What you need to know about the Medicare eRx penalty in 2012
In order to avoid a 1% penalty in 2012 all eligible professionals must use the claims based reporting option and submit at least 10 claims between January 1, 2011 and June 30, 2011 indicating prescriptions for Medicare patients have been submitted electronically using a qualified eRx system.
- Who is eligible? Physicians for whom office visits, eye exams, psychotherapy, nursing home or home care, or other services listed in the CMS E-prescribing Measure specifications represent at least 10 percent of their Medicare charges.
- What are the reporting requirements?
- Through the Part B claims processing system, using code G8553 – At least one prescription created during the encounter was generated and transmitted electronically using a qualified eRx system.
- When you submit a Medicare claim for one of the visit codes included in the CMS E-prescribing Measure specifications you should also submit code G8553 on a separate line item with a charge of $0.00. (If your billing software does not allow you to submit a zero charge, you can submit a nominal charge that will be denied by Medicare and is not billable to the patient.)
- The eRx line item will be denied but passed through the claims processing system to the National Claims History database (NCH) and used for eRx claims analysis. The Remittance Advice will include the remark code N365 – This procedure code is not payable. It is for reporting/information purposes only. This remark code indicates that the eRx G-code was passed into the NCH.
- Claims cannot be resubmitted for the sole purpose of adding an eRx code.
- Submission of the prescription via fax does not meet the eRx requirements. The prescription must be generated electronically from the physician’s e-prescribing system or tool even if the prescription is ultimately converted into a fax on the pharmacy end.
- Are there exemptions for the 2012 penalties? Yes. On a case-by-case basis CMS may exempt an eligible professional from the application of the e-Rx payment adjustment if compliance would result in a significant hardship. For 2012 the following situations would qualify for the exemption:
- The eligible professional practices in a rural area without sufficient high speed internet access. To request this exemption you must submit code G8642 on at least one claim during the period of January 1, 2011 through June 30, 2011.
- The eligible professional practices in an area without sufficient availability of pharmacies for electronic prescribing. To request this exemption you must submit code G8643 on at least one claim during the period of January 1, 2011 through June 30, 2011.
- What is the Group Practice Reporting Option (GPRO)? For both the PQRI and eRx incentive programs Medicare began accepting group reporting as an option to individual professional reporting in 2010. Initially CMS classified an eligible group practice as one with 200 or more physicians under the same tax ID number, however, beginning in 2011 there are two group practice reporting options. For 2011 GPRO I still pertains to groups of 200 or more physicians, the new reporting option is GPRO II for groups of between 2 to 199 physicians. If you want to be considered for group reporting you must submit a self-nomination letter to CMS. For more information and the self-nomination requirements see www.cms.gov/ERxIncentive/07_Group_Practice_Reporting_Option.asp.
- What about the 2011 eRx incentives? In order to receive the 1% incentive for 2011 individual physicians will need to report a minimum of 25 unique visits/prescriptions during the entire year. Group practices will have to meet the reporting requirements as outlined in the GPRO Self Nomination Requirements, the requirements are tiered based on the number of eligible professionals in the group.
- Note: In order for the group practice to avoid the 1% penalty in 2012 all of the eligible professional in the group must use the claims based reporting option and submit at least 10 claims between January 1, 2011 and June 30, 2011 indicating prescriptions for Medicare patients have been submitted electronically using a qualified eRx system.
- Physicians can use either claims or registry reporting to be considered a successful electronic prescriber for the purposes of receiving the 2011 incentive payment.
Updates as of 10/2011
Original requirements to avoid the penalties/payment adjustments:
In addition to establishing the requirements for successful reporting of the electronic prescribing measure for the 2011 eRx incentive, the CY 2011 MPFS Final Rule also establishes the program requirements for purposes of avoiding the 2012 payment adjustment.
An eligible professional will not be subject to the 2012 payment adjustment if one of the following applies:
- The eligible professional is not a physician (MD, DO, or podiatrist), nurse practitioner, or physician assistant as of June 30, 2011 (This determination is based on the primary taxonomy code in the National Plan and Provider Enumeration System (NPPES)) and does not generally have prescribing privileges, and reports g-codeG8644 (defined as not having prescribing privileges) at least one time on an eligible claim prior to June 30, 2011;
- The eligible professional does not have at least 100 cases containing an encounter code in the electronic prescribing measure’s denominator;
- The eligible professional’s allowed charges for covered professional services submitted for the electronic prescribing measure’s denominator codes is less than 10 percent of the eligible professional’s total 2011 Medicare Part B PFS allowed charges;
- The eligible professional reports a significant hardship code and CMS determines that the hardship code applies(see “Significant Hardship Exemptions” section below) and is granted an exemption; OR
- The eligible professional becomes a successful electronic prescriber for purposes of the 2012 payment adjustment by reporting the electronic prescribing measure via claims for at least 10 unique electronic prescribing events for patients in the denominator of the measure between January 1, 2011 and June 30, 2011.
A group practice that is participating in the 2011 eRx group practice reporting option will not be subject to the 2012 payment adjustment if one of the following applies:
- The group practice reports a significant hardship in its 2011 self-nomination letter for participation in the eRx Incentive Program group practice reporting option (see “Significant Hardship Exemptions” section below) and is granted an exemption; OR
- The group practice becomes a successful electronic prescriber. The group practice becomes a successful electronic prescriber for purposes of the 2012 payment adjustment by reporting the electronic prescribing measure via claims for between 75-2,500 unique electronic prescribing events (depending on the group practice size) for patients in the denominator of the measure between January 1, 2011 and June 30, 2011.
Original hardship exemptions:
Significant Hardship Exemptions. Section1848(a)(5)(B) of the Act provides that the Secretary may, on a case-by-case basis, exempt an eligible professional from the payment adjustment, if the Secretary determines, subject to annual renewal, that compliance with the requirement for being a successful electronic prescriber would result in a significant hardship. In the CY 2011 MPFS Final Rule, CMS established the following two significant hardship exemptions in the form of g-codes for purposes of the 2012 payment adjustment:
- The eligible professional practices in a rural area without sufficient high speed internet access (report codeG8642)
- The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing (report code G8643)
In order to request consideration for an exemption from the 2012 payment adjustment via one of the two aforementioned significant hardship g-codes, the eligible professional must report the g-code at least onetime on a claim between January 1, 2011 and June 30, 2011. A group practice participating in the eRx group practice reporting option for 2011 must have requested the significant hardship exemption at the time the practice self-nominated to participate.
New Hardship exemptions:
The eligible professional or group practice must demonstrate that one of these situations applies to the respective practice:
- Eligible professionals who register to participate in the Medicare or Medicaid EHR Incentive Programs and adopt certified EHR technology;
- Inability to electronically prescribe due to local, state, or federal law or regulation;
- Limited prescribing activity; or
- Insufficient opportunities to report the electronic prescribing measure.
If this doesn’t happen, then they are subject to the penalties:
In addition to the electronic prescribing incentive payment, MIPPA called for a Medicare Physician Fee Schedule (MPFS) payment adjustment that will apply beginning in January 2012to eligible professionals who are not successful electronic prescribers, as defined in the Calendar Year (CY) 2011 MPFS final rule. For eligible professionals who are subject to the 2012 eRx payment adjustment, the fee schedule amount for covered professional services furnished by eligible professionals during the year shall be 1 percent less than the fee schedule amount that would otherwise apply for 2012. The potential MPFS reductions in the future are a 1.5 percent reduction for 2013 and 2.0 percent reduction for 2014.
Additional information and resources are available at: