CM coding and ICD-10-CM coding.

50%

• All denominator-eligible claims for the selected measure(s)/measures group(s) are identified and captured and reporting frequency of the selected measure(s) and/or measure group(s) is reviewed and understood.

SUPPORT STAFF NEED TO UNDERSTAND THE MEASURES SELECTED FOR REPORTING

Teamwork is essential for successful claims reporting

STEP #1 - The quality measure box needs to be checked for every Medicare insurance

REMINDER: report data on quality measures for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B beneficiaries (including Railroad and Medicare as secondary payer).

STEP #2 – Review individual measure(This information is found on pages 9-15 of the 2014 Claims Registry Specification Manual)

Page 20 will give the details of the measure

Reporting option “C” for claims

Measure #1

Learn the description

Page 20

Continue to review details of the measure

each visit or once per reporting period are the most common

Page

21

3046F

3044F

3045F

Find the CPT II codes that correspond with the measure

Page 22

Clinical recommendations tell you who thought this data is important and why they think this rule is important

Continue to review details of the measure

STEP 3 - Enter CPT II Codes

Quality Measure needs to be checked and you must have an amount in the billed area

Amount can be $0.00 or $0.01 but there must be an amount

STEP 4 – Preview some claims to check the data

The Remittance Advice (RA)/Explanation of Benefits (EOB) for the denial code N365 is your indication that the PQRS codes are valid for the 2014 PQRS reporting year. The N365 denial code is just an indicator that the QDC codes are valid for 2014 PQRS. It does not guarantee the QDC was correct or that reporting thresholds were met. However, when a QDC is reported satisfactorily (by the individual EP), the N365 can indicate that the claim will be used in calculating incentive eligibility.

All claims adjustments, re-openings, or appeals must reach the national

Medicare claims system data warehouse (National Claims History [NCH] file)

by February 27, 2015 to be included in the 2014 PQRS analysis.

Claim Adjustment Reason Code (CARC) for QDCs with $0.01 o The new CARC 246 with Group Code CO or PR and with RARC N572 indicates that this procedure is not payable unless non-payable reporting codes and appropriate modifiers are submitted. o CARC 246 reads: This non-payable code is for required reporting only. o EPs who bill with a charge of $0.01 on a QDC item will receive CO 246 N572 on the EOB.

Please Note: Effective on 4/1/2014, EPs who bill on a $0.00 QDC line item will receive the N620 code. It replaces the current N365, which will be deactivated effective 7/1/2014. EPs who bill on a $0.01 QDC line item will receive the CO 246 N572 code.

Remittance Advice Remark Code (RARC) for QDCs with $0.00 o The new RARC code N620 is your indication that the PQRS codes were received into the CMS National Claims History (NCH) database. o EPs will receive code N620 on the claim EOB form beginning 4/1/2014. o N620 reads: This procedure code is for quality reporting/informational purposes only.

Claim Adjustment Reason Code (CARC) for QDCs with $0.01

o The new CARC 246 with Group Code CO or PR and with RARC N572 indicates

that this procedure is not payable unless non-payable reporting codes and

appropriate modifiers are submitted.

o CARC 246 reads: This non-payable code is for required reporting only.

o EPs who bill with a charge of $0.01 on a QDC item will receive CO 246 N572 on

the EOB.

STEP 5 - Check EOB’s for the status of the data submitted

5 STEPS - CLAIMS BASED PQRS REPORTING

Medicare needs to be

set up to report Quality Data

Review the measures you will report

Enter CPT II codes into

Practice Manager

Preview claims

Monitor EOB’s

TIPS FOR SUCCESSFUL CLAIMS REPORTINGAvoid including multiple dates of service and/or multiple rendering providers on the same claim. This will help eliminate diagnosis codes associated with other services being attributed to another provider’s services.

For measures that require more than one QDC, please ensure that all codes are captured on the claim.

Report the QDC on each eligible claim that falls into the denominator. Failure to submit a QDC on claims for these Medicare patients will result in a “missed” reporting opportunity that can impact incentive eligibility.

Claims may not be resubmitted only to add or correct QDCs. Claims with only QDCs on them with a zero total dollar amount may not be resubmitted to the Carrier or A/B MAC. Refer to the Implementation Guide for specifics for reporting via the claims method.

All denominator coding is represented on the claim form prior to application of numerator coding.

NOTE: This document is provided for informational and educational purposes only. It is not intended nor should it be relied upon to provide regulatory or legal advice. Please review all regulatory requirements in regards to this document and consult the appropriate counsel.

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• qnetsupport@sdps.org

QualityNet Help Desk

Additional PQRS assistance from STI is billable at $120 per hour. This includes emails, phone calls, staff training and setup. This request can be made at www.sticomputer.com, customers, login, select contact us, click here to contact the training department, enter your information