The final rule for the 2011 Medicare Physician Fee Schedule was published two weeks ago. At just over 2,000 pages, the PFS contains a few nasty surprises related to e-prescribing. Participating in the e-prescribing incentive program next year will work just like it does today: during the course of 2011, generate and transmit at least one prescription using a qualified e-prescribing tool during 25 eligible encounters with Medicare part B beneficiaries and you may be in line to receive an additional 1% bonus for your entire Medicare part B allowable charges for the year. What is an eligible encounter? One that is defined by the 56 CPT codes in the e-prescribing measure denominator. For the nephrologist this effectively limits eligible encounters to office-based follow-up visits (99211-215) or new patient encounters (99201-205).
When I say you may be in line for the incentive, I am referring to the 10% hurdle. In order to be eligible for this incentive, at least 10% of your Medicare part B allowable charges must originate from the CPT codes in the measure’s denominator. Basically CMS will add up all of your office-based part B allowable charges and divide this sum by your entire Medicare part B book of business for the year (office, hospital, dialysis, access center, etc). If this fraction is less than 10% you will not receive the 1% incentive even if you send the required number of scripts electronically.
Nothing new here and, in fact, the ways you can communicate participation to CMS have not changed as you may 1) put the e-Rx G-code on the claim for the office encounter (G8553), 2) submit the e-Rx data through a qualified PQRI Registry or 3) submit directly from a handful of EHRs. One thing you cannot do is participate in both the CMS e-Rx incentive program and the CMS EHR (meaningful use) incentive program. These two programs are mutually exclusive.
The bombshell in the final rule for the 2011 PFS is the description of how CMS intends to identify providers to penalize in 2012. You may recall that CMS has established a 1% “adjustment” to the Medicare PFS for 2012 to apply to providers deemed not successful e-prescribers. In order to apply this 1% reduction during 2012, CMS has created a mechanism to identify providers to penalize well before the start of 2012. Essentially this is how it works:
“To be a successful electronic prescriber for purposes of avoiding the 2012 eRx payment adjustment, the eligible professional must report that at least 1 prescription for Medicare Part B FFS patients created during an encounter that is represented by 1 of the codes in the denominator of the 2011 electronic prescribing measure was generated and transmitted electronically using a qualified eRx system at least 10 times during the 2012 eRx payment adjustment reporting period (that is, January 1, 2011 through June 30, 2011).”
I kid you not, this is a direct quote from the final rule. Read this carefully—if you are an MD, DO, PA, or NP and you do not e-prescribe at least 10 times in the first 6 months of 2011, you may see your Medicare fee schedule drop in 2012 to 99% of the 2012 PFS. Before panic sets in consider the following exclusions, which will apply to many nephrology practices but not to all. You are excluded from the penalty if any of the following apply:
• You do not clear the e-Rx 10% hurdle I described above in the first 6 months of 2011 (most interventionalist for example will not face the penalty).
• You have fewer than 100 encounters defined by the e-Rx denominator codes (office encounters for the nephrologist) with Medicare part B patients in the first 6 months of 2011. (That’s about 4 patients per week in the office—many of the nephrology NPs and PAs will escape the penalty here.)
• You practice in a rural area without sufficient high-speed internet access.
• You practice in an area without sufficient available pharmacies for electronic prescribing.
The last two are considered hardship exemptions and will require the provider to submit a new G-code on a claim during the first 6 months of the year (codes not available today) attesting to the hardship. One final very important nuance of this program: you must convey to CMS that you have successfully e-prescribed for at least 10 eligible patients in the first 6 months of next year by submitting the e-Rx G-code (G8553) with the claim for the office encounter. Let me repeat, if you are participating in the CMS EHR incentive program you must submit the G-code for 10 part B patients or you may be penalized (even if you successfully demonstrate meaningful use). If you postpone participating in the EHR incentive program and you submit e-prescribing data through a PQRI Registry or through an EHR in 2011 you must also submit the G-code on the claim for 10 part B patients or you may be penalized (even if you are deemed a successful e-prescriber for the 2011 reporting period!).
While I do not enjoy the role of bearing bad news, the 2011 PFS also states CMS plans to identify those providers to penalize in 2013 (1.5% Medicare PFS adjustment) using similar criteria but examining the provider’s success during the entire 2011 e-prescribing reporting period as the measure for whether or not to apply the 2013 penalty. This of course could change with the 2012 PFS.
Bottom line: If you have an e-prescribing tool today make sure you use it and report it on a claim for at least 10 office based encounters with Medicare part B patients in the first 6 months of next year unless you are certain one of the exclusions I mentioned above apply. You should do so regardless of whether you intend to demonstrate meaningful use in 2011 and even if you intend to postpone meaningful use but plan to use a Registry or EHR to report the e-prescribing incentive data for 2011. Those of you without an e-prescribing tool should consider exploring one now in anticipation of the above. I would start my search with the SureScripts website.
Apologies for delivering the news this time of year, but hopefully this knowledge will facilitate the appropriate preparation within your practices. Happy Thanksgiving to all.
Leave a Reply