As the first month of the New Year draws to a close, I thought I would remind everyone about a topic that for some has become a bit of a sore spot. 2012 represents the first year CMS will impose a penalty upon providers for not successfully e-prescribing. That penalty is 1.0 % of the allowable for all Medicare Part B services rendered this year. For those of you confused by the phrase “Part B Allowable,” and believe me you are in good company if you find yourself in this boat, check out this FAQ from the CMS web site which provides an enlightening example.
Check and Double Check
Many of you may have received a communication from the AMA related to this topic. Apparently CMS has a backlog of hardship exemptions. Unfortunately, this means there are providers with legitimate exemptions who are being inappropriately penalized. As you may recall, of the six eRx hardship exemptions available in 2011, the one most applicable to nephrology basically stated that by demonstrating meaningful use in 2011, you were in fact exempt from the eRx penalty even if you did not put the eRx G-code on the claim for ten eligible Part B beneficiaries seen prior to June 30, 2011. If you find yourself in this position, I would suggest asking someone to spot check an Advice Remittance for a Part B service rendered this year to ensure you are receiving 100% of the Part B allowable. One percent does not sound like much, but remember this comes off the top. If CMS has determined that you are not a successful e-prescriber, the term “LE” will appear on every Remittance for Part B services rendered in 2012.
For your reading pleasure, I have copied the pertinent section from the CMS communication related to this issue:
“Providers who receive the 2012 eRx payment adjustment will see the term “LE” on their Remittance Advice for all Medicare Part B services rendered January 1 – December 31, 2012. The remittance advice will also contain the following Claim Adjustment Reason Code (CARC) and Remittance Advice Remark Code (RARC):
o CARC 237 – Legislated/Regulatory Penalty. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).
o RARC N545 – Payment reduced based on status as an unsuccessful eprescriber per the Electronic Prescribing (eRx) Incentive Program.”
2013: Avoiding the Penalty Gets Easier
I am not particularly fond of discussing penalties, but while we are on the subject I would encourage you to do what is necessary to avoid being on the wrong list in 2013. Avoiding the 1.5 % 2013 eRx penalty is not difficult if you have access to a qualified eRx tool. Using the tool, you simply need to generate and transmit a prescription during any encounter with ten Medicare Part B beneficiaries prior to June 30, 2012. You must also convey this action to CMS by adding the eRx G-code to the claim for that service. Notice I have emphasized any encounter. CMS has made it much easier to avoid the penalty than in years past when the encounters had to be those represented by CPT codes in the measures denominator (office E&M codes for the typical nephrologist). This restriction no longer applies.
You will also be excluded from the 2013 penalty if you successfully participated in the 2011 eRx program by sending a script electronically for a minimum of 25 eligible Part B encounters in 2011. Participation here could have been conveyed to CMS either by placing the eRx G-code on the claim or reporting those 25 instances through a qualified PQRS Registry.
Note there will not be a meaningful use hardship exemption in 2012! Do not fall asleep at the wheel. Even if you are demonstrating meaningful use this year you must separately let CMS know you have electronically prescribed for the appropriate number of Part B beneficiaries.
The rules related to eRx penalties can be confusing; and while the percentages sound small, this is your money we’re talking about. Appropriately avoiding these penalties is not difficult once you wade through the morass of the regulations. Let us know what your experience has been and join the conversation.
Randy Gertner says
I believe our group did the 25 ERX for 2011. Would you suggest we still put in the G code for the 2012 year? Would this serve as an “insurance policy?” Although it sounds simple, it is not the easiest thing to remember to click that G code. Another question: If I read the above correctly, my understanding is that we can now use the G Code for face to face dialysis visits? If so, that is a bit more tricky since the coding is done at the end of the month. Logisticly, how would that work? Who gets credit, the comprehensive doctor or the face to face doctor?
Terry Ketchersid, Vice President and Medical Officer at HITSG says
Randy, I think it is better safe than sorry and would advise putting the G-code on the claim for 10 Part B encounters between now and June 30. Yes all encounters with Medicare Part B beneficiaries are part of the denominator to avoid the penalty including the dialysis MCP CPT codes. The performing provider on the claim (comp note doc) would receive the credit. Personally I would stick with office based encounters, 10 is a low hurdle to clear from my perspecitve.