2011 eRx incentive - Avoiding the 2012 eRx payment adjustment

In November, the Centers for Medicare & Medicaid Services (CMS) announced that beginning in calendar year 2012, eligible professionals who are not successful electronic prescribers based on claims submitted between January 1, 2011-June 30, 2011, may be subject to a payment adjustment on their Medicare Part B physician fee schedule (PFS) covered professional services. Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) authorizes CMS to apply this payment adjustment whether or not the eligible professional is planning to participate in the eRx incentive program.

From 2012 through 2014, the payment adjustment will increase each calendar year. In 2012, the payment adjustment for not being a successful electronic prescriber will result in an eligible professional or group practice receiving 99 percent of their Medicare Part B PFS amount that would otherwise apply to such services. In 2013, an eligible professional or group practice will receive 98.5 percent of their Medicare Part B PFS covered professional services for not being a successful electronic prescriber in 2011 or as defined in a future regulation. In 2014, the payment adjustment for not being a successful electronic prescriber is 2 percent, resulting in an eligible professional or group practice receiving 98 percent of their Medicare Part B PFS covered professional services.

The payment adjustment does not apply if less than 10 percent of an eligible professional’s (or group practice’s) allowed charges for the January 1, 2011, through June 30, 2011, reporting period are comprised of codes in the denominator of the 2011 eRx measure.

Please note that earning an eRx incentive for 2011 will not necessarily exempt an eligible professional or group practice from the payment adjustment in 2012.

How to avoid the 2012 eRx payment adjustment

 

• Eligible professionals -- an eligible professional can avoid the 2012 eRx payment if he/she:

• Is not a physician (MD, DO, or podiatrist), nurse practitioner, or physician assistant as of June 30, 2011, based on primary taxonomy code in National Plan & Provider Enumeration System (NPPES);

• Does not have prescribing privileges. Note: He/she must report (G8644) at least one time on an eligible claim prior to June 30, 2011;

• Does not have at least 100 cases containing an encounter code in the measure denominator;

• Becomes a successful e-prescriber; and

• Reports the eRx measure for at least 10 unique eRx events for patients in the denominator of the measure.

• Group Practices -- for group practices that are participating in eRx GPRO I or GPRO II during 2011, the group practice must become a successful e-prescriber.

• Depending on the group’s size, the group practice must report the eRx measure for 75-2,500 unique eRx events for patients in the denominator of the measure.

For additional information, please visit the “Getting Started” page at http://www.cms.gov/erxincentive on the CMS website for more information; or download the Medicare’s Practical Guide to the Electronic Prescribing (eRx) Incentive Program under “Educational Resources.”

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Source: PERL 201104-23, PERL 201103-67, PERL 201103-37, PERL 201102-09 CMS