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Medical Coding News Archives

Top Reasons for Unsuccessful PQRI Reporting

April 28, 2009:

In a recent Physician Quality Reporting Initiative (PQRI) open door forum, the Centers for Medicare & Medicaid Services (CMS) listed some of the most common errors in claim-based reporting along with tips to help physicians meet the criteria for receiving the 2 percent incentive payment.

Among the most common errors reported by the agency are:

Eligible claim issubmitted without QDC(s):

  • Providers are not identifying all eligible claims. It is important to remember that some measures include additional sites of service other than the office. For example, CMS indicates that many Medicare secondary payer claims are submitted without the appropriate quality data codes (QDC).

Eligible claim submitted as a QDC‐only claim (no denominator information on the claim):

  • Medicare will not process a claim that has a zero charge or that does not have denominator information. Providers should verify that all eligible QDC codes are submitted on the same claim as the services or conditions making that encounter eligible. For example, if a diabetic patient has a diabetic foot exam but the physician fails to submit the appropriate QDC code, the office cannot file a claim with just the QDC code the following day.
  • Another reason this may be occurring is that the billing software may be splitting claims. CMS can match encounters that require multiple claims through the common working file; however, if the second claim has no fees (QDC only) then the claim is not processed and therefore cannot be matched. It’s a good idea to talk to the billing service or clearinghouse to see how this can best be managed.

Ineligible claim with QDC for measure:

  • CMS indicates that it is receiving claims that have a QDC but that the diagnosis is either incorrect or there is insufficient information on the claim to support the submitted QDC. Other common reasons for this error include incorrect surgical procedure codes or incorrect age or sex.

Eligible claim with insufficient QDCs:

  • Remember to determine and submit the QDC on the same claim as the encounter. Medicare will not reprocess claims that are resubmitted just to report the QDC.

Eligible claim is denied by carrier, subsequently submitted but without QDC:

  • If a claim is denied and is corrected and resubmitted, it must include the appropriate QDCs.

Eligible claim is paid partially by the primary payer but is submitted without QDC as a Medicare secondary payer claim:

  • It may be necessary, particularly when a claim is automatically crossed over to Medicare, that the appropriate QDC codes be submitted to the primary payer. If the primary payer does not accept codes with a $0.00 charge, submit the claim with a nominal fee, such as $0.01.

Eligible claim does not have an individual NPI:

  • The individual provider’s NPI must be included on the claim so that Medicare can process the PQRI data.

Deborah C. Hall
Clinical/Technical Editor


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