E-Prescribing Measures Evolve in 2010

Stay current to keep incentive payments flowing.

By Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, and John Verhovshek, MA, CPC

The Centers for Medicare & Medicaid Services’ (CMS’) electronic prescription drug program continues to evolve since its inception in 2008. For 2010, providers still can receive incentive payments for successful e-prescribing (also known as eRx). Three numerator G codes used in 2009 are eliminated, a new numerator G code is available, and denominator codes are expanded to include a greater number of services.

Reporting Circumstances Contract

Visits reported under the e-prescribing measure must include both a numerator code and a denominator code. The numerator identifies the availability and use of an e-prescribing system during a patient encounter. In 2009, CMS designated three HCPCS Level II codes for this purpose:

G8443     All prescriptions created during the encounter were generated using a qualified e-prescribing system

G8445     No prescriptions were generated during the encounter; provider does have access to a qualified e-prescribing system

G8446     Some or all prescriptions generated during the encounter were handwritten or phoned in due to one of the following: required by state law, patient request, or qualified e-prescribing system being temporarily inoperable

For 2010, these codes are deleted and replaced by a single, new numerator:

G8553     At least one prescription created during the encounter was generated and transmitted electronically using a qualified eRx system.

In the past, the provider could claim credit when a qualified eRx system was available, even if it was not used during the particular visit reported. For 2010, eligible professionals report an eRx code only when an electronic prescription is placed.

Code G8553 must be reported on the same claim as the denominator code (a complete list of denominator service codes follows). The same eligible provider who performs the denominator service reports G8553 for the same beneficiary, on the same service date only.

Submit G8553 with a line-item charge of zero dollars ($0.00) at the time the associated covered service is performed. If a system does not allow a $0.00 line-item charge, a nominal amount (such as one cent) may be substituted, but the beneficiary is not liable to pay this amount.

Eligible Services Expand

The denominator codes are those CPT® or HCPCS Level II codes describing the visit during which eRx occurs. In 2009, services eligible for eRx reporting were:

  • Psychiatric services 90801-90802 and 90804-90809
  • Ophthalmological services 92002-92014
  • Health and behavior assessment/interventions 96150-96152
  • New patient office visits 992201-99205
  • Established patient office visits 99211-99215
  • Outpatient consultation services 99241-99245
  • Pelvic and breast exam G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination
  • Diabetes training G0108 Diabetes outpatient self-management training services, individual, per 30 minutes and G0109 Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes

For 2010, the available denominator codes include those just listed, but were expanded to include the following:

  • Pharmacologic management 90862 Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy
  • Nursing facility care 99304-99306, 99307-99310, and 99315-99316
  • Domiciliary, rest home, or custodial care services 99324-99328 and 99334-99337
  • Home health services 99341-99345 and 99347-99350

Consistent with CMS’ decision not to recognize CPT® codes to describe consultation services, codes 99241-99245 were eliminated from the list of eligible eRx services for 2010.

An example of proper eRx reporting would be when a diabetic patient sees his endocrinologist for a quarterly follow-up. On completion of the visit, the physician prescribes the patient’s insulin via a qualified eScribing system. The visit documented and supported via medical necessity would be 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family, so the claim would include 99214, as well as G8553.

If the patient did not need insulin or any other drugs eligible for eScribing but the physician prescribed a controlled substance for the patient’s neuralgia, that script would have to be handwritten. Drug Enforcement Administration (DEA) rules do not allow electronic prescribing of controlled substances. And because the prescription did not go through the eScribing system, the doctor could not report G8553 on the claim.

If the patient was prescribed his insulin and the controlled substance — the insulin via eScribing and the pain medication via a paper script — G8553 would be supported because one of the prescriptions did go through the eScribing system.

Be Sure Your System Qualifies

A qualified eRx system may be part of an electronic medical records (EMR) system, or stand alone via the Internet (see sidebar for more information on standalone eScribing systems). A qualified eRx system must be able to:

  • Generate a complete medication list that incorporates data from pharmacies and benefit managers (if available);
  • Select medications;
  • Transmit prescriptions electronically using the applicable standards; and
  • Warn the prescriber of possible undesirable or unsafe situations.

Simply faxing a prescription, for instance, would not count as eRx.

Resource tip: The full definition of a qualified eRx system may be found in any of the resources provided at the end of this article.

A word of caution: All states allow e-prescribing, but some have certain regulatory requirements. Check your state guidelines to be sure you comply with any applicable e-prescribing requirements specific to your state.

Payments Depend on Participation Thresholds

As in 2009, only “eligible professionals” may qualify for eRx incentive payments this year. A full list of eligible professionals may be found on the CMS website (www.cms.hhs.gov/PQRI/Downloads/EligibleProfessionals.pdf). Note that, to be an eligible professional, the provider also needs prescribing rights, along with a license, in his or her particular state. Incentive payments will equal 2 percent of the covered professional services furnished by an eligible professional during the reporting year, as long as all measures are reported no later than February 2011.

For 2010, CMS revises the eRx requirements so you no longer must report a numerator code in at least 50 percent of applicable cases during the reporting period. Instead, each eligible professional must report an eRx measure at a minimum of 25 unique visits during the reporting period (Jan.1-Dec. 31, 2010). To qualify for eRx incentive payments, an eligible professional’s Medicare Part B physician fee schedule allowed charges for denominator services must be equal to or greater than 10 percent of the same eligible professional’s total 2010 estimated allowable charges, in dollars. For example, if total eligible Medicare payments are $150,000, the denominator services (e.g., evaluation and management (E/M) services or the added services listed previously) must equal at least 10 percent of the dollars received (in this example, $15,000 for the year).

Group practices (as opposed to individuals) also may participate as a group in the eRx program, but only those group practices who also participate in the Physician Quality Reporting Initiative (PQRI). Group practices that wish to participate in the eRx program must notify CMS at the time they self-nominate to participate in the 2010 PQRI program. Reporting requirements for a group practice are different from those for an individual provider, as follows:

  • To participate as a group practice in the eRx measure, the group practice “would consist of a physician group practice, as defined by a TIN, with at least 200 or more individual eligible professionals (or, NPIs) who have reassigned their billing rights to the TIN,” according to CMS in the 2010 Physician Fee Schedule Final Rule [emphasis added]. CMS recognizes that the required group practice size of 200 or more individual eligible professionals will limit group practice participation. CMS has stated that it would like to limit the groups participating in the group practice reporting option, “until we get further experience with the group practice reporting option.”
  • The group practice must report the eRx measure at least 2,500 times during the reporting period for the group practice to be considered a “successful electronic prescriber.”
  • Incentive payments apply only to groups whose Medicare Part B physician fee schedule-allowed charges for denominator services are equal to or greater than 10 percent of the same group’s total 2010 estimated allowed charges.

If an individual eligible provider bills Medicare under the same TIN as a group practice participating in the eRx program, the individual eligible provider will not be eligible to qualify for individual eRx incentive payments in addition to any payments provided to the group. Individual providers who are part of a group practice not participating in the eRx program may elect to participate in the program on an individual basis, according to the 2010 Medicare Physician Fee Schedule (MPFS) Final Rule.

Following distribution of 2010 incentive payments, CMS will post on its website the names of individual physicians and group practices who are successful e-prescribers for the 2010 program. Beginning in 2012, the program will impose penalties on EPs who are not successful e-prescribers.

Resource tip: For additional information on the 2010 Electronic Prescribing Incentive Program – Adoption/Use of Medication Electronic Prescribing Measure, you may access the following:

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  • 2010 Physician Fee Schedule Final Rule, Nov. 25 2009 Federal Register (eRx information begins on page 61849, or 113 of the PDF file): http://edocket.access.gpo.gov/2009/pdf/E9-26502.pdf
  • 2010 Electronic Prescribing Incentive Program – Adoption/Use of Medication Electronic Prescribing Measure www.cms.hhs.gov/ERxIncentive/06_E-Prescribing_Measure.asp#TopOfPage
  • Physician Quality Reporting Initiative (PQRI) National Provider Call (Nov. 10, 2009) www.cms.hhs.gov/PQRI/04_CMSSponsoredCalls.asp#TopOfPage
  • Changes to the Physician Quality Reporting Initiative and the Electronic Prescribing Incentive Program
  • Surescripts Certification Status of eRx systems: http://surescripts.com/certification-status.html
  • Surescripts “Get Connected” information for Physicians: http://surescripts.com/certification-status.html

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