Not e-prescribing in 2011 may cost you in 2012

By law, Medicare must apply a 1-percent reduction to Medicare Physician Fee Schedule (MPFS) payments in 2012 for those physicians who do not successfully participate in the Medicare e-prescribing (eRx) incentive program in 2011. This applies to all physicians who provide at least 100 evaluation and management (E/M) and/or other services designated by the Centers for Medicare & Medicaid Services (CMS) as eRx denominator codes and receive at least 10 percent of their MPFS income from these. To avoid the fee reduction, covered physicians must adopt a "qualified" eRx system and report its use during at least 10 distinct encounters for services represented by a denominator code in the first six months of 2011 to avoid a 1-percent decrease in MPFS payments in 2012. The code to report is G8553, "At least one prescription created during the encounter was generated and transmitted electronically using a qualified eRx system," and it must be reported on the same claim as the associated denominator code.

The denominator codes are 90801, 90802, 90804-90806, 90807-90809, 90862, 92002, 92004, 92012, 92014, 96150-96152, 99201-99205, 99211-99215, 99304-99310, 99315, 99316, 99324-99328, 99334-99337, 99341-99343, 99345, 99347-99350, G0101, G0108, G0109.

CMS does allow for two hardship exceptions. These require reporting one of the following codes once during the period from Jan. 1, 2011, to June 30, 2011. The exceptions and codes are as follows:

• G8642 - The eligible professional practices in a rural area without sufficient high speed Internet access and requests a hardship exemption from the application of the payment adjustment under section 1848(a)(5)(A) of the Social Security Act,

• G8643 - The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing and requests a hardship exemption from the application of the payment adjustment under section 1848(a)(5)(A) of the Social Security Act.

For a physician or nonphysician provider who would otherwise be required to participate in the eRx program but does not have prescribing privileges, a one-time reporting of code G8644, "Eligible provider does not have prescribing privileges," is required to be granted an exception.

On the up-side of this, successful eRx for the entire year in 2011 (reporting 25 encounters) will earn a bonus of 1 percent of all MPFS allowed charges for 2011. Also, it is not too late to claim a bonus of 2 percent for 2010 if you have been using an eRx system that qualifies for the incentive. Here's how:

1. Determine if you are using a qualified eRx system. There are two types of systems. You may use either a stand-alone eRx system or an electronic health record (EHR) system with eRx functionality. Your system must be able to perform the following tasks:

• Generate a complete active medication list incorporating electronic data received from applicable pharmacies and pharmacy benefit managers (PBMs), if available.

• Select medications, print prescriptions, electronically transmit prescriptions, and provide all alerts.

• Provide information related to lower cost, therapeutically appropriate alternatives, if any. (The availability of an eRx system to receive tiered-formulary information, if available, would meet this requirement for 2010.)

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

2. Submit code G8553 on at least 25 of your claims for E/M services with dates of service in 2010. Alternatively, you may choose to report a minimum of 25 patient encounters through a qualified registry or qualified EHR. CMS also offers a group reporting option for practices that also participate as a group in the Physician Quality Reporting System (PQRS, formerly PQRI).

The opportunity for a bonus will continue through 2013 but is reduced by .5 percent each year. I hope you can take advantage of the opportunities to receive a bonus while they exist and avoid the penalties that are scheduled to increase by .5 percent in each year through 2014.