Otolaryngology Coding Alert

CMS: Youve got to be on top of your age, gender, dx.

Most practices would agree that a 57.2 percent success rate isnt overly impressive -- but thats exactly what CMS found in its recent analysis of PQRI submissions.

Almost 43 percent of the quality data codes (QDCs) that practices submitted to CMS were ineligible for the PQRI bonus because physicians reported them improperly, CMS noted in its Feb. 13 report, Quality-Data Code Submissions Error Report. The report analyzed PQRI submissions over the first three quarters of 2008. For 2009, the PQRI incentive payment is 2 percent of your physicians allowed charges under the Medicare Physician Fee Schedule. If youd like to keep that money flowing into your practice, avoid these errors that CMS found:

1. Missing NPI. CMS notes that 97,131 of the QDC submissions were missing their national provider identifier (NPI). For measure 64, (Asthma assessment), 52 of the 2,977 QDCs were missing an NPI.

2. Wrong HCPCS code. A whopping 15.6 percent of QDC submissions (nearly 3 million claims) had incorrect HCPCS codes. For instance, coders used the wrong HCPCS codes 17.6 percent of the time when reporting measure 114 (Inquiry regarding tobacco use).You dont want to face a double-whammy -- a denied claim due to a wrong code, as well as lost PQRI bonus money for the same reason, says Carla Whitmire with Strategic Coding Systems in Little Rock, Ark. Therefore,double-check your code selection before you submit your claim.

3. Wrong diagnosis. CMS found that 14.9 percent of QDC submissions included incorrect diagnosis codes. A prime offender in this category was upper respiratory infection measure 65, Appropriate treatment for children, which had incorrect diagnosis codes 79.9 percent of the time.

Keep in mind: CMS looks for errors in other aspects of QDC submissions, says Jay Neal, an Atlanta-based coding consultant. Auditors look for discrepancies in patient-age mismatches, as well as patient-gender mismatches.

For instance, coders mismatched age a stunning 92.2 percent of the time when reporting PQRI measure 64.

The age range for 1005F (Asthma symptoms evaluated [includes physician documentation of numeric frequency of symptoms or patient completion of an asthma assessment tool/survey/questionnaire] [Asthma]) was 5- 40. Almost all of the reporting -- 2,977 cases -- was on patients who fell outside that range.

To read the errors, visit www.cms.hhs.gov/PQRI/Downloads/2008QDCError3rdQuarter.pdf.