In 2008 Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) authorized E-Prescribing as a new and separate incentive program for eligible professionals and was implemented in January 1, 2009.  Thus, E-Prescribing was separated from the quality reporting incentive program known as the Physician Quality Reporting System.

From 2009 through 2011 there have been incentives for qualified or eligible professionals who are e-prescribing and appropriately reporting their e-prescribing activity with the G-Codes added to the claims.

The year 2012 is the beginning of a graduated disincentive, or payment adjustment, for eligible providers who are not e-prescribing. As most providers are already aware, Centers for Medicare and Medicaid Services (CMS) has a fiscal year of October 1 through September 30. Therefore, the year 2012 for CMS actually begins October 1, 2011. 

 The first six months of 2011 will be the determining time frame for the 2012 decrease, as recorded from a CMS update released November 18, 2010:

“For purposes of determining which eligible professionals or group practices are subject to the payment adjustment in 2012, CMS will analyze claims data from January 1, 2011 -  June 30, 2011, to determine if the eligible professional has submitted at least 10 electronic prescriptions during the first six months of calendar year 2011.  Group practices reporting as a GPRO I or GPRO II in 2011 must report all of their required electronic prescribing events in the first six months of 2011 to avoid the payment adjustment in 2012.” 

In the most recent release from CMS dated April 14, 2011, the payment adjustment, which will be effective October 1, 2011, is an eligible professional or group practice receiving 99 percent of their Medicare Part B Physician Fee Schedule (PFS) amount that would otherwise apply to such services.  The adjustment progresses to 98.5 percent in 2013, and by 2014, the payment adjustment for not being a successful electronic prescriber is 2 percent, resulting in an eligible professional or group practice receiving 98 percent of their Medicare Part B PFS covered professional services.

Please remember there are exemption or hardship codes that should be included on a claim for eligible providers who are unable to e-prescribe to avoid payment adjustments.  These codes are G8642 and G8643 for rural areas and unavailable pharmacies to receive an e-prescription, respectively. See the code definitions below.

G8642: 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 under section 1848(a)(5)(A) of the Social Security Act

G8643: 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 under section 1848(a)(5)(A) of the Social Security Act

The hardship exception is subject to annual renewal. Also, G8644 may be used for a provider who may not have prescription privileges.

Unfortunately earning an incentive for 2011 does not necessarily exempt an eligible professional or group practice from the payment adjustment in 2012.  Remember the qualifying period to avoid the payment adjustment for 2012 is January 1, 2011, through June 30, 2011.

Providers that will be able to avoid the payment adjustment are those who: become a successful e-prescriber; appropriately use the G-codes (G8642-G8644) mentioned above; do not have at least 100 cases containing an encounter code in the measure denominator; or is not an eligible provider based on a primary taxonomy code in NPPES as of June 30, 2011, meaning if you become an eligible provider after June 30.

The encounter codes in the measures denominator are as follows; 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, 99315, 99316, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0101, G0108, G0109.

For group practices that are participating in GPRO I or GPRO II during 2011, the group practice must become a successful e-prescriber, which requires the group practice to report 75-2,500 unique eRx events for patients in the denominator of the measure (see encounter codes above), depending on the group’s size.

Providers who do not participate in Medicare or “Non-Participating” yet bill Medicare, and do not utilize e-prescribing, will still be subject to the payment adjustment.  The adjustment will be applied to the initial allowable amount in the Medicare Physician Fee Schedule.

So, eligible providers submitting the listed encounter codes, participating or non-participating, will be subject to the payment adjustments unless they are both successfully e-prescribing and appropriately reporting the e-prescribing activity.

For additional information, please visit the “Getting Started” webpage at http://www.cms.gov/erxincentive on the CMS website for more information; or download the Medicare’s Practical Guide to the Electronic Prescribing (eRx) Incentive Program under Educational Resources.

Becky Englehardt, CPC, CHC, is a healthcare manager and consultant for HORNE LLP. HORNE LLP is one of the top 50 accounting and business advisory firms in the country, as reported by the Public Accounting Report (PAR), and one of the top 10 accounting and business advisory firms in the Southeast. With offices in Mississippi, Tennessee, Alabama, Louisiana and Texas, the firm serves clients across the nation. For more information on HORNE, visit www.horne-llp.com.

Tags:

Bookmark:

Digg

Facebook

Technorati

Newsvine

Google

Related: