Coding and Reporting Principles for Claims-based Reporting

50.1.1 – Coding and Reporting Principles for Claims-based Reporting (Rev. 82, Issued: 03-22-19, Effective: 04-22-19, Implementation: 04-22-19) The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes. 11 The following principles apply to the reporting of QDCs for Physician Quality Reporting System measures: • The CPT Category II code(s) and/or G-code(s), which supply the numerator, must be reported: o on the same claim(s) as the denominator billing code(s) for the same date of service (DOS) o for the same beneficiary o for the same date of service (DOS) o by the same eligible professional (individual NPI) who performed the covered service as the payment codes, usually ICD diagnosis , CPT Category I or HCPCS codes, which supply the denominator. • All diagnoses reported on the claim will be included in Physician Quality Reporting System analysis, as some Physician Quality Reporting System measures require reporting more than one diagnosis on a claim. For line items containing a QDC, only a single reference number in the diagnosis pointer field will pass into the NCH file. To report a QDC for a measure that requires reporting of multiple diagnoses, enter the reference number in the diagnosis pointer field that corresponds to one of the measure’s diagnoses listed on the base claim. Regardless of the reference number in the diagnosis pointer field, both primary and all secondary diagnoses (base claim diagnoses) are considered in Physician Quality Reporting System analysis. • Up to twelve diagnoses can be reported in the header on the Form CMS-1500 paper claim and up to eight diagnoses can be reported in the header on the electronic claim. However, only one diagnosis can be linked to each line item, whether billing on paper or electronically. The Physician Quality Reporting System analyzes claims data using ALL diagnoses from the base claim (the ASC X12 837 professional claim format or Item 21 of the Form CMS-1500) and service codes for each individual professional identified by his or her rendering individual NPI. In other words, base claim diagnoses apply to all rendering TIN/NPIs on the claim. Eligible professionals should review ALL diagnosis and encounter codes listed on the claim to make sure they are capturing ALL reported measures applicable to that patient’s care. • If the eligible clinician’s billing software limits the number of line items available on a claim, an eligible clinician may add a nominal amount such as a penny, to one of the line items on that second claim for a total charge of one penny. CMS will look across all claims data for common occurrences of A/B MAC (B) claim control numbers, Medicare beneficiary identifiers, and A/B MAC (B) numbers. Only final action claims will be analyzed for Physician Quality Reporting System. For Physician Quality Reporting System measure calculation purposes, claims will be combined based on the same beneficiary for the same date-of-service, for the same TIN/NPI and 12 analyzed as one claim. Providers should work with their billing software vendor/clearinghouse regarding line limitations for claims to ensure that diagnoses or QDCs are not dropped. • QDCs must be submitted with a line-item charge of zero dollars ($0.00) at the time the associated covered professional service is performed. o The submitted charge field cannot be blank. o The line item charge should be $0.00. o If an eligible professional’s billing software does not allow a $0.00 line-item charge, a nominal amount can be substituted such as 1 penny ($0.01) – the beneficiary is not liable for this nominal amount. o Entire claims with a zero charge will be rejected. (Total charge for the claim cannot be $0.00.) o Whether a $0.00 charge or a nominal amount is submitted to the A/B MAC (B), the Physician Quality Reporting System QDC code line is denied and tracked. • QDC line items will be denied for payment, but are then passed through the claims processing system for Physician Quality Reporting System analysis. Eligible professionals will receive a Remittance Advice (RA) associated with the claim which will contain the Physician Quality Reporting System quality-data code line-item and will include a standard remark code (N365) and a message that confirms that the QDCs passed into the NCH file. N365 reads: “This procedure code is not payable. It is for reporting/information purposes only.” The N365 remark code does NOT indicate whether the QDC is accurate for that claim or for the measure the eligible professional is attempting to report. o Keep track of all Physician Quality Reporting System cases reported so that the eligible professionals can verify QDCs reported against the remittance advice notice sent by the A/B MAC (B). Each QDC line-item will be listed with the N365 denial remark code. • Multiple eligible professionals’ QDCs can be reported on the same claim using their individual NPI. Therefore, when a group is billing, the group should follow its normal billing practice of placing the NPI of the individual eligible professional who rendered the service on each line item on the claim including the QDC line(s). • Some measures require the submission of more than one QDC in order to properly report the measure. Eligible professionals may report each QDC as a separate line item, referencing one diagnosis and including the rendering provider NPI. 13 • Use of CPT II modifiers (1P, 2P, 3P, 8P) is unique to CPT II codes and may not be used with other types of CPT codes. Only CPT II modifiers may be appended to CPT II codes. Do not append CPT I modifiers to CPT II codes or vice versa. • Solo practitioners should follow their normal billing practice of placing their individual NPI in the billing provider field, (on the ASC X12 837 professional claim format or item 33b on the Form CMS-1500). • Eligible professionals may submit multiple codes for more than one measure on a single claim. • Multiple CPT Category II and/or G-codes for multiple measures that are applicable to a patient visit can be reported on the same claim, as long as the corresponding denominator codes are also line items on that claim. • If a denied claim is subsequently corrected through the appeals process to the A/B MAC (B), with accurate codes that also correspond to the measure’s denominator, then QDCs that correspond to the numerator should also be included on the resubmitted claim as instructed in the measure specifications. • Claims may NOT be resubmitted for the sole purpose of adding or correcting QDCs. • Eligible Professionals should use the 8P reporting modifier judiciously for applicable measures they have selected to report. The 8P modifier may not be used indiscriminately in an attempt to meet satisfactory reporting criteria without regard toward meeting the practice’s quality improvement goals. Submission through A/B MACs (B) QDCs shall be submitted to A/B MACs (B) either through: Electronic submission, which is accomplished using the current version of the ASC X12 837 professional claim format. CPT Category II and/or temporary G-codes should be submitted in the SV101-2 “Product/Service ID” Data Element on the SV1 “Professional Service” Segment of the 2400 “Service Line” Loop. • It is also necessary to identify in this segment that a HCPCS code (HC) is being supplied by submitting the HC in data element SV101-1 within the SV1 “Professional Service” Segment. • Diagnosis codes are submitted at the claim level, Loop 2300, in data element HI01, and if there are multiple diagnosis codes, in HI02 through HI12 as needed with a single reference number in the diagnosis pointer. 14 • In general for group billing, report the NPI for the rendering provider in Loop 2310B (Rendering Provider Name, claim level) or 2420A (Rendering Provider Name, line level), using data elements NM109 (NM108=XX). OR Paper-based submission, which is accomplished by using the Form CMS-1500 claim (version 02-12). Relevant diagnosis codes are entered in Field 21. Service codes (including CPT, HCPCS, CPT Category II and/or G-codes) with any associated modifiers are entered in Field 24D with a single reference letter in the diagnosis pointer Field 24E that corresponds with the diagnosis letter in Field 21. • For group billing, the National Provider Identifier (NPI) of the rendering provider is entered in Field 24J. • The Tax Identification Number (TIN) of the employer is entered in Field 25. Group NPI Submission When a group bills, the group’s NPI is submitted at the claim level, therefore, the individual rendering physician’s NPI must be placed on each line item, including all allowed charges and quality-data line items. Individual NPI Submission The individual NPI of the solo practitioner must be included on the claim line as is the normal billing process for submitting Medicare claims. For the Physician Quality Reporting System, the QDC must be included on the same claim that is submitted for payment at the time the claim is initially submitted in order to be included in Physician Quality Reporting System analysis. Form CMS-1500 Claim Example An example of a claim in CMS-1500 format that illustrates how to report several Physician Quality Reporting System measures is available in the Physician Quality Reporting System Implementation Guide, a downloadable document that is updated for each program year and posted on the CMS Physician Quality Reporting System website http://www.cms.hhs.gov/PQRS. Satisfactorily Reporting Measures Physician Quality Reporting System participants should also refer to the “How to Get Started” section of the Physician Quality Reporting System website, available at http://www.cms.gov/PQRS. This section provides helpful information on how to get started with reporting quality measures for the Physician Quality Reporting System. Timeliness of Quality Data Submission Claims processed by the A/B MAC (B) must reach the National Claims History (NCH) file by no later than 2 months after the end of the reporting period to be included in the analysis. For the 2010 Physician Quality Reporting System, for example, claims processed by the A/B MAC (B) must reach the NCH file by no later than February 28, 2011 to be included in the analysis. Claims for services furnished toward the end of the reporting period should be filed promptly. 15 Claims that are resubmitted only to add QDCs will not be included in the analysis for Physician Quality Reporting System.