PQRI News and Alerts

PQRI participants must use their NPIs correctly for their quality-data submissions to count toward successful reporting.

In recent NPI related communications, CMS indicated that since October 15, 2007, Medicare is sending informational warnings that indicate there was no NPI shown in the primary provider fields on your claim(s). Medicare is including these informational warnings on your pre-pass reject reports provided to you directly or to your bulletin board.

Medicare informational warnings called “Provider Identification Code Qualifier Invalid Value” messages will be labeled M389, M390, M391, and/or M392, but, again, these are only reminders. If you receive one of these messages, your claim did not include an NPI as required for PQRI reporting. If you are certain that your claim was submitted with an NPI, you may want to contact your clearinghouse or billing agent to ascertain the reason behind the message. It is possible that the clearinghouse or billing agent removed the NPI prior to submitting the claim to Medicare. You may also want to call your carrier/MAC to ask about the message and how you can correct future claims.

The AOA is receiving reports that optometrists are receiving denials with the reporting of the new quality measure/CPT II codes with the remark on the Explanation of Benefits (EOB) forms that indicate:

CO or PR-185, the rendering provider is not eligible to perform the service billed.

While the CPT II codes will denied for payment, the above remark code is inappropriate for the six quality measure codes reported by optometrists and may prevent the reporting of these quality codes for analysis for the PQRI bonus incentive payment. The appropriate Remittance Advice Remark Code should be N365 (this procedure code is not payable; it is for informational/reporting purposes only) with claim adjustment reason Code CO-96 (non-covered service).

Because of AOA’s proactive outreach to CMS regarding this concern, CMS has contacted all of its Medicare Carriers to advise them of the error and to seek remedy for these claims. This fix requires an edit by the Medicare carriers. In order to correct claims that optometrists have received with this error, CMS is requesting that AOA submit to CMS the ICN#’s that appear on the Explanation of Benefits (EOBs) for claims that included one or more of the new CPT-II codes for the quality measures that references the incorrect remittance remark code.

RESOLUTION: Currently, the only mechanism for resolving this error is to submit the EOBs to CMS who will instruct the carrier to re-open the claim to correct the error. Optometrists may not re-submit these claims for the purpose of correcting the reporting of the quality measure codes.

Any optometrist receiving a CO/PR-185 remark on their EOBs for the submission of the new eye care quality measures/CPT-II codes should fax a copy of their EOB, with patient name and SSN removed for HIPAA purposes, to Jodi Mitchell at 703-739-9497. Should you have any questions, please contact Jodi at 703-837-1348 or jcmitchell@aoa.org.

It has come to the attention of Centers for Medicare & Medicaid Services (CMS) that some Clearinghouses are stripping the National Provider Identifier (NPI) prior to submission of the claim to Medicare. This will adversely affect Eligible Professionals in that these claims will not count toward PQRI participation. CMS urges Eligible Professionals that use clearinghouses to check with their clearinghouse to assure NPIs are not being stripped from claims. If the Eligible Professional determines that their clearinghouse is stripping NPIs from the claim, the Eligible Professional may want to consider other billing options.

A recent Special Edition MLN Matters article contains important information for Medicare providers and suppliers, including how to use the NPI correctly on Part A and Part B claims.