Applying the PDS to your business needs

Home

PDS

Last Modified: 8/22/2010 Location: FL, PR, USVI Business: Part B

Applying the PDS to your business needs

This document is designed to help familiarize you with the Provider Data Summary (PDS) report. When looking at the PDS report, it is important to remember that data included represents claims finalized during the applicable months. Pending claims data is not included. For best results, please have your PDS report ready when going over this material. By applying what you learn by reviewing your personalized PDS report, you create an opportunity for a more satisfying and efficient Medicare billing process.

Introduction to PDS elements

At the upper left hand corner of the PDS report, you will see your entity name and address. In addition, you will see your NPI, Provider Specialty, and the Reporting Period that you are viewing.

YOUR PROVIDER NAME HERE
123 WEST 1ST STREET
JACKSONVILLE, FL 32202-0000
NPI Number: 1234567890
Provider Specialty: 11 Internal Medicine
Reporting Period: JUL10 and JUN10 By Paid Date

Let’s focus on the first of three tables in your report. If you are viewing the current month and previous month data together, your columns at the top will look similar to this:

JUL10	% of Total (A)	JUN10	% of Total (B)	Change JUL10 – JUN10	% Change (B-A)	JUL10 PEER AVG	% of Total (C)	Diff (+/-)	% Diff (A-C)

These columns represent volumes for the applicable months and the percentages of changes between the two. In addition, certain rows enable you to compare your statistics to those of your peers. Your peers are all individuals in your area (Florida, Puerto Rico, or U.S. Virgin Islands) that belong to the same facility type as you. Based on the data, you may not have peer data available for every category.

Now, let’s focus on the rows of the first table:

Claim Totals provides the total of allowed amount, paid amount, claims paid and the average amount paid on paid claims in the applicable months.

Claim Volumes provides volumes and percentages of the claims paid, denied, duplicate, subtotal (processed) and unprocessable in the applicable months.

Claim Billed Dollars provides dollar amounts and percentage of the claims paid, denied, duplicate, subtotal (processed) and unprocessable in the applicable months.

% of Services Received provides volumes and percentages of processed and unprocessable services within the applicable months.

% of Services Processed provides volumes and percentages of denied and duplicate services within the applicable months.

Now, let’s take a quick look at the columns on the second table. The ‘Category’ column will reflect information related to denied, top duplicate and unprocessable claims encountered in July. The message code, description, and volumes are then provided. The columns will look similar to this:

Message Code	Top Explain MsgCodes	Volume

Now let’s go over our first table on our PDS report.

Claim Totals

By reviewing our PDS report, we can see that our total allowed and total paid amounts increased from June to July. When we look in the next section at our total claims paid volume, we’ll see that we also had an increase in that category and that could be a contributing factor to our increase in dollar amounts. In addition, it appears that our average amount paid per claim is $4,994 lower than that of our internal medicine peers.

		JUL10	JUN10	Change JUL10 – JUN10	JUL10 PEER AVG	Diff (+/-)

Claim Totals	Total Allowed $	1,391	1,082	309	6,385	-4,994
	Total Paid $	960	650	310	4,847	-3,887
	Total Claims Paid	22	21	1	83	-61
	Avg. Paid/Paid Claim	27	17	10	0	27

Claim volumes

It is good to see that we have decreased our unprocessable claims from June to July. We can look at our second table within the PDS report to identify the top unprocessable, duplicate, and denied codes to get a better idea of what we might need to focus on in the future. We can also see that we experienced a decrease in paid claims from June to July, but that could also be due to submitting fewer claims.

		JUL10	% of Total (A)	JUN10	% of Total (B)	Change JUL10 – JUN10	% Change (B-A)	JUL10 PEER AVG	% of Total (C)	Diff (+/-)	% Diff (A-C)

Claim Volumes	Paid	25	33.8%	26	30.2%	-1	(3.60%)	134	79.8%	-109	(46.0%)
	Denied	10	13.5%	13	15.1%	-3	1.60%	13	7.70%	-3	5.80%
	Duplicate	1	1.40%	0	0.00%	1	(1.40%)	5	3.00%	-4	(1.60%)
	Subtotal (Processed)	36	48.6%	39	45.3%	-3	(3.30%)	152	90.5%	-116	(41.9%)
	Unprocessable	38	51.4%	47	54.7%	-9	3.30%	16	9.50%	22	41.9%
	Total	74	100%	86	100%	-12	0.00%	168	100%	-94	0.00%

Claim billed dollars

In July, $2,526 worth of claims was processed. As we did not have any duplicate claims processed in June, this billed amount is $0.

		JUL10	% of Total (A)	JUN10	% of Total (B)	Change JUL10 – JUN10	% Change (B-A)	JUL10 PEER AVG	% of Total (C)	Diff (+/-)	% Diff (A-C)

Claim Billed Dollars (Services)	Paid	1,590	31.3%	1,230	30.0%	360	(1.30%)	8,259	79.2%	-6,669	(47.9%)
	Denied	858	16.9%	625	15.3%	233	(1.60%)	935	9.00%	-77	7.90%
	Duplicate	78	1.50%	0	0.00%	78	(1.50%)	359	3.40%	-281	(1.90%)
	Subtotal (Processed)	2,526	49.7%	1,855	45.3%	671	(4.40%)	9,553	91.6%	-7,027	(41.9%)
	Unprocessable	2,555	50.3%	2,243	54.7%	312	4.40%	873	8.40%	1,682	41.9%
	Total	5,081	100%	4,098	100%	983	0.00%	10,426	100%	-5,345	0.00%

% of services received and % of services processed

This section shows us that we had just over 3% higher processed claims than our internal medicine peers for the month of June. We also experienced a lower percentage of unprocessable claims than our peers during this same month. It looks like we received a few more denied claims than our peers in June. It might be helpful to review our top denials in the second table to determine what we may need to focus on in the future.

		JUL10	JUN10	Change JUL10 – JUN10	JUL10 PEER AVG

% of Services Received	Processed	48.6%	45.3%	3.30%	90.5%
	Unprocessable	51.4%	54.7%	(3.30%)	9.50%
% of Services Processed	Denied	27.8%	33.3%	(5.50%)	8.60%
	Duplicate	2.80%	0.00%	2.80%	3.30%
	Number of Patients	59	67	-8

Now we’ll go ahead and review the second table on the PDS report. It appears that our biggest denial experienced in July was due to the duplicate claim/service. It might be a good idea to research the IVR and research claims that has processed so claims will not be refilled. While we’re looking at our Medicare Remittance Notice, we might also want to look for our top unprocessable code, CO 16 to gather more information to address any issues we may have.

Message Code	Top Explain MsgCodes	Volume
CO 97	Payment adjusted because this procedure/service in not paid separately	7
CO 22	Payment adjusted because this care may be covered by another payer per coordination of benefits	6
CO 11	The diagnosis is inconsistent with the procedure.	4
CO 26	Expenses incurred prior to coverage	3
CO B9	Services are not covered because the patient is enrolled in a hospice	1
CO 18	Duplicate claim/service. HBDRMSGT DATE 07/08/2005	21
CO 16	Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advi	9
CO 31	Claim denied as patient cannot be identified as our insured	3

Sample PDS Report

Below is the sample PDS report we just reviewed in its entirety. We hope this brief introduction helped you to familiarize yourself with the data within the PDS report to assist you in reaching your own personal Medicare billing goals in your office. When utilized alongside other Medicare resources, such as the provider website and your Medicare Remittance Notices, you have an increased potential to create a more satisfying and efficient Medicare billing experience.

YOUR PROVIDER NAME HERE
123 WEST 1ST STREET
JACKSONVILLE, FL 32202-0000
NPI Number: 1234567890
Provider Specialty: 11 Internal Medicine
Reporting Period: JUL10 and JUN10 By Paid Date

		JUL10	% of total (A)	JUN10	% of total (B)	Change JUL10-JUN10	% Change (B - A)	JUL10 PEER AVG	% of total (C)	Diff(+/-)	%Diff(A - C)
Claim Totals	Total Allowed $	1,391		1,082		309		6,385		-4,994	.
	Total Paid $	960		650		310		4,847		-3,887	.
	Total Claims Paid	22		21		1		83		-61	.
	Avg. Paid/Paid Claim	27		17		10		0		27	.
Claim Volumes (Services)	Paid	25	33.8%	26	30.2%	-1	(3.60%)	134	79.8%	-109	(46.0%)
	Denied	10	13.5%	13	15.1%	-3	1.60%	13	7.70%	-3	5.80%
	Duplicate	1	1.40%	0	0.00%	1	(1.40%)	5	3.00%	-4	(1.60%)
	Subtotal (Processed)	36	48.6%	39	45.3%	-3	(3.30%)	152	90.5%	-116	(41.9%)
	Unprocessable	38	51.4%	47	54.7%	-9	3.30%	16	9.50%	22	41.9%
	Total	74	100%	86	100%	-12	0.00%	168	100%	-94	0.00%
Claim Billed Dollars (Services)	Paid	1,590	31.3%	1,230	30.0%	360	(1.30%)	8,259	79.2%	-6,669	(47.9%)
	Denied	858	16.9%	625	15.3%	233	(1.60%)	935	9.00%	-77	7.90%
	Duplicate	78	1.50%	0	0.00%	78	(1.50%)	359	3.40%	-281	(1.90%)
	Subtotal (Processed)	2,526	49.7%	1,855	45.3%	671	(4.40%)	9,553	91.6%	-7,027	(41.9%)
	Unprocessable	2,555	50.3%	2,243	54.7%	312	4.40%	873	8.40%	1,682	41.9%
	Total	5,081	100%	4,098	100%	983	0.00%	10,426	100%	-5,345	0.00%
% of Services Received	Processed	48.6%		45.3%		3.30%		90.5%
	Unprocessable	51.4%		54.7%		(3.30%)		9.50%
% of Services Processed	Denied	27.8%		33.3%		(5.50%)		8.60%
	Duplicate	2.80%		0.00%		2.80%		3.30%
	Number of Patients	59		67		-8

Message Code	Top Explain MsgCodes	Volume
CO 49	These are non-covered services because this is a routine exam or screening procedure done in conjunction with a	1
CO 22	Payment adjusted because this care may be covered by another payer per coordination of benefits.	1
CO 16	Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice	36
CO 31	Claim denied as patient cannot be identified as our insured.	1