2013 PQRS and/or eRx Incentive Program: Stripped N365 Remark Code
MLN Connects Provider e-News | Thursday, June 27, 2013
For those eligible professionals participating in the 2013 Physician Quality Reporting System (PQRS) and/or Electronic Prescribing (eRx) Incentive Program via claims, CMS is aware the Remittance Advice (RA)/Explanation of Benefits (EOBs) may not be displaying the N365 remark code for program quality-data codes (QDCs) for claims processed April 2013 through July 2013. The N365 remark code will reappear again starting for claims that are processed in July 2013. QDCs submitted on Medicare Part B Physician Fee Schedule (PFS) claims with $0.00 line items have been (and will be) processed into the National Claims History (NCH) file even though the RA/EOB did not indicate the N365 remark code, given the claim was in final-action status and not pended, rejected, etc.
What should I do if I don’t see the N365 Remark Code?
The N365 remark code on the RA/EOB is an indication that the QDC is associated with current program year PQRS and/or eRx Incentive Program specifications, but does not confirm whether the QDC was accurately reported per program requirements. If the QDC $0.00 line item shows on the RA, but without the N365, it is possible the QDC is not within current program year specifications. It is also possible that the N365 is simply missing due to reporting using the $0.00 line item. All submitted QDCs on fully processed claims are forwarded to the NCH for analysis by the PQRS and/or eRx programs, so providers will first want to be sure they do see the QDC line item on the RA/EOB, regardless of whether the N365 appears. If there is no QDC line item, it is possible that the provider’s claims software has stripped any $0.00 line items, and this will need to be corrected, either within the software, or by adding a $0.01 charge rather than $0.00.
Adding the $0.01 charge to the QDC line item will help generate the N365 remark code, which will indicate whether the QDC is current. Providers may work with their vendors/billing systems/clearing houses to determine whether the option to submit a $0.00 or $0.01 charge for QDC line items will work best for their practice.
Tips for Reporting
CMS would like to remind providers that no PQRS/eRx Incentive Program reporting validation or analysis occurs at the Carrier or A/B Medicare Administrative Contractor (MAC) claims level, beyond forwarding QDCs to the NCH. So it is imperative that providers make sure they are coding claims with the current program year measure specifications, either for individual measures or measures groups. They will want to verify that the patient they are reporting on falls within the measure’s denominator for age/gender, as well as diagnosis and service/encounter when applicable. Then be sure to follow the specifications showing the available numerator QDC reporting options, and report the one(s) that best describes the quality action performed.
Again, CMS is aware that RA/EOBs may not display the N365 remark codes for $0.00 QDC line items and is actively working with Carrier/Medicare Administrative Contractors (MACs) to resolve this issue. The N365 remark code will reappear again with claims that are processed after July 2013.
The entire 12-page e-News can be read on the CMS website at http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-06-27Enews.pdf