Time running out for PQRS and eRx incentives

It's not too late to participate in a pair of federal incentive programs targeting clinical quality and computerized prescriptions. But you need to move fast.

The Centers for Medicare and Medicaid Services (CMS) this week hosted a national call to discuss how physicians and other eligible health care professionals can submit 2012 program year data for the Physician Quality Reporting System (PQRS) and the Electronic Prescribing (eRx) Incentive Program.

In case you missed it, below are some of the highlights.

For individual eligible professionals, you still have time to participate in the 2012 PQRS if you report your information either through a qualified registry or through a qualified electronic health record (EHR). The EHR option can communicate either directly or through a data submission vendor.

Registry vendors can submit data between Feb. 1 and March 31. EHR users can already submit their data, but they only have until Feb. 28. No submissions after the end dates will be allowed.

You may potentially qualify to receive a full-year incentive payment. But even if you don't, it's good experience in reporting PQRS measures before tackling 2013, which is the reporting period CMS will use in determining PQRS penalties in 2015.

The same options and dates apply with respect to the eRx Incentive Program. As with the PQRS, you may potentially qualify to receive a full-year incentive payment, and you may potentially qualify to avoid the 2014 eRx penalty. However, to avoid a penalty this year, you had to have complied with the program by June 30, 2012.

For more information on the programs, you can find the presentation from the national call online.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Posted at 11:09AM Jan 23, 2013 by David Twiddy, Associate Editor  |  Comments[0]

Audit alert: Notable items in the 2013 OIG work plan

Oct. 1, 2012 represents the start of the federal fiscal year. That makes now a good time to look at the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) work plan for the current fiscal year, especially as it relates to physician services under the Medicare program. Knowing what the OIG is examining can sometimes provide a useful “heads up” on issues that Medicare itself may focus on during the coming 12 months.

First, OIG has no fewer than five items on its work plan aimed at diabetes testing supplies:

• Supplier compliance with payment requirements for blood glucose test strips and lancets,
• Effectiveness of system edits to prevent inappropriate payments for blood-glucose test strips and lancets to multiple suppliers,
• Potential questionable billing for test strips in 2011,
• Improper supplier billing for test strips in competitive bidding areas,
• Supplier compliance with requirements for nonmail order claims.

Although most of these items are aimed at suppliers, it is reasonable to expect that such attention may prompt those suppliers to be more demanding of physician prescribers. Given the incidence of diabetes among family medicine patients, family physicians are among the most common prescribers of such supplies.

For those practices that have office laboratories, the OIG’s work plan has at least three items of interest:

• Billing characteristics and questionable billing in 2010,
• Reasonableness of Medicare payments compared to those by state Medicaid and Federal Employees Health Benefit programs,
• Part B payments for glycated hemoglobin A1C tests.

Finally, in the particular area of physician services, the following items stand out:

• Noncompliance with assignment rules and excessive billing of beneficiaries,
• Error rate for incident-to services performed by nonphysicians,
• Place-of-service coding errors,
• Evaluation and management (E/M) services—potentially inappropriate payments in 2010.

Regarding the last item on this list, the OIG work plan states:
We will determine the extent to which the Centers for Medicare & Medicaid (CMS) made potentially inappropriate payments for E/M services in 2010 and the consistency of E/M medical review determinations. We will also review multiple E/M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. Medicare requires providers to select the code for the service on the basis of the content of the service and have documentation to support the level of service reported.

The OIG’s review will focus on 2010 services, but it is reasonable to expect that this will be an area of focus going forward. Since E/M services represent the “bread and butter” of family medicine, and in light of the increasing use of EHRs in family medicine practices, this is one area that probably merits an internal review for most family medicine practices now and in the future.

Of course, the OIG’s work plan is more extensive than just the items listed above, so a scan of the table of contents for that work plan would probably be in order to see if there are other items that may be relevant to your particular practice.  Explanations of all items are included in the OIG work plan.

–Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Posted at 04:09PM Oct 24, 2012 by Lindsey Hoover, Asst. Editor  |  Comments[0]

EHR incentives and PQRS can work together

I have written before about the Medicare Physician Quality Reporting System (PQRS) and the advantages of the registry-based or electronic health record (EHR)-based reporting options. Though the incentive payment for successful reporting in 2012 will be only .5% of your total allowed charges for covered Medicare Part B services provided during the reporting period, there are other reasons to report.

First, those of you who are participating in the Medicare EHR incentive program may be able to satisfy the core requirements for reporting clinical quality measures (CQMs) through Medicare's Physician Quality Reporting System – Electronic Health Record (EHR) Incentive Pilot. Beginning in 2012, eligible professionals may satisfy the meaningful use objective to report the 44 CQMs to the Centers for Medicare & Medicaid Services (CMS) in two ways:

1. Using the Medicare and Medicaid EHR Incentive Programs’ web-based Registration and Attestation System, or

2. Participating in the Physician Quality Reporting System – Medicare EHR Incentive Pilot, which utilizes the 2012 Physician Quality Reporting System EHR Measure Specifications.

By submitting specific Physician Quality Reporting EHR Measures through the pilot, participants can focus on the same sample of beneficiaries for the Medicare EHR Incentive Program and for the Physician Quality Reporting System for the 2012 program year. Eligible professionals participating in the Physician Quality Reporting System – Medicare EHR Incentive Pilot are still required to report the other meaningful use objectives through the Medicare and Medicaid EHR Incentive Programs Registration and Attestation System.

Second, beginning in 2013, failure to successfully report PQRS measures will result in an adjustment (penalty) of -1.5 percent on all Medicare payments in 2015.

Third, even those without a qualified EHR system can successfully participate in the PQRS program without the hassles of the claims-based reporting that has proven quite burdensome and unsuccessful for many practices. The registry-based option allows for successful reporting with selection of a measures group for which you will report on 30 Medicare patients using an online registry program such as the AAFP PQRIwizard.

You can find more information on the PQRS program and the EHR-based and registry-based reporting options on the CMS PQRS Alternative Reporting Mechanisms page. Don't give up the full amounts allowed under the Medicare Physician Fee Schedule.

Posted at 02:17PM Mar 08, 2012 by Cindy Hughes  |  Comments[0]

CMS proposes to align eRx and EHR incentive programs

We have previously posted that even though physicians who are participating in the Centers for Medicare & Medicaid Services (CMS) EHR Incentive Program in 2011 are not eligible to receive an incentive under the CMS eRx Incentive Program, they could be subject to a penalty for not participating in the eRx Incentive Program (1 percent for 2012, 1.5 percent for 2013, and 2 percent for 2014). In a proposed rule published in the June 1, 2011, Federal Register, CMS has noted their desire to better align the two programs. This proposed rule is complex but has key provisions of importance to any physician who may be subject to a penalty for failure to participate in the CMS eRx Incentive Program but who intends to participate in the EHR Incentive Program this year.

CMS proposes that use of an EHR meeting the certification requirements for meaningful use will qualify for a hardship exemption under the CMS eRx Incentive Program. CMS is proposing that the eligible professional  must: 

1. Have registered for either the Medicare or Medicaid EHR Incentive Program (for instructions on how to register for one of the EHR Incentive Programs, see the registration page of the EHR Incentive Programs section of the CMS web site); and 

2. Provide identifying information as to the certified EHR technology (as defined at 45 CFR 170.102) that has been adopted for use no later than October 1, 2011, for a hardship exemption to be submitted, which then would be reviewed on a case-by-case basis.

In requesting a significant hardship exemption of the type CMS is proposing, physicians would be attesting to having purchased certified EHR technology (as identified by the certification number and/or serial number) or having the specified certified EHR technology available for immediate use with the intention of using it to qualify for a Medicare or Medicaid EHR incentive payment for 2011.

Because this proposed change would not be finalized before June 30, 2011 (the end of the 2012 eRx payment adjustment reporting period), it would not apply for purposes of reporting the eRx measure for the 2012 eRx payment adjustment. In other words, meeting this new hardship exemption could qualify you for the 1 percent incentive in 2011 and exempt you from the 1.5 percent penalty in 2013, but you will still need to submit 10 claims indicating your use of a qualified eRx system before June 30, 2011 to avoid the off-setting 1 percent penalty for 2012.

In the proposed rule, CMS has suggested additional exemptions for the eRx program. If the rule is implemented, physicians would be able to request consideration for a significant hardship exemption from the 2012 eRx payment adjustment if one of the following circumstances applies:

• The practice is located in a rural area without high speed Internet access.

• The practice is located in an area without sufficient available pharmacies for electronic prescribing.

• The physician has registered to participate in the Medicare or Medicaid EHR Incentive Program and adoption of certified EHR technology.

• The physician lives in an  area where a local, state or federal law or regulation prevents e-prescribing (e.g., such as those prohibiting paperless prescriptions for narcotics). (Must cite law/regulation.)

• The physician has limited prescribing activity. (Must submit number of prescriptions written.)

• The physician has insufficient opportunities to report the electronic prescribing measure due to limitations of the measure's denominator.

The proposed rule would require that you provide the following to CMS by Oct. 1, 2011, to request an exemption:

1. Identifying information such as the TIN, NPI, name, mailing address, and e-mail address of all affected eligible professionals.

2. The significant hardship exemption category(ies) above that apply.

3. A justification statement describing how compliance with the requirement for being a successful electronic prescriber for the 2012 eRx payment adjustment during the reporting period would result in a significant hardship to the eligible professional or group practice.

4. An attestation of the accuracy of the information provided.

CMS proposes to have an online tool for submission of exemptions by Oct. 1, 2011, but should that fail to happen, requests for exemption would need to be submitted by mail and postmarked no later than that date. We will keep you posted on how this works out.

CMS is requesting comments on this proposed rule and particularly on whether the serial number of the EHR product should be required for identification of the certified EHR technology the physician has purchased and adopted to meet the requirements for the EHR incentive program. The AAFP will submit a comment letter about this still overly complex process. You too can provide comments online at www.regulations.gov (enter ID CMS-3248-P to bring up this docket). The rule is open for public comment until July 25, 2011.

Posted at 05:07PM Jun 11, 2011 by Cindy Hughes  |  Comments[4]

Performance measurement and reporting: Finding a method in the madness

As if it wasn't already hard enough for physicians to provide care and get paid by Medicare, many physicians and their staffs are now documenting and reporting data to demonstrate "meaningful use" of electronic health record (EHR) systems, quality (for the Physician Quality Reporting System, or PQRS, formerly PQRI), successful e-prescribing and more. The seeming (and sometimes glaring) lack of coordination across these programs has created barriers to successful participation that may actually detract from the intended increases in quality and coordination of care. 

I hope I have stumbled onto something that might help family physicians and their staff members who are considering how to report the required measures while still having the time and sanity to provide patient care. In developing information on the new Medicare annual wellness visit and the documentation necessary to be paid for that newly covered benefit, I researched the extent to which documentation of preventive services might also be used to support both the PQRS and the meaningful use reporting requirements.

The following table identifies areas of overlap and notes regarding the frequency with which Medicare will pay for the preventive services.

Of course each of the programs has its own measure specifications and reporting methodologies, so it may provide much relief to use one measure to meet multiple reporting requirements. However, the table might help you to better organize your efforts.

For instance, is your EHR approved by CMS for use in reporting data to the PQRS program? If not, have you considered using a registry for this purpose? If you are providing annual wellness visits or otherwise documenting your patients' preventive care, registry-based reporting, which requires reporting data for only 30 Medicare patients, might be more easily accomplished. Do you have other ideas for participating in these initiatives with the least amount of administrative burden? If so, I hope you'll share your comments below. Others will appreciate your help.

Posted at 02:30PM Apr 21, 2011 by Cindy Hughes  |  Comments[0]

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.

Posted at 11:37AM Dec 06, 2010 by Cindy Hughes  |  Comments[0]

ICD-10: Y2K all over again?

People often see things differently. Two neighbors may call their county government offices, one to ask that weeds be sprayed along the road and another asking for a no-spray ordinance. Health care is not immune to such conflicting priorities.

Some are anxiously counting the days until the Oct. 1, 2013, deadline for adoption of the ICD-10-CM codes and the "granularity" they promise. I doubt many practicing physicians are among that group. A letter to the Centers for Medicare & Medicaid Services from Jim King, MD, chairman of the AAFP Board of Directors, left no doubt the AAFP did not support this change. That said, I hope you are not losing sleep, hoarding canned goods or preparing to duck for cover. The transition from ICD-9 to ICD-10 will create some challenges but will not likely result in widespread calamity.

Don't get me wrong. This is not your average annual code update. As reported by the American Academy of Professional Coders, when the Blue Cross Blue Shield Association converted the 164 ICD-9 codes included in FPM's model superbill to ICD-10, the resulting mess was seven pages longer than the original list. (The FPM Superbill has been updated for 2009; you can download it from the FPM Toolbox.) Clearly the ICD-10 code set is cumbersome compared to ICD-9, but it's not as difficult as learning to diagnose and manage the 68,105 conditions that may be reported with ICD-10. You can handle this.

Here are some things to consider as the Oct. 1, 2013, implementation deadline approaches:

1. You will no doubt soon receive ads for ICD-10 products and educational resources. Please don't waste your money. Learning a complex coding system that you will not use for nearly five years isn't productive, and changes could be made to the code set before 2013. Keep reading FPM and plan to learn more when implementation is closer.

2. Don't let ICD-10 overshadow another change with the potential for significant financial impact, especially for solo and small practices -- the conversion to the HIPAA 5010 electronic transaction standards, which must be completed by Jan. 1, 2012. Version 5010 is an extensive revision and paves the way for submission of ICD-10-CM codes. If your software vendor charges for upgrades or floundered during prior changes, now is the time to start asking questions about implementation plans and considering your options (e.g., upgrade or change vendors).

3. If you think you might need to change your software, consider a combined EHR/practice management system. A combined system may relieve some of the ongoing burdens and costs of transitioning to ICD-10. Imagine having an ICD-10 look-up tool similar to the FPM ICD-9 Look-Up Tool built into your EHR and integrated with your billing system, or a system that automatically converts standardized nomenclature to codes.

Most of you have endured the Medicare enrollment process, so you are combat-tested. And you are not alone. The AAFP and FPM will continue to provide you with the best resources that we can find or create to help you make the transition to ICD-10.

Posted at 03:50PM Jan 29, 2009 by Cindy Hughes  |  Comments[1]