Medicare eRx Payment Adjustments Starting January 1, 2012

Medicare will begin making eRx payment adjustments starting January 1, 2012 for those professionals who did not meet the 2011 claim filing requirements.  This adjustment will amount to a 1% reduction in your 2012 Medicare allowable rates.  The adjustment amount will increase to 1.5% for 2013 and 2.0% for 2014 and each subsequent years for those eligible professionals who are not a successful e-Prescriber for the reporting period of that year.

An eligible professional can avoid the 2012 eRx Payment Adjustment where nothing further is needed to be done if he or she:

• Is not a physician (MD, DO, or podiatrist), Nurse Practitioner, or Physician Assistant as of June 30, 2011, based on primary taxonomy code in the National Plan and Provider Enumeration System (NPPES);
• Does not have prescribing privileges and reports G-code G8644 at least one time on an eligible claim prior to June 30, 2011;
• Does not meet the 10% denominator threshold (At least 10% of the Medicare allowable charges must originate/be comprised of codes from the CPT/G-codes in the measure’s denominator (see list below));
• Does not have at least 100 cases containing an encounter code in the measure’s denominator (see list below);
• Becomes a successful electronic prescriber (submits a required number of electronic prescriptions (10 for individual) via claims (reporting G8553) and reports this to CMS before June 30, 2011

An eligible professional can avoid the 2012 eRx Payment Adjustment; however, further action is required if he or she:

• Meets and reports a significant hardship exemption by November 1, 2011.
  • Hardship Qualifications – eligible professionals who meet any hardship requirement must submit a hardship request by November 1, 2011. One way to do so is via a new web-based tool, the Quality Reporting Communication Support Page, which will be available at http://www.qualitynet.org/pqrs:
    • Register to participate in the Medicare or Medicaid EHR Incentive Program and adopt Certified EHR Technology, please call 888-734-6433 if you have questions regarding registration for the EHR Incentive Program;
    • Inability to electronically prescribe due to local, state or federal law or regulation (e.g., controlled substances);
    • Limited prescribing activity (had fewer than 10 prescriptions between January 1, 2011 and June 30, 2011);
    • Insufficient opportunities to report the electronic prescribing measure due to limitations in the measure’s denominator (see list below) (did not have at least 10 prescriptions that were given with the measure’s denominator code);
    • The eligible professional practices in a rural area without sufficient high speed internet access and requests a hardship exemption from the application of the payment adjustment; or
    • The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing and requests a hardship exemption from the application of the payment adjustment.

Measure Denominator Codes:

90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90862, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99215, 99316, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0101, G0108, G0109

2011 E-Prescribing Incentive Program

It’s not too late to qualify for the 2011 eRx Incentive Program which will pay an additional 1% on all 2011 Medicare claims.  You must have a “qualified” system.  The “qualified” system can be either a system for eRx only (stand-alone) or an electronic health record (EHR system) with eRx functionality.  Regardless of the type of system used, to be considered “qualified” it must be based on ALL of the following capabilities:

• Generating a complete active medication list incorporating electronic data received from applicable pharmacies and pharmacy benefit managers (PBMs) is available
• Selecting medication, printing prescriptions, electronically transmitting prescription, and conducting all alerts
• Providing information related to lower cost, therapeutically appropriate alternative (if any). (The availability of an eRx system to receive tiered formulary information, if available, would meet this requirement for 2011.)
• Providing information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient’s drug plan, if available.

You can begin by reporting eRx data for January 1-December 31, 2011 (on at least 25 cases in 2011) using any of the following three options for purposes of qualifying for the 2011 incentive:

1. Claims-based reporting of the eRx measure. Reporting G8553 – at least one prescription was created while the encounter was generated and transmitted electronically using a qualified eRx system.  G8553 must be reported to ABI in order to go on the claim submitted to Medicare.
2. Registry-based reporting using a CMS-selected *registry to submit 2011 data to CMS during the first quarter of 2012.
3. EHR-based reporting using a CMS-selected *electronic health record product, submitting 2011 data to CMB during the first quarter of 2012.

* Only registries and EHR vendors who have been vetted by CMS for the 2011 Physician Quality Reporting System/eRx Incentive Program and are on the posted list of registries/EHR vendors are eligible to be considered “qualified” for purposed of reporting the 2011 eRx Incentive Program.  These registries/EHR vendors are qualified to report eRx information to CMS.  However, please note that their systems have not been checked for eRx functionality as defined in the specifications of the measure.  A list of EHR Vendors for the 2011 eRx Incentive Program is available in the “Downloads” section found at http://www.cms.gov/ErxIncentive/03_How_To_Get_Started.asp.

For additional information on the Payment Adjustments or the Incentive Program, please visit the “How to Get Started” and “Payment Adjustment Information” sections at http://www.cms.gov/erxincentive on the CMS website or call the QualityNet Help Desk at 1-866-288-8912, 7:00 AM – 7:00 PM CT, Monday through Friday.  As always, please feel free to contact Stephanie Kurtz in our office at (316) 281-3710.

abinsights Contact Information

abinsights readers are invited to submit comments, questions, tips, and suggestions for articles on any subject related to billing, collections, coding, reimbursement, and compliance.  Send to:  Anesthesia Billing, Inc.,     P O Box 388, Newton, KS  67114-0388.  Phone 316-281-3700.  Fax 316-282-4322.

Our purpose is to help you meet inevitable challenges.  We hope to deliver practical knowledge and solutions drawn from top resources and business publications in every issue, knowledge you can use today.

Reasonable attempts have been made to be accurate.  However, medical billing, collections, coding and compliance are part science, part art, and even experts sometimes differ.  Neither Anesthesia Billing, Inc., the editors, publisher, contributors, or consultants warrant or guarantee the information contained will be applicable or appropriate in all situations.  For information specific to your practice, consult a qualified professional.

The information included in this publication is provided, among other things, to alert you to legal developments and should not be considered legal advice.  Specific questions about how this information affects your particular situation should be addressed to your attorney.

Editor:  Philip Blann (pblann@anesthesiabilling.com).