****01/07/17 Update**** If you are looking at this article, Medicare will be replacing these rules soon. Please see my articles and webinars on the new Medicare called MACRA***
As most of you know, I try and give you the benefit of my experience. And sometimes, that experience comes with a very painful lesson that I am trying to help you avoid. Such as this one.
We have several doctors who have not been using the Medicare PQRS codes. For those of you who haven’t heard of these before, that stands for the Medicare Physician Quality Reporting Services, and “PQRS is a quality reporting program that uses negative payment adjustments to promote reporting of quality information by individual EPs and group practices.” That quote is from the 2015 PQRS Implementation Guide. This is a very long document that will explain what the program is, why Medicare is doing it, and most importantly, what happens when doctors don’t use these new codes.
If your provider has not been using the PQRS codes, Medicare will be garnishing providers checks 1.5% this year and 2.0% for all subsequent years. However, the garnishment taken in 2015 is a result of 2013 PQRS reporting, and the garnishment that will be taken in 2016 is a result of your 2014 reporting. So, if, for the last two years, your provider has not used these codes, her Medicare checks will be subject to a “negative payment.”
Each type of provider has different PQRS codes that they are eligible and responsible to report. The codes are usually five digits total with four numbers first and then a letter, or they have the letter “G” first, with four numbers following. Please review the 2015 PQRS Individual Measure Spec Manual and the 2015 PQRS Individual Measure Spec Manual to find which codes apply to your physicians and what documentation needs to be included in the office notes to justify the service.
So here is what a charge that includes the PQRS codes would look like:
DX CPT Charge
715.09 724.5 244.9 99213 $100.00
715.09 724.5 244.9 G8427 (medications reviewed) $0.01
715.09 724.5 244.9 1036F (non-smoker) $0.01
Total Claim Charge: $100.02
When you send those codes on your claims, they aren’t going to get paid. Medicare wants us to send them in with a charge of $0.01. These charges are for informational purposes only and you will end up writing them all off. Again, Medicare is NOT going to pay for them. They are required codes they will penalize you for NOT using, but they will not pay a single penny extra for these line items. Literally, not one penny. If you are not using these, please start ASAP to prevent negative payments in future years. If you are, tell everyone you know.
As always, if you need any additional help or clarification, or if you have some information I don’t, please email firstname.lastname@example.org or call me at (909) 374-5439.