Part B Insider (Multispecialty) Coding Alert

Published on Fri Jan 28, 2011 PDF

Plus: You may still be subject to E-prescribing penalty -- even if you don't prescribe many meds.

Biting your nails about how to avoid the E-prescribing penalty in 2012? CMS reps had plenty to say on the subject during a Jan. 25 national provider call on the subject. Read on for tips about your 2011 PQRS and E-prescribing payments.

Keep in mind: Physician Quality Reporting is no longer an "initiative" -- and therefore, the previous acronym "PQRI" that we've all used for over a year no longer applies. Instead, the program is now referred to as the Physician Quality Reporting System, or PQRS. And that's not all that's changed in the program, CMS reps said during a Jan. 25 CMS call on the matter.

For example: You should already be using the 2011 measures specifications, and not last year's, said CMS's Jacquelyn Kosh-Suber during the call. The 2011 guidelines are all available on the CMS Web site at www.cms.gov/pqri.

The 2011 set includes five new measures for claims and registry reporting, 11 new registry-only measures, and four new measures for electronic health record (EHR)-based reporting only, said CMS's Michelle Allender-Smith during the call.

Report on Medicare patients: Another change for this year involves reporting for non-Medicare beneficiaries. "For the 2011 measures group, for registry-based reporting, in the past you were able to receive non-Medicare beneficiaries, but for 2011, the 30 patients [on whom you must report] must all be Medicare," said CMS's Molly MacHarris during the call. "They can be unique, however -- they do not need to be consecutive."

Get to Know the E-Prescribing Process

CMS also discussed the electronic prescribing program during the call, which has created a lot of confusion throughout the Medicare community because practices that don't use e-prescribing are concerned about financial penalties if they don't participate.

"For most folks, it's important to know that they need to electronically prescribe at least ten prescriptions using a qualified system in the first six months of 2011, and this is necessary to avoid a prospective payment adjustment which would take place in 2012," said CMS's Daniel Green, MD, during the call.

If you don't meet the criteria, Green said, you will face a one percent penalty on your Medicare pay in 2012 unless you meet one of CMS's exemption rules. For instance, if you do not have at least 100 cases containing an encounter code in the measure denominator, you may be able to get an exemption. For information on the other exemptions, see Part B Insider Vol. 12, No. 2.

Hardship exemption: On a case-by-case basis, CMS may exempt an eligible professional (EP) from the payment adjustment "if compliance with the requirement for being a successful electronic prescriber would result in a significant hardship," Green said. For the 2012 eRx payment adjustment, if the EP practices in a rural area with limited high-speed internet access or in an area with limited available pharmacies that can receive electronic prescriptions, they could qualify for the hardship exemption, Green noted.

Determine eligibility: Before you can participate in the e-prescribing program, you need to determine whether you're eligible using the following steps, Green noted:

• Visit the CMS Web site at www.cms.gov/erxincentive to confirm that you meet the eligibility requirements
• Review the 2010 eRx Measure Specification, available on the CMS Web site, to determine if the measure applies to your practice
• Ensure that you're using a "qualified" e-prescribing system or program that you're using routinely
• Confirm that your Medicare Part B charges for the codes in the measure's denominator (90801-90809, 90862, 92002-92014, 96150-96152, 99201-99215, 99304-99316, 99324-99337, 99341-99343, 99345-99350, G0101, or G0108-G0109) make up at least ten percent of your total Medicare Part B charges for 2011.

Not enough prescriptions? A caller to the forum who works for a radiation oncology group asked whether her practice will face an e-prescribing penalty since it meets the criteria for e-prescribing and more than ten percent of its Medicare charges are for E/M codes, but the doctors don't often prescribe medications. "Unfortunately, they would be accountable," Green said. "They would be subject to the payment adjustment if they don't do at least ten prescriptions over the six months."

Refill policy: Another caller asked whether filling refills for a patient counts toward the e-prescribing benefit. If you are actually seeing the patient and e-prescribing the refill as part of a visit with the patient, then that counts, Green said. However, if the pharmacy calls you and you simply check a box authorizing the refill for the pharmacy without seeing the patient, you won't qualify for the e-prescribing event.

Find Out Why Incentive Payments Aren't Flowing

One caller asked the CMS reps whether feedback reports will ever get more specific. Although feedback reports show that a physician didn't receive an incentive payment for certain items, it does not show the particular reasons why the practice failed to meet the criteria and the caller wanted to know so she can fix it for future submissions. In these situations, practices should contact the Help Desk, which can offer specific reasons for denials, Green advised. The Help Desk can be reached at 866-288-8912.