That’s right. You have six more days to avoid the 2013 eRx penalty. I know what you are thinking. Is he really going to bring this up again? I must admit I thought I was finished with the 2013 penalty. But I recently had the pleasure of discussing the CMS incentive programs in front of a large audience of nephrologists, and unfortunately confusion continues to envelop this topic. So with one last chance to get the word out before the window closes on June 30, how could I possibly resist? Those of you who are confident the penalty does not apply to you should stop reading now. But let me suggest that, with rare exception, it is very difficult to be certain you are home free.
As easy as counting to 10
Let me start by reiterating what in my mind is the simplest way to avoid this penalty. When you generate and transmit at least one prescription during any encounter with a Medicare Part B beneficiary, you can add the eRx G-code (G8553) to the claim you send to Medicare. Do this for 10 different Part B patients prior to June 30 and you should be home free. I say “should” because all of us have heard stories about disappearing G-codes. I am not sure where the abandoned G-codes land but perhaps years from now their final resting place will be revealed.
Notice I have highlighted the word any in the sentence above. This too has created confusion. As you may recall, to collect an incentive or bonus within this program, only specific encounters are counted. These so-called eligible encounters are defined by a list of CPT codes. Noticeably absent from the list are the dialysis MCP codes. In other words, to receive the bonus side of the incentive, as a nephrologist you must e-prescribe during office-based encounters with your part B beneficiaries. You cannot receive credit for sending a script electronically from the dialysis facility where many of you spend a substantial amount of time. In sharp contrast, CMS will shield you from the penalty phase of the program in 2013 if you simply let them know you are using your eRx application for your Part B patients regardless of the venue of care. This was news to many folks in the audience last week and some have asked for clarification from CMS. For those who continue to question the validity of this statement, take a close look at page 6 of this PDF from the CMS website.
Other ways out
CMS has established a number of ways in which providers will be excluded from the penalty. Some of these require action on your part and some do not. Those that do not include:
- You have less than 100 “denominator eligible” encounters with Part B beneficiaries during the first six months of this year. CMS is basically saying if you have a small outpatient Medicare practice, they will not penalize you. Those of you who do not spend a lot of time in the office or perhaps face a younger demographic than the typical nephrologist may find yourselves in this bucket.
- Less than 10 percent of your Part B allowable during the first six months of 2012 originates from the eRx denominator eligible codes. This one basically states that if very little of your time is spent seeing patients in the office, you are exempt from the penalty. As a point of reference, in 2010 roughly 12% of the nephrologists who submitted eRx G-codes did not clear this 10% hurdle (too much Part B revenue outside the office). Many interventional nephrologists will find themselves in this bucket.
- You successfully participated in the 2011 eRx incentive program. The upshot here is that if you were able to demonstrate that you could e-prescribe last year, you are home free for 2013. Why demonstrating meaningful use does not count in this bucket is beyond me.
The exemptions mentioned above are “passive” because CMS will do the heavy lifting. You do not need to run a report in your practice management system to count how many Part B patients you have seen during the first six months of this year. CMS will make these calculations in August after sufficient time has passed to process the claims submitted during the adjustment reporting period. The challenge of course is you will not have your answer before this Saturday.
There are other ways to avoid the penalty but each of these requires applying for a hardship exemption and they do not apply to most nephrologists, although exceptions exist. Take a close look at page 3 of the PDF referenced above to see if you might be eligible for one of these exemptions. One thing I will again point out is the difference between this year and last year. Last year if you demonstrated meaningful use you could apply for a hardship exemption. This made perfect sense to me; however, demonstrating meaningful use in 2012 is not a valid exemption for the 2013 penalty.
Six days is not a lot of time, but if you find yourself making rounds in a dialysis facility this week, your 10 opportunities to avoid the penalty are right in front of you. The window closes on Saturday and perhaps the only benefit to that date is you will not be compelled to read another blog post about the subject in this forum…at least not anytime soon. Best of luck.