CMS/Medicare: HCPCS, NPI, & PQRI

The following information is provided by CMS/Medicare.

HCPCS
The Centers for Medicare & Medicaid Services has reposted the recent scheduled release of modifications to the Healthcare Common Procedure Coding System (HCPCS) code set to incorporate new changes. The revised update has been posted to the HCPCS website at http://www.cms.hhs.gov/HCPCSReleaseCodeSets/02_HCPCS_Quarterly_Update.asp.

NPI

Effective March 1, 2008, all 837P and CMS-1500 claims must have an NPI or NPI/legacy pair in the required primary provider fields. Failure to include an NPI will cause the claim to reject!

Background
One of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) required the Department of Health and Human Services (HHS) to establish unique national identifiers for providers. The purpose of these provisions is to improve the efficiency and effectiveness of the electronic transmission of health information. On March 1, 2008, Medicare claims submitted by physicians and other practitioners, laboratories, ambulance company suppliers, DMEPOS suppliers and others that bill Medicare are required to include the new National Provider Identifier (NPI).

Providers must use this information when they submit their claims to Medicare carriers, A/B Medicare Administrative Carriers (MACs), and DME MACs when they use certain electronic and paper Medicare claims (specifically the X12N 837P electronic claim and the CMS-1500 paper claims).

Hospitals, skilled nursing facilities, home health care agencies and other such institutional providers were required to begin using their NPI beginning on January 1, 2008

The deadlines for submitting Medicare claims using the NPI are necessary to help the Centers for Medicare & Medicaid Services (CMS), the Medicare contractors and health care providers prepare for the final May 23, 2008 deadline for full NPI compliance. While the final NPI Rule required compliance on May 23, 2007,CMS stated in the NPI National Contingency Guidance that it will not take enforcement action against covered entities that deploy contingency plans through May 23, 2008, provided that conditions in the Guidance were met.

CMS is anticipating that some providers will experience some problems with claims submitted after March 1 – problems could arise in the following situations:
The provider does not have an NPI
The provider does not submit their NPI on their claim
The provider has already received an NPI, but the NPI is not consistent with the provider’s enrollment information received by the contractor.

Providers whose claims are rejected and returned to them should immediately contact their contractor before resubmitting that claim or submitting new claims for services provided to Medicare beneficiaries. Contact information for the Medicare contractors can be found at www.cms.hhs.gov/MLNGenInfo/ under “Downloads.” The file is named, “Provider Call Center Toll-Free Numbers Directory.”

Current Status
Physicians, non-physician practitioners, labs, ambulance company suppliers, DME suppliers, and others who traditionally bill carriers and DME MACs (2/22/08)

91.3% of Medicare carrier claims and 88.5% of DME MAC claims are being submitted with an NPI or NPI/legacy pair in the primary provider identifier fields (these numbers are consistent with institutional provider NPI use before the January 1 change).

For claims submitted with an NPI, the current reject rate for carrier and DME MAC claims ranges from 1-12%, depending on the carrier. CMS has received very few complaints from providers.

Institutional Providers (January 1, 2008, deadline)

In mid-January, the NPI submission rate jumped to 99% - compared to 90% in December.

Currently, the submission rate is over 99.9%. Less than 0.1% of claims are being rejected for not having an NPI in the appropriate fields.

The March 1, 2008, Deadline--Expectations for March 1
A small portion of claims will continue to be submitted without an NPI. These claims will be rejected. Providers have had over two years to acquire and test their NPI.

Some rejections may occur because a contractor has not completed processing a provider’s enrollment application, submitted by the provider to fix inconsistencies between a provider’s NPI and Medicare’s provider enrollment files.

Medicare Risk Mitigation
CMS and the Medicare contractors are taking aggressive steps to ensure that providers will be paid for treating Medicare beneficiaries after March 1.

Medicare contractors are enhancing their toll-free phone lines by expanding the number of people available to answer calls. Throughout the month of February, CMS has intensified its planning efforts to assist contractors to prepare for the March 1 implementation date. In February 2008, CMS held a training session with contractor call centers and CMS regional office staff to ensure they are able to address provider inquiries on NPI issues.

Daily calls with the carriers, A/B MACs, and DME MACS are scheduled to monitor the status of successful and rejected claims, inquiries, enrollment backlog status, and other relevant information.

Each contractor has created a NPI Coordination Team to quickly identify and resolve claims processing issues related to the submission of the NPI or NPI-Legacy combination, expedite the processing of enrollment applications, and address other issues that may arise.

CMS has implemented temporary measures to allow the Medicare contractors time to address some of the backlog issues, but at some contractors, more work is needed.

Current Claims Process as of March 1
Currently, most Medicare providers (and their claims clearinghouse vendors) are submitting claims that include their new NPI. For those providers who don’t have an NPI, they are submitting claims using their legacy provider numbers. When the claim is submitted, Medicare’s computer systems will check to confirm that the claim includes an NPI. If there is no NPI, the claim will be rejected and the provider will receive an error message pointing to the lack of an NPI. If the provider has an NPI, the provider should make sure that the number is on the claim and resubmit the claim. If at that point the claim is again rejected, the provider should immediately contact the Medicare contractor to ensure that all provider records are correct before resubmitting the claim.

Contact information for the Medicare contractors can be found at www.cms.hhs.gov/MLNGenInfo/ under “Downloads.” The file is named, “Provider Call Center Toll-Free Numbers Directory.”

Medicare contractors expect to be able to handle all incoming calls, but some callers may experience extended hold times. CMS is urging providers to be patient – their issues will be addressed.

The Future – May 23, 2008
With May 23, 2008 less than three months away, CMS and the Medicare health care providers must make sure they are ready for full NPI implementation. Providers must be certain their NPI information and Medicare enrollment information is accurate and up-to-date before that date. Further, if providers’ claims are being successfully processed with NPI/legacy pairs (and most are) now is the time for them to begin testing claims using only the NPI. Providers should start with small volumes of these NPI-only claims and gradually increase their submissions. Doing this testing now will allow time for any needed corrections prior to the May 23, 2008, deadline when claims must include the NPI only.

What to do if your 837P and CMS-1500 Claims are Rejected
• Check your record in the National Plan and Provider Enumeration System (NPPES)
Validate that the legacy identifier sent on the claim is reported in the provider/supplier’s NPI Registry record. If the legacy identifier is not there, instruct the provider/supplier to add it.
Validate that the Legal Business Name (if the provider/supplier is an organization) or the Legal Name (if the provider/supplier is an individual or a sole proprietorship) is correct.
Validate that the correct Entity type was selected by the provider/supplier when applying for the NPI. Individuals obtain an NPI as Entity Type 1. Organizations obtain an NPI as Entity Type 2 NPI.
(Note: If you enumerated through the EFI alternative, you should use the NPI Registry to check the content of the NPPES file. Make sure to have the Customer Service Representative at your Medicare contractor verify your TIN/EIN as the NPI Registry does not list this information.)

• If these claims are still rejecting, call your Medicare Contractor
Have a copy of the NPPES record in hand. A copy of the NPPES record can be obtained online at https://nppes.cms.hhs.gov . The Employer Identification Number or Social Security Number will not be shown on this print out.
Have the claim reject number and message
Be prepared to give the following information:
Legal Business Name of the Organization
Contractor Tracking Number (if known)
Approximate date (month/year) when the 855 enrollment application was submitted
Provider/Supplier Tax Identification Number or Social Security Number (SSN)
National Provider Identifier (NPI)
Medicare legacy Identifier
Practice location on claim (i.e. where is the practice located (e.g. 100 Main St. New Orleans, LA)
Contact Information where Provider/Supplier can be reached if further discussion is needed

TEST NPI-only NOW
If you have been submitting claims with both an NPI and a Medicare legacy number and those claims have been paid, you need to test your ability to get paid using only your NPI by submitting one or two claims today with just the NPI (i.e., no Medicare legacy number). If the Medicare NPI Crosswalk cannot match your NPI to your Medicare legacy number, the claim with an NPI-only will reject. You can and should do this test now! If the claim is processed and you are paid, continue to increase the volume of claims sent with only your NPI. If the claims rejects, go into your NPPES record and validate that the information you are sending on the claim is the same information in NPPES. If it is different, make the updates in NPPES and resend a small batch of claims 3-4 days later. If your claims are still rejecting, you may need to update your Medicare enrollment information to correct this problem. Call your Medicare carrier, FI, or A/B MAC enrollment staff or the National Supplier Clearinghouse for advice right away. Have a copy of your NPPES record available. The enrollment telephone numbers are likely to be quite busy, so don't wait.

Transcript from February 6th Roundtable now Available
The transcript from the February 6th NPI Roundtable on the FFS Medicare Implementation is now available at http://www.cms.hhs.gov/NationalProvIdentStand/06_implementation.asp on the CMS NPI web page.

Need More Information?
Still not sure what an NPI is and how you can get it, share it and use it? As always, more information and education on the NPI can be found through the CMS NPI page www.cms.hhs.gov/NationalProvIdentStand on the CMS website. Providers can apply for an NPI online athttps://nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at 1-800-465-3203. Having trouble viewing any of the URLs in this message? If so, try to cut and paste any URL in this message into your web browser to view the intended information.

Note: All current and past CMS NPI communications are available by clicking "CMSCommunications" in the left column of the www.cms.hhs.gov/NationalProvIdentStand CMSwebpage.

PQRI
The Centers for Medicare & Medicaid Services (CMS) is now accepting quality measure suggestions for consideration for possible inclusion in the proposed set of quality measures to be published in the 2009 Medicare Physician Fee Schedule (MPFS) Proposed Rule for the Physician Quality Reporting Initiative (PQRI). For details, visit http://www.cms.hhs.gov/pqri and select the Measures/Codes tab on the left side of the page. Next, scroll down to the Downloads section and select “Notice of 2009 Measure Suggestions.”

Updates to the 2008 PQRI Tool Kit
The PQRI Tool Kit has been updated to include a downloadable file containing Data Collection Worksheets for all 119 2008 PQRI quality measures. To access this file, please go to http://www.cms.hhs.gov/PQRI, and select the PQRI Tool Kit tab on the left side of the page. Then, scroll down to the Downloads section and select “2008 PQRI Data Collection Worksheets”.

NEW Frequently Asked Questions (FAQs)
CMS updates the FAQs for PQRI on an ongoing basis, as inquiry volumes and new program developments indicate the need for new or updated FAQs. The following new FAQs may be of particular interest at this time, as they focus on the process for validating whether a professional participating in the 2008 PQRI is reporting on a sufficient number of measures.

#8973 -- Question: Is there a Measure Applicability Validation (MAV) process for 2008 Physician Quality Reporting Initiative (PQRI)?
#8973 -- Answer: Yes. The PQRI 2008 Measure Applicability Validation Process for Claims-Based Participation is described in a document available for download from the Analysis and Payment page of the PQRI section of the CMS website (at url:http://www.cms.hhs.gov/PQRI/25_AnalysisAndPayment.asp).

#8974 -- Question: How does the two-step validation process work for the Physician Quality Reporting Initiative (PQRI)?
#8974 -- Answer: Professionals who report successfully on each of fewer than three measures are subject to the 2008 PQRI Measure Applicability Validation (MAV) process for claims-based participation. Professionals who report on three or more measures are not subject to MAV. (The 2008 PQRI Measure Finder Tool is available to assist you in finding measures that may apply to your practice, and is available for download from the PQRI Toolkit page of the CMS website at: http://www.cms.hhs.gov/PQRI/Downloads/2008PQRIMeasureFinderTool.zip )

Step 1 of MAV relates measures to one another by placing them in closely related clusters. This test is based on the concept that if one measure in a cluster of measures related to a particular clinical topic or professional service is applicable to a professional’s practice, then other closely related measures (measures in that same cluster) may also be applicable. The 2008 PQRI MAV clusters and the measures included in each are described in the document titled "2008 Measure-Applicability Validation Process for Claims-Based Participation", which is available for download from the Analysis and Payment page of the PQRI section of the CMS web site. CMS has not included in any clusters certain measures that are not suited for MAV clustering in the 2008 PQRI, for reasons described in the MAV process document.

Step 2 of MAV looks to see if an eligible professional treated more than a minimum number (threshold) of eligible cases that met the requirements of other measures within the cluster. For 2008 claims-based participation in PQRI, measure-specific thresholds may be determined based on analysis of data that will become available during the reporting period. In no case, however, will any measure’s 2008 PQRI applicability threshold be less than 30 reportable instances. The cases to which a measure applies are identified by the line-item diagnosis and service codes billed for each rendering NPI. Any complicating diagnoses on the Part B base claim are not considered in 2008 PQRI analyses for claims-based participation. Cases that count toward the applicability threshold for any individual NPI will also not include those for which the qualifying diagnosis and procedure codes are identified by another rendering professional’s individual NPI. Eligible professionals who pass Step 2 of 2008 PQRI MAV will be eligible for the PQRI incentive payment.