Medicare Update => Spring 2007

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Medicare Update => Spring 2007

Alfred H. moffett, Jr., MD
Medicare Representative

Two Tips for Reimbursement

For this issue, there are two items I'd like to bring to your attention-NPI/PIN and PQRI. The first insures you obtain reimbursement, and the second can help you maximize it.

NPI/PIN: Form CMS-1500 (08/05) is the basic form prescribed by the US Government's Centers for Medicare and Medicaid Services (CMS) for filing physician and supplier Medicare claims. However, some claims are being returned due to NPI/PIN being submitted incorrectly. Before submitting claims on the new Form CMS-1500, be aware it contains "split" fields (fields 17A and b, 24j, and 33a and b) for National Provider Identifier (NPI ) and Provider Identification Numbers (PIN). Many providers using the new 08/05 version of Form CMS-1500 have not changed their print layout, resulting in the PIN and/or NPI numbers printing in an incorrect position on the form. Medicare must return these claims as unprocessable.

Check to ensure the PIN and NPI numbers are printing in the correct blocks on the new form. If not printing correctly, contact your software vendor and have them update your software. Do not use Form CMS-1500 (08/05) until your software is corrected. A recommended solution is to submit your claims electronically.

NPI (National Provider Identifier): Please note that not only do you need and individual NPI number, but your group also needs to obtain a group NPI, as per Medicare.

PQRI (Physician Quality Reporting Initiative): On December 20, 2006 the President signed the Tax Relief and Health Care Act of 2006 (TRHCA). Section 101 under Title I authorizes the establishment of a physician quality reporting system by CMS. CMS has titled the statutory program the Physician Quality Reporting Initiative (PQRI).

PQRI establishes a financial incentive for eligible professionals to participate in a voluntary quality reporting program. 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.

Note that this initiative applies to the traditonal Medicare fee-for-service program only and is not applicable to the Medicare Advantage Plans, including the private fee-for-service plan.

Under PQRI, convered professional services are those based on the Medicare Physician Fee Schedule. To the extent eligible professionals are providing services which get paid under the Medicare Physician Fee Schedule, those services are eligible for PQRI.

The 2007 PQRI mesaures list and the descriptions of those meaures are available in the downloads section at www.cms.hhs.gov/PQRI/15_MeasuresCodes.asp. TRHCA section 101 specifies that, for 2007, CMS must use the taxpayer identification number (TIN) as the billing unit, so any bonus incentive payments earned will be paid to the holder of the TIN.