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Volume 7, Issue 1 February 2012

Important Deadlines Looming

Register & Attest for the 2011 EHR Incentive Payment by 2/29/2012

The reporting period for physicians participating in the Electronic Health Record (EHR) incentive program in 2011 ended on December 31, 2011. However, physicians who met the reporting requirements in 2011 have until February 29, 2012 to register and apply (through attestation) for 2011 incentive payments.

Registration details, resources and links are available on the Centers for Medicare and Medicaid Services (CMS) EHR website.

Eligible Professionals (EPs) are reminded to have the following information available during the registration process:

  • National Provider Identifier (NPI)
  • National Plan and Provider Enumerations System (NPPES) User ID and Password

If you are reassigning your benefits, you will also need the following:

  • Payee Tax Identification Number
  • Payee National Provider Identifier (NPI)

As of April 2011, EPs may designate a third party to register and attest on his or her behalf. The designated third party must have an Identity and Access Management System (I&A) web user account and been assigned a user ID and password, and be associated with the EP’s NPI.

EPs eligible for both the Medicare and Medicaid EHR Incentive Programs must choose one incentive program to participate in when they register. However, certain hospitals qualify for participation in both the Medicare and Medicaid EHR programs and are eligible for incentive payments in both programs. Details and qualifications for dually eligible hospitals are found on the CMS EHR website.

Included on the CMS EHR website is a very helpful 26-page Registration User Guide that provides step-by-step directions, tips and screen shots of the registration process.

Medicare EPs, who have successfully registered for the Medicare EHR Incentive Program and met the meaningful use criteria using certified EHR technology in 2011, will need to successfully attest by February 29, 2012 in order to receive an incentive payment for calendar year 2011.

EPs will access the EHR Registration and Attestation System to register and attest in the EHR Incentive Program.

To log in to the Attestation System, EPs will use the same user ID and password they used to register for the program. During the attestation process, EPs will be required to provide a CMS EHR Certification ID identifying the certified EHR technology being used to demonstrate meaningful use.

CMS outlines the following steps to obtaining a CMS EHR Certification ID:

  • Go to the ONC CHPL website: healthit.hhs.gov/chpl.
  • Select your practice type by selecting the Ambulatory or Inpatient buttons.
  • Search for EHR Products by browsing all products, searching by product name or criteria met.
  • Add product(s) to your cart to determine if your product(s) meet 100% of the CMS required criteria.
  • Request a CMS EHR Certification ID for CMS attestation.

CMS notes that the “Get CMS EHR Certification ID” button will not be activated until the products in your cart meet 100% of the CMS required criteria to demonstrate meaningful use.

CMS has created an Attestation User Guide designed to walk the EP through the online attestation process. Similar to the EHR Registration User Guide, the Attestation User Guide provides step-by-step directions complete with screen shots and tips.

EPs who are unsure whether they would meet all of the necessary measures to successfully demonstrate meaningful use may opt to use the Meaningful Use Attestation Calculator prior to beginning the attestation process. This calculator is an online tool through which eligible providers and eligible hospitals may determine whether or not they would successfully demonstrate meaningful use.

Incentive Payments
Incentive Payments
EHR incentive payments, subject to an annual limit, are based on 75% of the EPs Medicare allowed charges for covered professional services furnished by the EP during the entire calendar year and submitted no later than two months after the end of the calendar year.

For calendar year 2011, successful EPs may receive up to $18,000 based on claims for services performed by the EP from January 1, 2011-December 31, 2011, and submitted to Medicare no later than February 29, 2012.

EPs may qualify for and receive EHR incentive payments for up to five years, depending upon the year the EP first becomes a meaningful user. EPs who become successful meaningful users in 2011 or 2012 may qualify for the full five years of incentive payments and receive up to $44,000.

Incentive payments for the EHR program will be made approximately 4 to 8 weeks after the EP successfully attests that they have demonstrated meaningful use of certified EHR technology. However, to receive the maximum incentive payment of $18,000 for the first year of participation in 2011 or 2012, the EP must accumulate $24,000 in allowed Medicare charges. If the EP has not met the $24,000 threshold in allowed charges by the time of attestation, CMS will hold the incentive payment until the threshold is met in order to maximize the amount of the incentive payment.

The maximum incentive for the first year of
EHR participation in 2011 or 2012 is $18,000

The incentive payment is based on
75% of the estimated Medicare allowed charges

Therefore, the EP would earn the maximum incentive
when the accumulated allowed charges equal $24,000:

$24,000 x 75% = $18,000

EPs who predominately furnish more than 50% of services in an area designated as a geographic health professional shortage area (HPSA) may qualify for an additional 10% incentive payment.

EHR incentive payments to Medicare EPs will be made to the taxpayer identification number (TIN) reported at the time of registration in the EHR Incentive Program. The form of payment, electronic funds transfer or check, will be the same as the claims payments made to the TIN.

Bonus payments for HPSA qualifying EPs will be made as a lump-sum payment no later than 120 days after the end of the calendar year for which the EP was eligible for the bonus payment.

The EHR incentive payments are made by the Payment File Development Contractor (PFDC), not your A/B Medicare Administrative Contractor (MAC). Therefore, any questions related to the EHR incentive payment should be directed to the EHR Information Center at 1-888-734-6433.

Audits & Appeals in the EHR Incentive Program


The EHR Incentive Programs’ systems contain numerous prepayment edit checks that detect inaccuracies in eligibility and reporting and payment. In addition to these psrepayment edit checks, CMS, and its contractors, will be conducting post payment audits on Medicare providers and providers treating dually-eligible (Medicare and Medicaid) beneficiaries. States and their contractors will audit Medicaid providers.

A recent Office of Inspector General (OIG) survey of thirteen States with approved Medicaid EHR Incentive Program plans revealed that all thirteen States plan to review and verify at least half of the eligibility requirements prior to issuing EHR incentive payments.

CMS provides the following tips for preparing for an EHR Audit:

  • Save all supporting electronic or paper documentation that support your attestation. Also, save the documentation to support your clinical Quality Measures (CQMs). Hospitals should also maintain documentation to support their payment calculations.
    • Documentation to support the attestation should be retained for six years post-attestation.
    • Documentation to support payment calculations (such as cost report data) should continue to follow the current documentation retention processes.
  • Upon audit, the documentation will be used to validate that the provider accurately attested and submitted CQMs, as well as to verify that the incentive payment was correct.

Finally, there is still relatively little information on the EHR Incentive Program audits so it is very important that you keep informed about updates to the audit process as well as the outcome of any EHR Incentive Program audits.

As of December 1, 2011, Physicians Resource Inc. (PRI), the appeals support contractor, is accepting appeals in the EHR Incentive Program for EPs and eligible hospitals. In addition, on January 24, 2012, the CMS Office of Clinical Standards and Quality (OCSQ) published guidance as a step-by-step explanation on the EHR Incentive Program appeals process.

According to the OCSQ, the EHR appeals process is a two-level process that includes an informal review and a request for reconsideration. There are three types of appeals available in the EHR Incentive Program:

  • Eligibility Appeal – allows providers to show that all the EHR Incentive Program requirements were met and that he or she should have received a payment but could not because of circumstances outside of the provider’s control.
  • Meaningful Use Appeal – allows a provider to show that he or she used certified EHR technology and met the meaningful use objectives and associated measures after a successful attestation.
  • Incentive Payment Appeal – allows a provider to show that he or she provided claims data for inclusion that was not used in determining the amount of the incentive payment.

To file an appeal prior to March 1, 2012, providers must contact the OCSQ Appeals Support Center at 855-796-1515 between 7:30 a.m. – 6:30 p.m. Central Time, Monday-Friday. For questions, contact the OCSQ Appeals Support Center by email at OCSQAppeals@provider-resources.com.

Beginning March 1, 2012 EPs participating in the EHR Incentive Program may file an appeal online through the Administrative Appeals Portal.

Additional information and the guidance document, Administrative Review of Certain Electronic Health Record Incentive Program Determinations, are available on the CMS OCSQ website.


  • Eligibility Appeals: Must be filed no later than 30 days following the close of the attestation period. *
  • Meaningful Use Appeals: Must be filed no later than 30 days from the date of the demand letter or other finding that could result in the recoupment of an EHR incentive payment.
  • Incentive Payment Appeals: Must be filed no later than 60 days from the date the incentive payment was issued or 60 days from any Federal determination that the incentive payment amount was incorrect (including determinations that the payment was duplicative).

*EPs have until March 30, 2012 to file an eligibility appeal for payment year 2011.



The Medicare Electronic Prescribing Incentive Program (eRx), which began in 2009, provides incentives for eligible providers (EPs) who are successful electronic prescribers, and payment adjustments (penalties) for EPs who are not successful eRx prescribers.

EPs who are successful e-prescribers in 2011 will receive a 1% incentive payment for all Medicare Part B physician fee schedule (PFS) services rendered in 2012; while EPs who are subject to the eRx payment penalty in 2012 will receive a 1% payment penalty for all PFS services rendered in 2012. The eRx payment penalty increases to 1.5% in 2013 and 2% in 2014.

Perversely, it is possible for EPs to have both earned the 2011 incentive payment, resulting in a 1% incentive payment in 2012, and to have qualified for the 2012 payment penalty, resulting in a 1% payment penalty for the same services in 2012. Furthermore, EPs may qualify for both a payment incentive and payment penalty in 2013 so it is very important that you understand the Medicare requirements for the eRx incentive payments and the eRx payment penalties (payment adjustments).

As detailed in the December 2011 Best Practices Review newsletter, CMS has added a second reporting period to avoid the 2013 eRx payment adjustment. Therefore, EPs that are subject to the eRx payment adjustment can avoid the 2013 payment adjustment by:

  • Being a successful electronic prescriber in 2011; or
  • By filing for and being granted a hardship exemption; or
  • By reporting the eRx Quality Data Code (QDC) G8553 by the claims reporting method for at least 10 Medicare Part B PFS encounters for dates of service January 1, 2012-June 30, 2012. The eRx G-code can be reported on any Medicare Part B claim that includes a billable Part B service, regardless of whether the claim contains coding in the eRx measure’s denominator.

Consequently, if you are an eligible EP who does not qualify for a hardship exemption and who was not a successful eRx prescriber in 2011, you must electronically prescribe and successfully report the eRx QDC G8553 via the claims reporting mechanism for 10 unique patient encounters between January 1, 2012 and June 30, 2012.

Hardship Exemptions For 2013 eRx Payment Penalty
CMS may exempt eligible professionals from the application of the eRx payment penalty if CMS determines that compliance with the requirement for being a successful e-prescriber would result in a significant hardship. To avoid the 2013 eRx penalty, EPs may apply for one of the following penalty exemptions:

  • Inability to electronically prescribe due to state, or federal law, or local law or regulation
  • The eligible professional prescribes fewer than 100 prescriptions during a 6-month payment adjustment reporting period
  • The eligible professional practices in a rural area without sufficient high-speed internet access (report G-code G8642 )
  • The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing (report G-code G8643)

CMS established the Quality Reporting Communication Support Page at www.qualitynet.org/pqrs for EPs to submit hardship requests, including those that are associated with a G-code (as shown above).

Providers may also submit a hardship G-code at least once on a claim during the 6-month (January 1 – June 30, 2012) 2013 eRx payment adjustment reporting period, when applicable. CMS reminds providers that when submitting the hardship G-code on a claim:

  • The hardship G-code must be submitted on a claim with a billable Medicare Part B service.
  • The hardship G-code does not need to be submitted on a claim that contains eRx measure denominator codes.

For a very thorough explanation on avoiding the 2013 and 2014 eRx payment penalties, access the document: 2012 eRx Incentive Program: Future Payment Adjustments on the CMS eRx website www.cms.gov/ERxIncentive under the “Educational Resources” link.


Eligible providers, who were not successful e-Prescribers in 2011:

Report the ePrescribing G-code, G8553, at least 10 times during the January 1, 2012 through June 30, 2012* reporting period on the Medicare Part B claim forms along with any Medicare Part B Physician Fee Schedule (PFS) service. **

*Claims for dates of service between January 1 – June 30, 2012 must be received & processed by CMS no later than one month after the reporting period.

**Please note that while the eRx code G8533 may be reported with any PFS service to avoid the 2013 eRx penalty, reporting G8553 with denominator-eligible events is still required to earn an incentive payment for 2012.


Eligible providers can avoid the 2014 eRx penalty in two ways:

  • Report the e-prescribing G-code (G8553) 25 times in 2012 for encounters associated with at least 1 of the denominator codes (the same criteria as the 2012 eRx incentive), or
  • Report the e-prescribing G-code (G8553) 10 times in the first six months of 2013 (January 1-June 30, 2013) on Part B claims.



CMS is urging providers to review their 2012 remittance advice for services rendered in 2012 to make certain that they are not receiving the 1% (eRx) payment penalty in error. CMS asks that providers notify them immediately if the payment adjustment is being taken in error so that they may reprocess the claims.

Additionally, CMS has reported that due to the volume of hardship exemptions requested they were unable to process all of the exemptions requests before January 1, 2012. This has resulted in some claims being processed initially with the 1% payment reduction applied. CMS also states that some physicians whose exemption request has been honored may still see a 1% payment reduction initially, but that they will reprocess these claims as soon as they can.

The 2012 eRx payment adjustment will be indicated with an “LE” on the remittance advice along with the Claim Adjustment Reason Codes:

  • CARC 237 – Legislated/Regulatory Penalty
  • RARC N545 – Payment reduced based on status as an unsuccessful e-prescriber per eRx incentive program.

CMS states that if an EP receives the payment adjustment in error (e.g. , the eligible professional or group practice submitted a hardship exemption request that is ultimately approved by CMS), the claim will be reprocessed to return the 1.0% and the remittance advice for the reprocessed claim will include the following codes and messages:

  • CARC 237 – Legislated/Regulatory Penalty.
  • RARC N546 – Payment represents a previous reduction based on the Electronic Prescribing (eRx) Incentive Program.

EPs who meet all of the following criteria were included in the 2012 eRx payment adjustment analysis:

  • Was 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);
  • Had prescribing privileges from 1/1/11-6/30/11;
  • Had at least 100 cases containing an encounter code in the measure’s denominator from 1/1/11-6/30/11; AND
  • 10% or more of their Medicare Part B allowable charges (per Tax Identification Number (TIN)) from 1/1/11-6/30/11 were for encounter codes in the measure’s denominator

An EP who meets the inclusion criteria listed above will be subject to the 2012 eRx payment adjustment if they did not submit the following:

  • 10 valid 2011 eRx G-codes (G8553) via claims during the 6-month reporting period of January 1, 2011 – June 30, 2011; or
  • A hardship exemption (G8642, G8643) via claims during the 6-month reporting period; or
  • A G-code via claims indicating (s)he did not have prescribing privileges (G8644) during the 6-month reporting period; or
  • (S) he requested and was granted a hardship exemption through the Quality Reporting Communication Support Page.

CMS directs providers to contact the Help Desk Support at 1-866-288-8912 or by email at Qnetsupport@sdps.org for all inquiries regarding the eRx Incentive Program payment adjustment, including if an eligible professional believes a payment adjustment was erroneously applied

The AMA is in your Corner

The AMA is in Your Corner

The American Medical Association (AMA) has been in communication with CMS and working to help ensure that physicians who applied for an exemption to avoid the 2012 eRx payment penalty are notified as soon as possible on whether their exemption request has been accepted. The AMA also assists physicians who have been unsuccessful in resolving their Medicare e-prescribing concerns by making available an online e-prescribing incentive complaint form that the provider can fill out and email directly to CMS or fax to the AMA who will forward it on to CMS.
Are you new to Medicare’s eRx program? View the AMA’s document, Understanding the basics of Medicare’s Electronic Prescribing Program on the AMA website at www.ama-assn.org.


Published by Rise Marie Cleland. Sponsored by Lilly Oncology



Do you treat Medicaid patients? Read this…
Beneficiaries who qualify for coverage by both Medicare Part A and/or Part B and Medicaid are often referred to as “dual eligibles.” Medicare is always the primary payer for dual eligibles for Medicare covered services. Medicare covered services are first billed to and paid for by Medicare after which Medicaid may be billed. Providers must accept Medicaid’s payment as payment in full.

In the past, most state Medicaid programs paid the Medicare deductibles and coinsurance for dual eligibles at the full Medicare rate. However, the Balanced Budget Act of 1997 permits States to limit the payment to the amount that the Medicaid program would otherwise pay for the service. In response, by 2008, 17 states had limited their cost-sharing obligations for these dual eligibles to the payment level they adopted in their state plan.

Now, with the increasing enrollment in state Medicaid programs and the economic pressure on states to lower their costs, we are seeing an increase in the movement by states to lower their cost-sharing obligations for dual eligibles by limiting payment for their Medicare deductibles and coinsurance to no more than the Medicaid payment amount for the same service. Therefore, if the Medicare payment amount equals or exceeds the Medicaid payment rate, the state Medicaid program would not pay the Medicare deductible and coinsurance on a crossover claim. Moreover, providers must accept Medicaid’s payment as payment in full, even if the Medicaid rate is lower than that already received from Medicare, resulting in nonpayment from Medicaid. In such a case, the result is reimbursement equal to that of a Medicare only patient.

What to monitor…
Watch for any bulletins or alerts from your state Medicaid program announcing proposed changes to the reimbursement rate for dual eligibles. Be aware that states may achieve further cost savings by lowering Medicaid rates to equal or less than Medicare’s payment amount (80% of the Medicare allowable), which would mean that Medicaid would not pick up the 20% Medicare coinsurance for the dual eligibles and you would be obligated to write it off. Monitor your Medicaid reimbursement rate and identify those drugs and services for which the Medicaid allowable is equal to or less than the Medicare payment amount (not the Medicare allowable).

Remember, you may not balance bill the dual eligible Qualified Medicare Beneficiary (QMB), even when the amounts you receive from Medicare and Medicaid are less than the Medicare rate. Providers are also prohibited from accepting QMB patients as "private pay" in order to bill the patient directly.

The Texas Health and Human Services Commission (HHSC) has announced that effective January 1, 2012, HHSC will limit payment for dual eligibles to the lesser of the Medicare deductible and coinsurance or the amount remaining after the Medicare payment amount is subtracted from the Medicaid payment rate. Currently, the only exception to the new policy is for renal dialysis services which will see a 5% decrease in cost-sharing payments.

According to Texas state health officials, the change is expected to save $475 million in state funding over two years.

The Texas Medical Association (TMA) has been very vocal in their opposition of the Texas legislation limiting the reimbursement for dual eligibles and they continue their efforts to preserve access to “the states most vulnerable citizens. ” Initial analysis shows a significant number of drugs will be “underwater” when reimbursement is limited to no greater than the Texas Medicaid payment rate.

The TMA provides the following examples of the new Texas HHSC policy (allowable amounts are for illustration only as Medicare payments vary by region of the state):

Example 1: Established dual-eligible patient has not met any of the Medicare deductible and is seen during a routine office visit. Physician bills Medicare CPT code 99213. Maximum Medicare allowable is $66.90 (rest of Texas). Medicare pays $0 because deductible has not been met. Medicaid will pay $33.27, the Medicaid allowable for this code.

Example 2: Established dual-eligible patient has met $100 of $140 Medicare 2012 deductible. Patient is seen in office for routine office visit. Physician bills Medicare CPT code 99213. Medicare pays $21.52, which is 80 percent of the allowable after deductible. ($66.90-$40). Medicaid will pay $11.75 ($33.27-$21.52).

Example 3: Established dual-eligible patient visits physician office for routine visit, Medicare deductible has been met. Physician bills Medicare CPT code 99213. Medicare allowable is $66.90. Medicare pays $53.52, 80 percent of the allowable. Physician bills Medicaid for the remaining 20 percent. Medicaid allowable is $33.27, so no coinsurance will be paid.

Physicians who provide services to Medicare patients in areas designated by the Health Resources and Services Administration (HRSA) as primary care geographic health professional shortage areas (HPSAs) are eligible for a 10% bonus payment for services furnished from January 1, 2012-December 31, 2012.

HPSA designations and eligibility are determined annually. Each year, CMS publishes a list of ZIP codes that automatically receive the HPSA bonus. However, only areas where the entire ZIP code falls within the designated HPSA at the time the list is developed are listed. Physicians furnishing services in an area that is a designated HPSA, but not included in the list for the automatic bonus, must use the AQ modifier Physician Providing a Service in a Health Professional Shortage Area (HPSA) to receive the bonus.

More information on the HPSA bonus payment and the list of ZIP codes eligible for automatic bonus payment is available on the CMS website.

CMS outlines the following key points of the HPSA bonus payment:

  • The HPSA bonus is based on the amount Medicare actually paid (not the Medicare approved payment amount for each service) and the 10% bonus will be paid on a quarterly basis.
  • The HPSA bonus pertains only to physician's professional services. Should a service be billed that has both a professional and technical component, only the professional component will receive the bonus payment.
  • The key to eligibility is not that the beneficiary lives in a HPSA nor that the physician's office or primary location is in a HPSA, but rather that the services are actually rendered in a HPSA.
  • To be considered for the bonus payment, the name, address, and ZIP code of the location where the service was rendered must be included on all electronic and paper claim submissions.
  • Physicians should verify the eligibility of their area for a bonus before submitting services with a HPSA modifier for areas they think may still require the submission of a modifier to receive the bonus payment.
  • Services submitted with the AQ modifier will be subject to validation by Medicare.


2010 Newsletter Archives

Volume 6, Issues 4 & 5
Volume 6, Issue 3
Volume 6, Issue 2
Volume 6, Issue 1
Volume 5, Issue 6
Volume 5, Issue 5
Volume 5, Issue 4
Volume 5, Issue 3
Volume 5, Issue 2
Volume 5, Issue 1


Risë Marie Cleland

Oplinc, Inc.
113 W. 7th Street
Suite 205
Vancouver, WA 98660
360.695.1608 office
360.326.1733 fax


Comments and suggestions for future issues are welcome, please forward correspondence to Risë Marie Cleland by email at: Rise@Oplinc.com


Access all of our
previous newsletters.


Risë Marie Cleland is the Founder and CEO of Oplinc, Inc. , a national organization of oncology professionals. Through Oplinc, Inc. , Ms. Cleland publishes the weekly Oplinc Fast Facts focusing on the timely dissemination of information pertaining to billing, reimbursement and practice management in the oncology office and Oplinc’s Best Practices Review, which provides a more in-depth look at the issues and challenges facing oncology practices. Ms. Cleland also works as a consultant and advisor for physician practices, pharmaceutical companies and distributors.


Please note that this newsletter is presented for informational purposes only. It is not intended to provide coding, billing or legal advice. Regulations and policies concerning Medicare reimbursement are a rapidly changing area of the law. While we have made every effort to be current as of the issue date, the information may not be as current or comprehensive when you review it. Please consult with your legal counsel for any specific reimbursement information. For Medicare regulations visit: www.cms.gov.

CPT® is a Trademark of the American Medical Association Current Procedural Terminology (CPT) is copyright 2012 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein.

Copyright ©2012
Oplinc, Inc.
Oplinc, Inc. , grants permission to distribute this newsletter without prior permission provided it is forwarded unedited and in its entirety.

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