PQRI Eligibility - Error in EOB Remark and Adjustment Codes

Background:

The Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting Initiative (PQRI) establishes a financial incentive for optometrists and other health care providers who participate in a voluntary quality reporting program. The reporting period began on July 1, 2007 and will continue until December 31, 2007. More background information on the PQRI is available at www.aoa.org/PQRI.xml.

Problem or issue to be addressed:

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.

Action required:

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.

720 Light Street, Baltimore, MD 21230 TEL: (410) 727-7800• FAX: (410) 752-8295 EMAIL: MOA@assnhqtrs.com