American Academy of Family Physicians
Friday Aug 29, 2014

CMS providing Meaningful Use exemption for slow Internet

Physicians working to comply with stage 2 of the Centers for Medicare & Medicaid Services' (CMS) Meaningful Use program know that not all of the requirements are under their control.

Specifically, more than 5 percent of patients must send a secure message to their physician that is received using the electronic messaging function of the electronic health record (EHR), and more than 5 percent must view, download, or transmit their health information to a third party.

But both of those require the patient having access to broadband Internet service.

Enough physicians in Internet-poor locales have asked CMS how they can be required to meet those guidelines that the agency has finalized an exemption.

Under the rule, an eligible professional will not have to meet either of the above Meaningful Use measures if at least 50 percent of his or her patient encounters are in a county where more than 50 percent of the housing units lack access to broadband download speeds of at least 3 megabits per second (Mbps), as measured by the Federal Communications Commission (FCC) on the first day of the EHR reporting period.

Physicians can check the broadband download speed in their county through the FCC's National Broadband Map. Click "Analyze the data" and then "Rank your geography." Under step one, pick "Rank within a State," click "County," and then select your state. Under step two, click "Speed" (which defaults to a download speed of > 3Mbps). On the next screen select "Manage metrics" and then click "% housing units." As an example, here's the breakdown for FPM's home state of Kansas.

It must be noted, however, that the FCC map is based on advertised broadband speeds not typical ones, so the vast majority of counties in the United States are considered to have access to broadband speeds of 3 Mbps or more.

That means unless you practice in some truly remote areas of the country, slow broadband may not be an adequate defense against Meaningful Use stage 2.

Friday Aug 08, 2014

More physicians using EHR, but little information flowing between them

A new survey shows that physicians, particularly those in primary care, are continuing to adopt electronic health record systems at a rapid pace.

In fact, almost 80 percent of office-based physicians reported using some form of an electronic health record (EHR) in 2013, according to the study performed by the Centers for Disease Control and Prevention's National Center for Health Statistics and released this week in Health Affairs. Forty-eight percent of all physicians said their EHR systems could perform a series of "basic" EHR functions, such as recording medication and allergy lists, saving clinical notes, prescribing medication electronically, or viewing lab and imaging reports. That was double the adoption rate in 2009 and up 22 percent from 2012.

Primary care physicians' rate of adoption was highest with 53 percent saying they had a basic system, compared with 43 percent of physicians in other specialties.

But the survey also found that relatively few physicians are using or are capable of using their EHR systems to exchange patient care information with their fellow physicians, hospitals, or health systems, or even the patients themselves. Only 39 percent of office-based physicians said they had performed health information exchange with other providers or hospitals last year. Providers in larger practices or those owned by a hospital or academic medical center were far more likely to exchange information than small and solo practices.

Patient engagement with the EHR was also lagging as only 41 percent of physicians said they had the ability to let patients view, download, or transmit their health information online. Of those, about half said they actually used it. And while close to half of all physicians said they could exchange secure messages with patients through their EHR, two-thirds said they didn't in 2013.

Those results will continue to create concerns ahead of the deadline for complying with Stage 2 Meaningful Use requirements, which particularly stress interconnectivity and patient outreach.

A separate study that focused on EHR adoption and use by hospitals found that almost 60 percent of hospitals had adopted at least a basic EHR, but less than 6 percent were considered ready for Stage 2 Meaningful Use.

For information on how your practice can meet Stage 2 Meaningful Use requirements, see "Making Sense of Meaningful Use Stage 2: Second Wave or Tsunami?" in the January/February 2014 issue of FPM.

Thursday May 22, 2014

One-stop shopping Medicare quality reporting programs

One of the downsides to participating in multiple Medicare quality reporting programs, such as the Physician Quality Reporting System (PQRS) or Meaningful Use, is that you often have had to report the same data separately for each.

The Centers for Medicare & Medicaid Services (CMS) has heard your woes, however, and created a new interactive tool that will help you submit your quality data one time only and earn credit for multiple programs.

The “Reporting Once for 2014 Medicare Quality Reporting Programs” tool provides guidance based on how you plan to participate in PQRS in 2014:

•    As an individual eligible professional
•    As part of a group practice
•    As part of a Medicare Shared Savings Program Accountable Care Organization (ACO)
•    As part of a Pioneer ACO

Using the interactive tool, you will learn whether you will be eligible for PQRS incentives in 2014, will avoid PQRS Medicare penalties in 2016, and can satisfy the clinical quality measure component of the Medicare Electronic Health Record (EHR) Incentive Program. If you are part of a group practice with 10 or more eligible professionals, the tool will also help you assess the impact of your participation in PQRS on the Value-Based Payment Modifier.

You can use these streamlining options only if you have participated in the Medicare EHR Incentive Program for more than a year, and you are still required to report your core and menu objectives through the CMS Registration & Attestation System.

To use the interactive tool, simply click on the green “Start” button on page two of the tool. You can also use the “How to Report Once for 2014 Medicare Quality Reporting Programs” fact sheet  for an overview of the quality programs and reporting once in 2014.

For step-by step instructions for 2014 PQRS participation, view the PQRS How to Get Started web page on the CMS web site. If you have additional questions, contact the QualityNet Help Desk at 866-288-8912 or via The Help Desk is available Monday through Friday from 7:00 a.m. to 7:00 p.m. (Central Time).

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

Tuesday May 13, 2014

Time to register for the 2014 group practice reporting option (GPRO)

This blog recently discussed how to avoid a Medicare payment adjustment under the Physician Quality Reporting System (PQRS) in 2016. We'll focus on one of those methods, meeting the satisfactory reporting requirement for the group practice reporting option (GPRO), registration for which is now available under the 2014 PQRS.

The program defines a “group practice” as a physician organization with its own single tax identification number (TIN) and two or more eligible professionals (EPs) who have individual national provider identifiers and have reassigned their billing rights to the TIN. When your group is ready, you can register through the Physician Value-Physician Quality Reporting System (PV-PQRS) at To choose your group's reporting mechanism, you will need a valid user identification and password for authorized access to the Centers for Medicare & Medicaid Services' (CMS). The registration system for the 2014 PQRS program will be open until Sept. 30.

GPRO participants who satisfactorily report data on PQRS measures during the 2014 reporting period (Jan. 1-Dec. 31) are eligible for a 0.5 percent incentive and will avoid the 2 percent pay cut in 2016. This is the last year that EPs can earn an incentive payment under PQRS.

The report those measures, GPRO participants can choose one of three mechanisms:

•    Qualified PQRS registry
•    Directly from an electronic health record (EHR) using certified EHR technology (CEHRT)
•    CEHRT via a data submission vendor

If your group has 25 or more EPs, you can also participate in GPRO via Web Interface. If the group practice has 25 or more EPs, then the group can elect to supplement its PQRS reporting mechanism with the Clinician and Group Consumer Assessment of Health Providers and Systems (CAHPS) survey. However, if the group practice has 100 or more EPs and has selected the Web Interface reporting mechanism for 2014, then the group is required to report the CAHPS survey.

Additional information about the 2014 GPRO registration and 2014 PQRS GPRO requirements is available on the CMS web site. For more information on how to register in the PV-PQRS Registration system, please visit the Self Nomination/Registration page. Finally, for questions about how to register, please contact the Quality Net Help Desk at 866-288-8912 (TTY: 1-877-715-6222), or by email:

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

Tuesday Feb 25, 2014

What's new with PQRS in 2014?

Time has almost run out on those participating in the Physician Quality Reporting System (PQRS) for the 2013 program year. But for those wanting to participate in 2014, it's time to prepare.

Some things to keep in mind in the new program year:

    •    This is the last year for which you can earn an incentive for satisfactorily reporting, and those who don't satisfy the 2014 PQRS quality measures will face a 2 percent payment adjustment (i.e. penalty) in 2016.
    •    Eligible professionals must report on nine measures across three National Quality Strategy domains through the use of claims, qualified registry, or electronic health record (EHR). In general, that’s an increase from 2013, when only three measures were typically required.
    •    Participants have fewer quality measures to choose to satisfy in 2014. The Centers for Medicare and Medicaid Services (CMS) has added 37 new individual measures and retired 45 from the 2013 list. That said, there are still plenty of measures from which to choose, and you should use the most current version of the 2014 PQRS measure specifications.
    •    Measure groups can only be reported through a qualified registry.
    •    EHR-based reporting is now available for groups participating in the Group Practice Reporting Option, and eligible professionals can now participate in the qualified clinical data registry (QCDR), a new reporting option for 2014. A list of CMS-designated QCDRs will be available on the CMS PQRS website in May 2014.
    •    Eligible professionals and group practices can no longer use the administrative claims-based reporting method to avoid a 2016 payment adjustment.

For more information, please review the "What's New in 2014" fact sheet. You can also visit the PQRS website or contact the PQRS Help Desk.

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

Tuesday Jan 28, 2014

Medicare offers two-for-one deal, of sorts

Are you an eligible professional trying to earn a 2013 incentive payment through Medicare’s Physician Quality Reporting System (PQRS)? Do you also hope to achieve an electronic health record (EHR) incentive from Medicare? If so, the Centers for Medicare & Medicaid Services (CMS) is offering you the chance to do both through its PQRS Medicare EHR Incentive Pilot.

The pilot program allows eligible professionals to meet the clinical quality measure (CQM) reporting requirement for the EHR program through electronic submission while also reporting for the PQRS program.

If you would like to participate in the pilot you must submit 12 months of CQM data by 11:59 p.m. (EST) on February 28, 2014, by taking the following steps:

1.    Register for an Individuals Authorized Access to the CMS Computer Services (IACS) account (for EHR submission only), if you do not have one already.
2.    Indicate in EHR Registration & Attestation System your intent to report CQMs using the pilot.
3.    Generate required reporting files.
4.    Test data submission.
5.    Submit quality data.

If you cannot submit your CQM data for 12 months electronically through PQRS, you must return to the EHR Attestation System and deselect the electronic reporting option. Please note: if you do not submit your 2013 quality data or deselect the electronic reporting option in the EHR Attestation System, you will not receive an EHR incentive payment.

For further guidance on the 2013 PQRS-Medicare EHR Incentive Pilot, please read the participation guide and quick-reference guide. If you have questions, please contact the QualityNet Help Desk at 1-866-288-8912 or via The Help Desk is available Monday through Friday from 7:00 a.m.-7:00 p.m. (CST).

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

Wednesday Jan 22, 2014

Survey shows Stage 2 meaningful use compliance still low

If physicians were required today to comply with the Stage 2 requirements of the federal "meaningful use" program, instead of later this fall, relatively few would be able to do so, according to a new Centers for Disease Control and Prevention (CDC) survey.

The National Ambulatory Medical Care Survey, released this month, found that only about 13 percent of office-based physicians said they both intended to participate in the Medicare and Medicaid EHR incentive programs and that their EHR was capable of supporting 14 of the meaningful-use program's 17 "core" objectives.

To comply with Stage 2, physicians will have to show that their EHRs can support all 17 core objectives and three of six "menu" objectives. For that reason, the CDC added that its 13 percent estimate may be too high.

About 56 percent of physicians who intended to participate in meaningful use said their EHRs were not capable of supporting 14 core objectives. Nineteen percent were uncertain if they would apply for the incentive program, and almost 12 percent said they were not.

Not complying with at least Stage 1 meaningful-use requirements by the end of the year will result in Medicare reimbursement cuts for those physicians, beginning in 2015.

Physicians who have already complied with Stage 1 of meaningful use for at least two years will have until October 2014 to begin complying with Stage 2. Those who didn't start Stage 1 until more recently will have later deadlines.

The CDC did say that for the seven Stage 2 meaningful-use capabilities for which statistics are available – including the ability of an EHR to record patient information and demographics, order prescriptions, send prescriptions to a pharmacy electronically, warn of drug interactions or contraindications, order lab tests, issue reminders for guideline-based interventions, and report immunization information to online registries – all saw an increase between 2010 and 2013 of the percentage of physicians able to comply.

The survey also found that more than 78 percent of office-based physicians had some form of EHR system last year, compared with a little more than 17 percent in 2003 and 51 percent in 2010.

For more information on Stage 2 meaningful use and how to comply with the new regulations, see this article in the January/February issue of Family Practice Management.

Monday Dec 09, 2013

Using EHRs doesn't have to hurt productivity

A key concern for medical practices as they add or increase their use of electronic health records is that taking time to enter data into those programs may make physicians and their staff less productive.

A new study published in the American Journal of Managed Care found that's typically not true if done correctly.

Researchers reviewed three years of EHR data provided by Athenahealth Inc. for 42 practices that ranged in size from one to 14 clinicians. They found that increasing EHR use can actually increase productivity, as can delegating EHR-related work from clinicians to support staff.

Productivity was measured in terms of relative value units (RVUs), with the 42 practices producing an average of 17.5 RVUs per clinician workday. EHR use was measured in the number of actions (inputting a patient's weight and blood pressure, for instance) performed per appointment, with the practices performing an average of 370. The study also found that clinicians delegated EHR tasks to staff 16 percent of time, on average.

Reviewing what happened when practices increased the number of EHR tasks per appointment, researchers found that a boost from 370 actions to 548 actions (one standard deviation) resulted in a 5.3 percent increase in RVUs. This translated to an additional 0.9 RVU per clinician workday, or the equivalent of an additional 20-minute visit with a patient new to the practice.

Increasing the rate of EHR tasks performed by non-clinicians from 16 percent to 37 percent (one standard deviation) boosted productivity by 11 percent, or 1.9 RVUs per clinician workday. That's the equivalent of a 40-minute visit with an established patient.

Practices of all sizes showed similar levels of productivity gains from each EHR strategy. However, combining the strategies affected small and larger practices differently.

Researchers said practices of four or more clinicians that increased both EHR use and delegation by one standard deviation were expected to see productivity gains of up to 5 percent. Smaller practices that attempted the same thing were expected to see productivity declines of 2 percent.

The study suggested that small practices have trouble realizing the same productivity benefits because increasing EHR use can disrupt the close coordination many small practices already thrive under. Larger practices, on the other hand, regularly split staff into defined task groups and EHR delegation simply reinforces this strategy.

Ultimately, the researchers argue that those overseeing federal efforts to increase EHR use need to consider how practices integrate EHR work and how these actions influence productivity as they develop future meaningful use targets or other criteria.

Monday Oct 28, 2013

Family physicians among the largest group getting EHR incentives

The number of eligible professionals receiving federal incentives for using electronic health records (EHRs) increased last year with family physicians being among the most likely to receive them.

The U.S. Government Accountability Office on Thursday released a review of Medicare incentive payments awarded in 2011-2012.

Overall, the government gave out $6.3 billion in EHR incentives to providers and hospitals last year, compared with $2.3 billion in 2011.

The GAO said 62,285 "general practice" physicians, a group that included family practice and internal medicine, received incentives in 2012, representing 43 percent of eligible general practice physicians in the country.  Far more specialty practice physicians received incentives – 102,328 – but that represented only 29 percent of the total eligible.

By comparison, 22,094 general practice physicians (16 percent of those eligible) and 29,259 specialists (9 percent) participated in the incentive program in 2011.

About two-thirds of individuals received the maximum 2012 Medicare incentive of $18,000.

Other characteristics of the 2012 recipients, according to the GAO:

  • 9 of 10 work in urban areas,
  • 44 percent had relatively high amounts of Medicare Part B charges,
  • 44 percent worked in practices of 10 or fewer professionals
  • They were almost twice as likely to receive incentives if they had requested technical assistance from their Regional Extension Center.

Thursday Oct 10, 2013

Quality care linked to physician satisfaction

A new study suggests that physicians are most satisfied with their jobs when they believe they are providing high-quality care. Researchers said obstacles to such care can diminish physicians' satisfaction and point to hidden problems in the health care system.

The RAND Corp. survey also found that physicians are eagerly awaiting improvements in the operation of electronic health record (EHR) systems, saying that while they support the promise this technology has to improve clinical care, the inherent problems with user interface, data entry, and reduction of face-to-face interaction with patients represent significant obstacles to professional satisfaction.

The study, sponsored by the American Medical Association and released this week, surveyed 447 physicians in six states. While acknowledging that it was a relatively small sample size and not designed to represent practices on a national basis, the researchers said it did include voices from a wide number of practice types.

The study found that physicians generally have accepted the clinical and professional benefits of EHRs in their practices, with only one in five expressing an interest in staying with or returning to paper-only practices. But they continue to have serious misgivings about the current limitations of many EHRs. For instance, they complained that EHRs are frequently difficult to use, require too much time commitment for entering data, often don't share information with other EHR products, and result in less useful clinical documentation. Also, some practices continue to find the price tag for switching to an EHRs prohibitive.

While waiting for improvements, practices are trying to fix some of those problems themselves, including employing new or existing non-physician staff for data entry or to interact with the EHR while the physician focuses on direct patient care. The researchers recommended that federal authorities include improved usability as a key requirement for EHR certification.

Other findings included respondents saying that health care reform in general hasn't yet affected physician professional satisfaction in either direction, other than producing uncertainty. Several practices said they've responded to the economic uncertainty by joining a hospital or other large delivery system or, at least, are considering it.

Some other recent regulations, however, are having an effect, most notably the meaningful-use rules tied to EHR implementation. Respondents said the rules require too much time and paperwork for compliance.

As for primary care physicians in particular, the survey found some respondents complaining of physicians in other specialties treating them or their staff as inferior. They also said that their level of job satisfaction suffered when the pressure to provide more services to more people limited the amount of time and attention they could spend with individual patients. They also found that physicians of all kinds tend to get more satisfaction when they enjoy greater autonomy and control over the pace and content of their clinical work.

Respondents across the spectrum of health care also said they expected primary care physicians to see an increase in relative income in the future at the expense of sub-specialists.

Wednesday Jan 23, 2013

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

Wednesday Oct 24, 2012

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

Thursday Mar 08, 2012

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.

Saturday Jun 11, 2011

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 (enter ID CMS-3248-P to bring up this docket). The rule is open for public comment until July 25, 2011.

Thursday Apr 21, 2011

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.

Preventive service

2011 Medicare PQRS measure

EHR “meaningful use” incentive measure

Medicare benefit

Blood pressure


included in annual wellness visit benefit 

BMI screening and follow-up

yes yes

included in annual wellness visit benefit

Tobacco use screening and cessation intervention

yes yes

covered – up to 8 sessions in 12 months

Influenza immunization for patients 50 years and over

yes yes

covered once per season 

Pneumonia vaccination for patients 65 years and over



covered once

Screening mammography

yes yes

covered annually

Colorectal cancer screening

yes yes

covered – schedule depends on screening type

Alcohol use screening



national coverage analysis in progress

Osteoporosis screening or therapy



bone mass measurement covered for estrogen-deficient or clinically at-risk patients

Urinary incontinence screening for women 65 years and over





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.

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