Bulletin: June 27, 2007

Sending PQRI Data through HARP

By:  TechComm Services Manager

The Physician Quality Reporting Initiative (PQRI) from CMS establishes a financial incentive for eligible professionals to participate in a voluntary reporting program that assesses the quality of care for Medicare patients. Eligible professionals who successfully report a designated set of quality measures on claims for dates of service from July 1 to December 31, 2007 may earn a bonus payment, subject to a cap, of 1.5% of total allowed charges for covered Medicare Physician Fee Schedule services. The CMS Web site has details about the program at http://www.cms.hhs.gov/PQRI/.

HARP is ready to transmit PQRI data on claims for those practices participating in the program. The following is some information about how to add PQRI data with charges, what will appear on remittances, and which reports will help to track the data.

Setup in HARP

• Programming changes to HARP in release 2.30C/2.30H will allow zero-charge procedures to be included on non-zero-balance claims for Medicare fee-for-service insurance screen types MCAR and MCARNE.

• Fee schedules should be updated with the quality-data codes (CPT II codes) relevant to your practice. We recommend that these procedures have a $0.00 dollar charge amount. A $0.01 charge amount is also acceptable, but manual adjustments for these charges may be required at the time of payment posting.

• Each individual provider must have an NPI stored in the NPI insurance category.

Charges

• Quality-data codes must be entered on same ticket as the qualifying diagnosis and CPT service (Category I) code.

• The diagnosis code applicable to the quality measure should be the primary diagnosis on the qualifying charge line.

• Modifiers on quality-data codes may be required to explain why a measure was not performed for a qualifying patient. The applicable modifiers are:
  1P - Performance Measure Exclusion Modifier due to Medical Reasons
  2P - Performance Measure Exclusion Modifier due to Patient Reasons
  3P - Performance Measure Exclusion Modifier due to System Reasons
  8P - Performance Measure Reporting Modifier - action not performed, reason not otherwise specified

Claims

• Quality-data codes must be reported on the same claim form as the applicable diagnosis and CPT service codes. If they are on the same ticket, they will be on the same claim.

• Multiple quality-data codes can be reported on the same claim as long as the corresponding CPT service codes are also included.

• Entire claims with zero charges will be rejected in the HARP Insurance process and will appear on the Report of Insurance.

Remittances

• The quality-data code line items will be denied for payment but will be processed by CMS for PQRI analysis.

• The Remittance Advice will indicate that the quality-data code line item has been denied with the Claim Adjustment Reason Code message 96, “Non-covered charge(s).”

• HARP will not place tickets with non-covered charges on hold when the billed amount for the non-covered charge is zero.

• The confirmation that the data has been captured for PQRI analysis is the Remittance Advice Remark Code message N365, “This procedure code is not payable. It is for reporting/information purposes only.”

• Quality-data codes on rejected claims will not be processed by CMS, but they will be if the claim is resubmitted with both the quality-data code and the CPT code for the service.

HARP Reports

HARP reports that can help you keep track of how many quality-data codes have been submitted are:

• Transaction Date Summary. This report can be customized to show the number of charges, tickets, and/or patients with the quality-data CPT codes for a selected period of time.

• Transaction Report Writer. The TRW can show the ticket numbers of all tickets with the relevant quality-data CPT codes (and any modifiers) for a selected period of time.