# Pqrs - non covered charge



## herrera4 (Apr 3, 2013)

We are billing PQRS codes but they are coming back as non covered charge. Shouldnt they be coming back as approved. am i missing a step?
Thanks


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## Kisalyn (Apr 3, 2013)

You should be getting a denial code of N365 on the remittance advice or EOB, which means the codes were received. This code reads "This procedure code is not payable. It is for reporting/information purposes only."

This is the only way you know Medicare is receiving the quality data codes to count towards satisfactorily reporting the measure. Our office periodically run reports to make sure this is happening on our end.


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## herrera4 (Apr 3, 2013)

I thought so, our denials are CO-96 Non covered.  They meet the guidelines so Im not sure why the denials are non-cvrd?? We are claims reporting for 5 providers, so far none have the N365 denial


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## Kisalyn (Apr 3, 2013)

What measures are you reporting on? 

The first things that come to mind is that maybe you're missing a CPT II modifier, you're submitting to advantage plans, or the charge on the claim isn't included in the denominator.


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## herrera4 (Apr 5, 2013)

#226 for tobacco screening most is 1036f with office visits and #131 for pain assesment and follow up G8730 or G8731 usually again with office visit to medicare. I didnt have a problem last year submitting but i dont remember if i submitted a code to start reporting-that i didnt do this year


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## Kisalyn (Apr 8, 2013)

Pretty strange. I don't think you need to report a code to get started unless you're reporting on a group measure, but don't quote me on that. We've only ever reported on individual measures.

_#226: As long as you're reporting 1036F with one of the below, you should get credit:

Patient encounter during the reporting period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90839, 90845, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 97003, 97004, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99406, 99407, G0438, G0439

It does specify once per reporting period. Not sure if you're doing 6 months or 12 months._

I would suggest calling or opening a ticket by emailing Quality Net. They're the experts on all these quality measures:

E-mail: qnetsupport@sdps.org
Phone: (866) 288-8912 

Best of luck!


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## herrera4 (Apr 9, 2013)

ok thank you for the information


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## kathrynrr86 (Dec 30, 2013)

Kisalyn said:


> What measures are you reporting on?
> 
> The first things that come to mind is that maybe you're missing a CPT II modifier, you're submitting to advantage plans, or the charge on the claim isn't included in the denominator.



What modifiers are appropriate to bill with these codes?


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## Kisalyn (Dec 30, 2013)

I suggest going to the AMA website and pull the worksheets. Each year, the AMA usually publishes worksheets on nearly all measures to facilitate reporting the right codes. We are not reporting on this measure, but it looks like the applicable modifiers are 1P and 8P. Also, the below may not be up to date. I pulled it from the download I had earlier in the year/end of last year.

*DENOMINATOR:*
All patients aged 18 years and older

*Denominator Criteria (Eligible Cases):*
Patients aged ≥ 18 years on date of encounter
*AND*
Patient encounter during the reporting period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90839, 90845, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 97003, 97004, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99406, 99407, G0438, G0439​
*NUMERATOR:*
Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation counseling intervention if identified as a tobacco user

Definitions:
Tobacco Use – Includes use of any type of tobacco.
Cessation Counseling Intervention – Includes brief counseling (3 minutes or less), and/or pharmacotherapy.

*NUMERATOR NOTE*: In the event that a patient is screened for tobacco use and identified as a user but did not receive tobacco cessation counseling report *4004F* with *8P*.

*Numerator Quality-Data Coding Options for Reporting Satisfactorily:*
*Patient Screened for Tobacco Use*
*CPT II 4004F*: Patient screened for tobacco use AND received tobacco cessation intervention (counseling, pharmacotherapy, or both), if identified as a tobacco user
*OR*
*Patient Screened for Tobacco Use and Identified as a Non-User of Tobacco
CPT II 1036F*: Current tobacco non-user​
*OR*

*Tobacco Screening not Performed for Medical Reasons*
Append a modifier (1P) to CPT Category II code 4004F to report documented circumstances that appropriately exclude patients from the denominator
*4004F with 1P*: Documentation of medical reason(s) for not screening for tobacco use (eg, limited life expectancy, other medical reason)​
*OR*
*Tobacco Screening OR Tobacco Cessation Intervention not Performed Reason Not Otherwise Specified*
Append a reporting modifier (8P) to CPT Category II code 4004F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified.

*4004F with 8P*: Tobacco screening OR tobacco cessation intervention not performed, reason not otherwise specified​


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