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PQRI, E-prescribing, EHR Incentives, ICD-10―Don’t Wait!

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  • In Coding
  • October 6, 2010
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By Lynn S. Berry, PT, CPC
We all like to complain about government procrastination—but do we accept responsibility for our own shortcomings? Specifically, have you taken advantage of any of the government programs that could increase reimbursement in your practice or facility?


If you started (or will start) reporting on the physician quality reporting initiative (PQRI) in 2010, you could earn a 2 percent bonus on your total allowable Medicare charges for either a 12-month or six-month period. You have choices as to which measures fit your practice, which type of submission you choose (individual claims, registry, electronic health record (EHR), or the group option), whether you want to report individual measures or measures groups, and the time period for submission.
For 2011, you still can earn a 1 percent bonus on your total allowable charges (and with less effort—the required number of claims for measures groups and the percentage of reporting for individual measures both have decreased). There also are more options (including 12 new measures and one new measures group), more opportunities for utilizing registries and the EHR, and a new pilot group measure for fewer than 200 providers.
Through 2014, there also is an additional 0.5 percent incentive for eligible professionals who satisfactorily participate in PQRI and who, more frequently than is required to qualify for or to maintain board certification status, participate in the maintenance of certification program (MOCP) and an MOCP practice assessment.
From 2012-2014, the PQRI bonus incentive will decrease to 0.5 percent. For 2015, there will be a 1.5 percent penalty if you do not report. For 2016 and beyond, there will be a 2 percent penalty payment adjustment if you do not report.
The Physician Compare website will include information on physicians enrolled in Medicare and professionals who participate in PQRI (presumably for 2010) by January 2011. Also for 2011, the names of eligible professionals and group practices who have reported quality measures satisfactorily for 2011 will be posted on the website. What will it look like to your patients if your practice is not on the list? Who will be their practitioner of choice?
How will you respond? Will you continue to procrastinate, or will you get on board? For more information, go to


If you started (or will start) e-prescribing in 2010, you could receive an incentive bonus of 2 percent of allowed charges if you met the criteria of at least 25 events, with 10 percent of covered services made up of codes identified in the measure denominator. This could be by individual claims, registry, or EHR reporting. There also is a group practice measure option.
You still could meet these criteria by reporting on measures this year, either on an independent e-prescribing system or within your EHR. What are you waiting for?
For 2011, you could earn a 1 percent incentive bonus (unless you are receiving incentive from the EHR Incentive Program for 2011) by claims, qualified registry, or qualified EHR reporting. There also are proposed options for group practices (which are either the same as 2011), or for the pilot group option varying by size. Beginning in 2011, the Centers for Medicare & Medicaid Services (CMS) proposes to report publicly the names of eligible professionals and group practices that are successful e-prescribers for the 2011 program.
For 2012, the procrastinators may have an interesting problem. The penalty adjustment is retroactive to your performance in 2011. In 2012, you may be subject to a 1 percent payment adjustment unless during the Jan. 1, 2011-June 30, 2011 reporting period you:

  • Report 10 unique e-prescribing events for patients in the denominator;
  • Are not a physician, nurse practitioner (NP) or physician assistant (PA) as of June 30, 2011; or
  • Do not have at least 100 cases containing an encounter code in the measure denominator.

Even if you received the incentive in 2011, you must meet these criteria to avoid the penalty. Group practices must be successful e-prescribers during the 2011 reporting period and at least 10 percent of the professional of group’s allowed charges must be based on codes in the denominator for the penalty to apply.
If you are an office-based general practitioner or specialist who sees patients and regularly prescribes medications, you may be subject to this penalty and should act now to plan for 2011. Don’t procrastinate anymore. Your bottom line will be affected if the proposed rule goes through as written. For more information, see

EHR Incentive Program

Do you have an electronic medical record (EMR) that meets the meaningful use and certification criteria? Is there a price? Yes. Can we decrease our costs by acting sooner? Yes.
EHR incentive plans include the Medicare Fee-for-Service Program, the Medicare Advantage Incentive Program, and the Medicaid Incentive Program, with total incentives for individual providers that could equal over $60,000. In 2015, Medicare penalties of 1 percent will begin for eligible providers who are not meaningful users of EHR technology.
CMS envisions interconnectivity throughout the nation through a series of provider groups connected to a state Health Information Exchange Program or private health information exchanges that, in turn, connect to the Nationwide Health Information Network. This could revolutionize medicine through:

  • Efficiency
  • Sharing of health information for care coordination
  • Advancement of clinical processes with improved outcomes
  • Data gathering regarding general population and public health issues

For more information, see the article “EHR Final Rules: Prepare Now to Receive Incentive Payments” in this edition of Coding Edge.

HIPAA Version 2010, Version D.0, and ICD-10

HIPAA Version 2010 will go into effect on Jan. 1, 2012 for Version 5010 and D.0 Electronic Transactions, and ICD-10 for diagnoses will go into effect on Oct. 1, 2013.
These standards will be the only means to transfer medical information electronically. If you are not ready, you will not be able to bill—not only for Medicare, but for other insurances as well. You will not be able to obtain claim status, check patient eligibility, receive your reimbursement notices, enroll in a health plan, or participate in coordination of benefits.
We would like to put this off. AAPC has lobbied to put this off. But it is inevitable, and the timetable has been determined. Begin system implementation and put together a plan for staff training now!
For each of these incentives or upcoming changes, it’s natural to question whether getting on the bandwagon is worth the price. It will be in the long run. We will end up with evidence-based care, a value-based purchasing system, more patient safeguards, interconnectivity of information, more precise information, and more efficiency in our practices.
For more information, see “Early Lessons Learned: 5010” and “ICD-10 Roadmap” in this issue of Coding Edge.

No Responses to “PQRI, E-prescribing, EHR Incentives, ICD-10―Don’t Wait!”

  1. Kami says:

    Will Radiologists be penalized if they do not submit eRx codes for CMS patients?