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Will your Practice avoid Billing Pitfalls when Participating in PQRS?

June 18, 2015

Will your practice avoid Billing Pitfalls When Participating in PQRS?

Are your billers trained to bill appropriately while participating in PQRS? Prior to participation, ensuring the preparedness of your billing department is as important as reviewing the current year’s measure specifications. If eligible professionals don’t participate in the 2015 PQRS program successfully, they will have to face a 2% reduction in Medicare payments in 2017.

If practices are using claims-based reporting method for submitting PQRS data to the CMS, their coders will have to use the right codes. Additional documentation elements included in a physician’s report can help coders attach the right PQRS CPT codes. These codes are referred to as CPT II codes by Medicare, and addition of the CPT II codes triggers participation for the practice in PQRS. Since CMS tracks the use of PQRS codes thoroughly, it becomes necessary to have trained coders and billers on board.

Things to Know:

Claims processed by MAC (appeals, re-openings and claims adjustments) will have to reach the Medicare claims system data warehouse by 16th February 2016 in order to be included in the analysis
Penalty for not reporting 2015 PQRS is 4% for groups (with 2-9 providers) and solo providers. This includes 2% value modifier penalty and 2% PQRS penalty
For groups with ten or more providers, the penalty for not reporting 2015 PQRS is 6%. This includes 4% value modifier penalty and 2% PQRS penalty

Medical Billing Pitfalls to Avoid

In case the Medicare Administrative Contractor (MAC) denies payment for all billable services on the claim, the QDC (quality data codes) will not be included in the analysis of PQRS. If the denied claim is subsequently corrected and paid through re-opening, adjustment or appeals process with correct codes that also correspond to the measure’s denominator; any applicable QDC that correspond to the numerator should be included on the corrected claim.

It is also important for billers to know that claims may not get re-submitted only for adding or correcting QDCs. Claims that have only QDCs on them with a zero or $0.1 total amount will not go for re-submission to the MAC.

N620 is the EOB/RA (Remittance Advice/ Explanation of Benefits) denial code that is an indication of PQRS codes being valid for the 2015 PQRS reporting year. When an EP reports the QDC satisfactorily, N620 can indicate that the claim will be used in calculating satisfactory reporting.

N620 is the new RARC (Remittance Advice Remark Code) code for QDCs with $0.00. Eligible professionals who bill with $0.00 charge on a QDC line item will be receiving an N620 code on the EOB.

Practices Outsourcing to MBC for PQRS Assistance

Expert coders at MBC make use of appropriate PQRS codes and also provide timely feedback regarding the utilization of the codes. They also verify if Medicare is accepting the PQRS codes. MBC works in co-ordination with the physicians to ensure proper billing of CPT codes so that they participate in the PQRS program successfully and avoid penalties.


Category : Practice Administration