Health Information Compliance Alert

Published on Tue Feb 05, 2013 PDF

Check out what you need to have in place to avoid pay hits next year.

There’s more to filing electronic prescriptions than you might think — if you want to qualify for CMS incentives this year. Take a close look at the language used in the CMS website so that you can benefit from the pay boosts and sidestep penalties.

Why it matters: Incentives for using electronic prescription systems will continue in 2013, according to Kathy Bryant, deputy director of the division of practitioner services for CMS.

Choose Between 2 Criteria Options

The electronic prescription (eRx) system must meet the requirements specified for one of two criteria.

Option 1: The system must be capable of all of the following functionalities:

Generate a complete list of the patient’s active medications, incorporating electronic data received from pharmacies and pharmacy benefit managers, if available.

Allow the prescribing physician to select medications, print prescriptions, electronically transmit prescriptions, and conduct all alerts (as defined below). This functionality must be enabled.

Provide information related to lower cost, therapeutically appropriate alternatives (if any are available).

Provide information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient’s drug plan, if available.

Option 2: The system must be "Certified EHR Technology" as defined at 42 CFR 495.4 and 45 CFR 170.102. The technologies that meet these definitions are listed on the ONC (Office of the National Coordinator for Health Information Technology) website. Review the complete list at http://onc-chpl.force.com/ehrcert.

Verify That You’re Eligible for Incentives

Having an electronic prescription system in place doesn’t automatically qualify you for incentive payments. During 2013, an individual eligible provider must report the eRx measure for at least 25 unique visits in which the measure is reportable by the eligible provider.

"My understanding is that this can cover multiple visits for the same patient, but multiple prescriptions for a patient during a single visit only counts as one for this purpose," says Kent J. Moore, manager of healthcare delivery and finance systems for the American Academy of Family Practice (AAFP) in Leawood, Kan. "The language on the CMS website refers to ‘unique visits,’ not unique patients."

Translation: Multiple electronic prescriptions for an individual patient (during multiple encounters) can all count toward the qualifying 25 prescriptions. The physician doesn’t need to electronically prescribe medications to 25 unique patients to meet the qualifications.

Payment: Providers who qualify will receive a 0.5 percent incentive payment for 2013.

Penalty: Eligible providers who qualify but choose not to participate in the program will have a 1.5 percent reduction in Medicare payment, Bryant says. To avoid further reductions in 2014, the physician should report code G8553 (Prescription[s] generated and transmitted via a qualified eRx system or a certified EHR system) on at least ten claims for billable Medicare Part B PFS services provided between January 1, 2013 and June 30, 2013.

Submit eRx With Appropriate Services

Before submitting a claim with G8553, verify that it’s associated with the correct type of service.

"Code G8553 should only be submitted with services identified as denominator codes in the eRx measure specification," Moore explains. "Most of those codes/services are evaluation and management services such as office visits (99201-99215), nursing facility visits, (99304-99316), and domiciliary, rest home, and home visits (99324-99337, 99341-99350). However, there are some other codes/services done by family physicians that are also eligible."

Example: Code G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) is among the denominator codes. For a complete list of denominator codes, visit the CMS web site at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/How_To_Get_Started.html.