In this issue, we look at two key components of Medicare’s transition from the current fee-for-service reimbursement to a Value-Based Purchasing methodology of reimbursement, the Medicare eRx and EHR Incentive Programs.
What You Need to Know about Medicare’s eRx Program
Electronic prescribing is the transmission of prescription or prescription related information through electronic media. Electronic prescribing takes place between a prescriber, dispenser, pharmacy benefit manager (PBM), or health plan. It can take place directly or through an intermediary such as an electronic prescribing network.
While electronic prescribing can save time and enhance practice and pharmacy productivity and efficiency, the main goal of electronic prescribing is to improve patient safety and quality of care. In fact, eRx is a key component of Medicare’s transition from the current fee-for-service reimbursement to a value-based purchasing (VBP) methodology of reimbursement. Furthermore, electronic prescribing represents nearly half of the actions necessary to meet Medicare’s meaningful use requirements under the Electronic Health Record (EHR) incentive program.
With the goals of increased patient safety and the transition to VBP in mind, Medicare’s Electronic Prescribing (eRx) Incentive Program was authorized under section 132 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) to promote adoption and use of eRx systems. The eRx incentive program, which began on January 1, 2009, provides an incentive payment for eligible professionals who are successful electronic prescribers as defined by MIPPA. The eRx program is separate from Medicare’s EHR and Physician Quality Reporting System (PQRS) program. Each year CMS implements the eRx program through the annual rulemaking process published in the Federal Register.
Qualified eRx Systems
Qualified eRx systems may be either:
Qualified eRx systems have all of the following capabilities:
You can find the list of 2011 Qualified EHR Vendors for the eRx Incentive Program on the CMS eRx Webpage by clicking on the link “How to Get Started” and scrolling to the bottom of the page.
eRx Incentives & Penalties
In 2011, EPs who are successful electronic prescribers can earn an incentive payment of 1% of their total allowed charges for professional services covered by the Medicare Part B Physician Fee Schedule (MPFS) and furnished during the reporting period. This is a reduction from the 2% incentive successful e-prescribers earned in 2009 and 2010.
In 2011, the eRx incentive is limited to EPs whose estimated allowed charges for the e-prescribing denominator codes (payable CPT codes) listed below, represent at least 10% of their total MPFS allowed charges for the reporting period.
Denominator codes for eRx:
Additionally, in accordance with Section 132 of the MIPPA, EPs who are not successful e-prescribers may be subject to a penalty beginning January 1, 2012. In 2012, the penalty adjustment for not being a successful electronic prescriber is 1% and this penalty adjustment increases to 1.5% in 2013 and 2% in 2014 see Figure 1 below. The eRx payment adjustment is applied to the allowed amount the provider would have otherwise received for their covered Part B services paid under the MPFS.
The criteria for the application of the eRx penalty in 2012 & 2013 is the subject of much criticism in the medical community as CMS is basing the 2012 penalty on e-prescribing activity that occurs during January 1, 2011 – June 30, 2011, and the 2013 penalty on e-prescribing activity occurring throughout 2011.
Although CMS has indicated they may consider revisiting the criteria for the 2013 eRx penalty in future rulemaking, there has been no indication to date that they are willing to reconsider the criteria for the 2012 penalty.
What Does This Mean to You?
Moreover, unless CMS changes the 2013 eRx penalty criteria in future rulemaking, EPs must report at least 25 times throughout the reporting period of January 1, 2011 – December 31, 2011 to avoid the 1.5% penalty in 2013.
Exceptions to the 2012 eRx Penalty
The 2012 eRx penalty will not apply to:
In addition to the exceptions listed above, there are also two significant hardship exemptions. An eligible professional may request an exemption to the eRx Incentive Program and the 2012 payment adjustment, by reporting one of two hardship codes at least one time on a denominator-eligible claim during the 2012 payment adjustment reporting period (January 1 through June 30, 2011) if one of the following situations apply:
3 Methods for Successful eRx Reporting in 2011
The 2011 eRx reporting period is the entire calendar year, January 1-December 31, 2011. There is no registration necessary and EPs may begin reporting the eRx measure at any time throughout the reporting period to be eligible for the incentive.
In 2011, eRx data can be reported through:
Only those registries and EHRs qualified by CMS to report the 2011 PQRS are eligible to become qualified for purposes of submitting data on the eRx measure on behalf of eligible professionals. A list of CMS 2011 qualified registries and EHRs, is available on the Alternative Reporting Mechanisms page on the CMS Physician Quality Reporting site at www.cms.gov/pqrs.
To be a successful electronic prescriber and be eligible to receive the 1% eRx incentive payment, EPs must report G8553 the eRx measure (numerator) code, attesting that during the patient visit at least one prescription was electronically prescribed through a qualified eRx system, along with the qualifying visit (denominator) code on at least 25 unique encounters.
EPs who successfully report the eRx measure and associated denominator code at least 25 times during 2011, through claims or a qualified EHR or registry, may earn the incentive payment in 2012. However, if less than 10 of the qualifying events were reported through the claims process within the first six months of 2011, the EP will also be subject to the 1% payment penalty in 2012.
Claims Based eRx Reporting Tips
In a letter dated December 9, 2010, the American Medical Association (AMA), the American Society of Clinical Oncology (ASCO), and 102 state and specialty medical societies urged the Department of Health and Human Services to intervene and revise the current CMS policy for imposing eRx penalties in 2012 and 2013. As discussed in detail in this newsletter, to avoid penalties in 2012, CMS is requiring eligible providers to report the eRx G-Code, G8553, via claims, at least ten times for applicable Medicare office visits and services during the January 1, 2011 through June 30, 2011 reporting period.
The letter recommends that at the very minimum, CMS extend the reporting period so that physicians can report the eRx code, G8553, at least ten times during the first ten, rather than six, months of 2011 to avoid the 2012 penalty. The letter also calls for CMS to add more exception categories so that more providers will be eligible for an exemption from eRx penalties in 2012 and suggests that physicians who attest to meaningful use in 2011 or 2012 should be exempt from eRx penalties.
The Electronic Health Record (EHR) Incentive Program was established by the Health Information Technology for Economic and Clinical Health (HITECH) Act of the American Recovery & Reinvestment Act (ARRA) of 2009. The stated goal of the EHR program is to transform the nation's health care system and improve the quality, safety and efficiency of patient health care through the use of electronic health records.
Along with eRx, the EHR Incentive Program is another step forward in Medicare’s transition from the current fee-for-service reimbursement to a value-based purchasing (VBP) methodology of reimbursement.
The EHR program is a rather complicated program and while this article will focus on its key elements readers who have yet to register and attest in this program are urged to devote the necessary time to review the program details on the CMS EHR Website. As mentioned earlier in this newsletter, EPs can wait until 2012 to participate in the EHR program and still qualify for the maximum allowed incentive payment.
The Medicare and Medicaid EHR Incentive Programs provide incentive payments to eligible professionals (EPs), eligible hospitals and critical access hospitals (CAHs) as they adopt, implement, upgrade or demonstrate “meaningful use” of certified EHR technology. Meaningful use in the EHR Incentive Program is defined as, “Using certified EHR technology to improve quality, safety, efficiency, and reduce health disparities.”
Under the Medicare EHR program, an EP is a doctor of medicine or osteopathy, a doctor of dental surgery or dental medicine, a doctor of podiatric medicine, a doctor of optometry, or a chiropractor, who is legally authorized to practice under state law. Moreover, a qualifying EP is one who successfully demonstrates meaningful use for the EHR reporting period.
Providers can only participate in one EHR incentive program. Therefore, providers who meet the eligibility requirements for both the Medicare and Medicaid EHR incentive programs will need to select which program they would like to participate in when they register. It is unlikely that many oncologists would meet the criteria for the Medicaid EHR incentive program as they must have a minimum 30% Medicaid patient volume or practice predominantly in a Federally Qualified Health Center or Rural Health Center and have a minimum 30% patient volume attributable to needy individuals. Therefore, this article will focus on the Medicare EHR program.
The program starts in 2011 and continues through 2016. Depending on the first year they participate, eligible professionals can participate for up to 5 years throughout the duration of the program. The last year to begin participation in the Medicare EHR Incentive Program is 2014.
Future EHR program rules and criteria are still being developed; sign up for the CMS EHR listserv to stay abreast of the latest EHR Incentive Program news.
EHR Incentive Payments & Penalties
The maximum incentive payments available in the Medicare EHR incentive program varies depending on the year the EP becomes eligible for the incentive. EPs who begin participation in either 2011 or 2012 are eligible to earn the maximum incentive payment of up to $44,000 over 5 years. The maximum payment that a physician can receive is limited to 75% of their professional part B allowable charges submitted to Medicare in the calendar year. Physicians who practice in a health-care provider shortage area receive an additional 10% of their qualifying amount. As illustrated below in Figure 2, you can enroll in 2011 or 2012 and still earn the maximum allowable incentive of up to $44,000.
Beginning in 2015, Medicare payment adjustments will begin for EPs and eligible hospitals that are not meaningful users of EHR technology.
Consequently, if you are still trying to determine which incentive programs to participate in this year and you do not have the resources to participate in all three programs, EHR, PQRS and eRx, it would be advisable to participate in the PQRS and the eRx programs this year, while they still provide an incentive payment and in order to avoid the eRx penalty in 2012, and begin the EHR program in 2012.
For the first year for which an EP applies for and receives an incentive payment (2011 or 2012), the EHR Reporting Period is 90 days for any continuous period beginning and ending within the year. For every year after the first payment year, the EHR reporting period is the entire year.
In order to earn an EHR incentive payment EPs must accomplish the following:
The last year during which EPs can initiate participation in the Medicare EHR Incentive Program is 2014, and in 2015, EPs who are not meaningful users will receive a 1% Medicare payment penalty. See Figure 3 for a timeline of the Medicare and Medicaid EHR Incentive Programs.
EHR Incentive Programs Timeline
Adapted from the CMS Medicare and Medicaid EHR Incentive Programs Milestone Timeline
EHR Meaningful Use
EPs demonstrate meaningful use by using EHR technology in ways that can be measured significantly in quality and quantity. ARRA identified the following three main components of meaningful use:
The specific criteria for meaningful use will be staged in three steps over the next five years:
In stage 1, 2011 and 2012, there are a total of 25 meaningful use objectives. To qualify for an incentive payment, EPs must meet 20 of these 25 objectives, including 15 required core objectives and 5 menu set objectives that may be chosen from a list of 10. In addition, EPs must report on 6 total clinical quality measures: 3 required core measures (substituting alternate core measures where necessary) and 3 additional measures (selected from a set of 38 clinical quality measures).
CMS has developed a document with links to a Meaningful Use Specification Sheet for each meaningful use objective. Similar to the PQRS measures specification sheets, each meaningful use specification sheet includes information on meeting the measures objective, calculating the numerator and denominator for the objective, qualifying for an exclusion to the objective, definitions of terms that clarify objective requirements and the requirements for attesting to each measure.
CMS has also published a Clinical Quality Measure Overview/Description sheet for each clinical quality measure. Each measure sheet contains the measure title, description, number, measurement period, measure steward, and other relevant information to the measure. The clinical quality measure sheets can be found on the electronic specifications section of the Quality Measures Webpage.
Registering in the EHR Program
In order to complete the on-line registration process EPs will need to have their:
During the registration process, providers will be prompted to answer whether or not they have a certified EHR. While a certified EHR is not required to complete the registration process, an EHR Certification Number is required when you attest for payment. Therefore, providers who are in the process of choosing and implementing an EHR could choose to register now.
Attesting in the EHR Program
Attestation for the EHR Incentive Program opened April 18, 2011, and several oncology clinics have already reported achieving successful attestation. According to CMS, incentive payments for the Medicare EHR Incentive Program will be made approximately four to eight weeks after an EP, eligible hospital or critical access hospital meets the program requirements and successfully attests to meaningful use of certified EHR technology. CMS says they expect the first payments to begin in May 2011.
Providers attesting to receive an EHR incentive payment may be subject to an audit. For this reason, CMS instructs providers attesting to receive an incentive payment to retain all relevant supporting documentation (in either paper or electronic format used in the completion of the Attestation Module responses) for six years post-attestation. Relevant supporting documentation includes electronic or paper documentation that support your attestation as well as the documentation to support your Clinical Quality Measures (CQMs).
If audited, this documentation will be used to validate that you accurately attested and submitted CQMs, as well as to verify that the incentive payment was accurate.
2011 eRx Codes
eRx Numerator Code:
Qualifying Denominator Codes:
eRx Hardship Exemption Codes:
Practices that have not yet begun participation in the Medicare eRx program should first begin by carefully reviewing the program details and resources available on the CMS eRx Website. To gather all pertinent information one should work their way through each link and review all of the pertinent resources under the Downloads and Related Links on each page.
Another excellent and reliable source of eRx Incentive Program information is the AMA’s Zero-In RX ePrescribing Learning Center. On the site, the AMA makes available an interactive tool through which providers can find and compare eRx systems based on their responses to a brief on-line questionnaire, and read vendor feedback and ratings from other users. The learning center also includes calculators to estimate potential timesavings and eligibility for incentive payments along with tools to help determine and facilitate practice readiness for implementation of new technologies.
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