Medicare Compliance & Reimbursement

Red flag: You can't resubmit botched claims just to fix PQRI problems

If your clearinghouse was dropping your doctors' National Provider Identifiers (NPIs) off claims, then you won't receive any credit for quality measures you may have included on those claims.

There's nothing you can do about that problem now, warned officials from the Centers for Medicare & Medicaid Services (CMS) on a Sept. 26 physician conference call about the Physician Quality Reporting Initiative (PQRI). You can't resubmit those claims just to add the PQRI information that got lost.

And CMS can't work with the clearinghouses to fix the problem, warned Thomas Valuck, a CMS official working on the PQRI. "The clearinghouse works for you and has no relationship formally to CMS," he cautioned.

If a clearinghouse hasn't met your needs, you should consider taking your business elsewhere, he added.

Some clearinghouses are refusing to fix the NPI problem because the NPIs aren't required for payment purposes yet, one caller reported.

You should ask your specialty society or local association for feedback on how different clearinghouses are performing, CMS officials advised. Many societies have been tracking issues with the PQRI in general.

On the call, CMS officials also answered some of your toughest PQRI questions:

• You don't have to rearrange the order of your diagnosis codes on the claims form to make sure they apply to the correct PQRI measure. But the line item containing the PQRI measure should point to one diagnosis code, officials cautioned.


• You should report measures such as hemoglobin A1C or lipoprotein on the date that the doctor reviews the test results. And these could be tests that someone else performed in the hospital, as long as your doctor reviews them.

• You should start preparing as soon as possible to report quality measures in 2008. The 2008 physician fee schedule proposed rule includes a list of all the measures that may become part of the PQRI next year.

But you won't know the final list of measures until the final rule comes out in mid-November. (You can view the proposed rule by going to www.cms.hhs.gov/PhysicianFeeSched and clicking on "Federal Regulation Notices.")

• You shouldn't include PQRI codes on claims submitted to other insurers where Medicare is a secondary payor, according to a new FAQ on the CMS PQRI Web site.

• You also shouldn't append other modifiers besides the PQRI ones (1P, 2P, 3P or 8P) to PQRI codes, CMS says on its Web site.