ALERT: You Must E-Prescribe By June 30th To Avoid Medicare Penalty

All physicians who receive Medicare reimbursement must e-prescribe by June 30, 2011, or they will face a one percent payment decrease beginning in 2012. 

The payment penalty will applied to to all Part-B covered professional services regardless of whether the eligible professional is planning to participate in the eRX Incentive Program or not.  

To determine which professionals or group practices are subject to the payment reduction, CMS will analyze claims data from January 1, 2011 - June 30, 2011, to determine if the eligible professional has submitted at least ten (10) electronic prescriptions during the first six months of calendar year 2011.

Group practices reporting as a GPRO I or GPRO II in 2011 must report all of their required electronic prescribing events in the first six months of 2011 to avoid the payment adjustment in 2012. Even practices that plan to adopt EHR systems between July and December, 2011 will be subject to Medicare payment reductions in 2012 if the eligible professional has not submitted 10 claims coded for e-prescribing between January and June, 2011.

Coding for E-presribing or for exemptions from e-prescribing include the following:

  • G8553 - At least one prescription created during the encounter was generated and transmitted electronically using a qualified EHR system. Note: If more than one prescription is generated for a patient during the same visit, then this would count as only ONE instance of E-prescribing

  • 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

  • G8644 - The eligible professional does not have prescribing privileges

The G-code should be combined with a visit that includes one of the following service codes: 90801, 90802,90804, 90805, 90806, 90807, 90808, 90809, 90862,  92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99324, 99325, 99326, 99327, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, and G Codes: G0101, G0108, G0109. The measure has no diagnostic code or age/gender requirements in order to be included in the denominator.

In order to avoid Medicare payment cuts in 2012 and 2013 all prescribers must be using an E-Prescribing system that is able to:

  • Generate a complete active medication list incorporating electronic data received from applicable pharmacies and benefit managers (PBMs if available).
  • Generate a prescription and allow users to print the prescription or send it electronically.
  • Alert users regarding undesirable or unsafe situations including potentially inappropriate dose/route of a drug, drug-drug interactions, drug allergy warnings.
  • Provide information on lower-cost, therapeutically appropriate alternatives if there are any. (The availability of an E-Prescribing system to receive tiered formulary information electronically would meet this requirement.)
  • Provide information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient’s drug plan (if available).
  • Convey the above information using the messaging and interoperability standards currently in effect for the Medicare Part D E-Prescription program.

Unfortunately there are no certifications that ensure an E-Prescribing system meets the requirements. As a result, you will need to ask your E-Prescribing vendor if they are compliant. 

If your practice does not have a full EHR system capable of generating an e-prescription, you may still meet the Medicare e-prescribing requirements by utilizing a stand-alone e-prescribing module. The following is a list of the e-prescribing modular systems that are approvable by the Ohio Board of Pharmacy:

*The Ohio Department of Job and Family Services (ODJFS) has contracted with ACS, its Pharmacy Benefits Manager (PBM) for Medicaid, to provide the CyberAccess system. CyberAccess is a user-friendly, HIPAA-compliant internet portal for providers to access pharmacy information regarding their patients. Prescribers can also use the tool to verify a drug's prior authorization status and to send “e-prescriptions” to pharmacies.  CyberAccess is fully funded by ODJFS and is FREE for all Ohio Medicaid Providers.  Please contact ACS at (614) 985-4534 to set up an in-office demonstration or to sign up for CyberAccess.

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