Part B Insider (Multispecialty) Coding Alert

Published on Wed Jun 20, 2007 PDF

Talk to your vendors, save your bonus

Warning: Some clearinghouses may be sabotaging your efforts to obtain the 1.5-percent bonus in the Physician Quality Reporting Initiative (PQRI).

The Centers for Medicare & Medicaid Services (CMS) sounded the alarm that some clearinghouses are stripping the National Provider Identifier (NPI) from claims before sending them to Medicare. CMS isn't yet denying claims that lack an NPI--but claims without NPIs won't count toward the PQRI.

PQRI basics: You have to report on your chosen quality measures at least 80 percent of the time that they apply. Where applicable, you should have one to three quality codes per claim. And if you meet the 80-percent threshold but still don't report quality measures often enough, you might still get less than the full 1.5-percent bonus, due to a -cap.-

So it's really important to start reporting on quality measures for all of your applicable services with dates of service starting July 1.

The only advice CMS offers: Talk to your clearinghouse and make sure it's not stripping the NPIs from your claims. And if your clearinghouse does have a problem, you -may want to consider other billing options,- CMS urges.

As the Insider reported last week, one of the clearinghouses facing this problem is PayerPath, based in Richmond, VA. PayerPath had a problem with -batching- its claims that included NPIs, for some payors, according to company officials. Rather than cause problems with processing the claims, the company decided to stop including NPIs until it resolved the issue.

When PayerPath became aware that NPI-less claims would have a PQRI problem, it decided to notify its clients proactively, says Steve Sanders, director of product management. The problem only affects one of two PayerPath processing centers.

PayerPath aims to fix all its NPI problems by early August, says Ellen Latimer, PayerPath's director of quality services. And it will resolve issues with some payors earlier than that, she promises. As PayerPath solves each issue, it will notify its clients.

What to do: PayerPath is advising its clients who are concerned with the PQRI to hold their claims until PayerPath has resolved its issues with your particular carrier. PayerPath is also talking to CMS, to find out if Medicare will allow -backward reporting- of quality indicators for claims that were affected by the NPI issue.