3/29/2012
eRx Penalty Updates

CMS Considers eRx Penalty Errors on Case-by-Case Basis

In their March 21, AMA Wire Newsletter, the American Medical Association (AMA) urges physicians who believe their Medicare payments have been reduced by the ePrescribing (eRx) penalty in error to contact the Centers for Medicare & Medicaid Services (CMS) and ask them to reconsider their case. In the article, the AMA states that they have, “secured CMS's commitment to reconsider the cases of physicians who believe they fulfilled the 2011 Medicare ePrescribing program requirements or applied for a hardship exemption.”

The AMA published the following examples of common scenarios that they say may allow you to avoid the penalty:

·         You ePrescribed in 2011, but the G8533 code was removed from the claims you submitted to Medicare. (For example, your billing vendor or clearinghouse mistakenly removed the code.) You must have documentation of your ePrescribing activity.

·         You reported the wrong G-code on your claims. (For instance, you used a 2009 ePrescribing code instead of the 2011 code.) You must have documentation of your ePrescribing activity.

·         Your hardship exemption request was denied because you included your group National Provider Identifier (NPI) rather than your individual NPI.

·         You filed a hardship exemption request but did not receive a response from CMS.

The AMA directs physicians who feel they are receiving the 1% 2012 eRx penalty in error to contact CMS's Quality Net Help Desk by calling (866) 288-8912 or by sending an email to qnetsupport@sdps.org.

CMS also recently emailed an eRx Payment Adjustment Update addressing the many inquiries they are receiving about the Medicare Electronic Prescribing (eRx) Incentive Program and the 1% eRx payment adjustment. In their message, CMS sought to clarify their statutory authority, as outlined in Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), to adjust the payments of eligible professionals who are not successful electronic prescribers beginning in 2012. 

CMS reminds providers that the requirements for being a successful e-prescriber and avoiding the 2012 payment adjustment were listed in the 2011 Physician Fee Schedule final rule. CMS further states that in February 2012, all eligible professionals who did not meet these requirements were sent a letter notifying them of this fact.  Finally, CMS refers to the stand-alone eRx rule published on Tuesday, September 6, 2011, which provided additional circumstances under which eligible professionals would qualify for hardship exemptions. CMS extended the deadline for eligible professionals to submit a request for a hardship exemption for the 2012 eRx payment adjustment to November 8, 2011.  CMS reports that they finished reviewing the hardship requests in February 2012, and they are continuing to notify requestors via email whether their request was approved or denied. 

While there is no appeal or review process for the Medicare eRx Incentive Program and payment adjustment, CMS is encouraging eligible professionals with questions or concerns about the eRx payment adjustment and hardship exemption requests to contact the QualityNet Help Desk.  CMS reports that they are handling all hardship exemption requests and any questions or concerns on a case-by-case basis. The QualityNet Help Desk can be reached Mon – Fri, 7am-7pm CMT, at 866-288-8912 or QNetSupport@sdps.org.

Act Now to Avoid the 2013 & 2014 eRx Penalty

Eligible providers who were not successful e-prescribers in 2011, and who do not qualify for a hardship exemption must report G8553 for at least 10 Medicare physician fee schedule (MPFS) encounters via the claims process for dates of service January 1 – June 30, 2012 to avoid the 1.5% eRx penalty in 2013. The eRx G-code, G8553, can be reported on any Medicare Part B claim that includes a billable Part B service, regardless of whether the claim contains coding in the eRx measure’s denominator. The claims containing the eRx G-code must be processed into the NCH no later than July 27, 2012.

To avoid the 2014 2% eRx penalty, eligible providers must be a successful e-prescriber in 2012 or report G8553 for at least 10 Medicare physician fee schedule (MPFS) encounters via the claims process for dates of service between January 1 – June 30, 2013. The eRx G-code can be reported on any Medicare Part B claim that includes a billable Part B service, regardless of whether the claim contains coding in the eRx measure’s denominator. The claims containing the eRx G-code must be processed into the NCH no later than July 26, 2013.

It is important to remember that the directions above for avoiding the 2013 eRx penalty do not qualify the eligible provider to receive the eRx payment incentive. To qualify for the incentive payment in 2012, EPs must report the eRx measure G8553 for at least 25 unique visits associated with one or more denominator-eligible visits (listed below) during the reporting period of January 1- December 31, 2012.

Denominator-eligible visits:
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, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0101, G0108, and G0109.

For complete information on how to avoid the 2013 and 2014 eRx payment adjustments, please visit the Electronic Prescribing Incentive Program webpage and review MLN Matters Article #SE1206.

CMS provides the following guidelines for an individual eligible professional or group practice participating in the eRx Group Practice Reporting Option (eRx GPRO) to follow in order to become incentive eligible:

•      Each visit must be accompanied by the eRx G-code indicating at least one prescription was electronically prescribed (electronic prescriptions not associated with a code in the denominator of the eRx measure specification do not count toward the minimum eRx events).

•      Electronically generated refills not associated with a face-to-face visit do not qualify as an eRx event.

•      Faxes do not qualify as an eRx event.

•      Submit a minimum of 25 denominator-eligible eRx events between January 1 and December 31, 2012 (for individual eligible professionals).

•      Submit a minimum of 625 denominator-eligible eRx events between January 1 and December 31, 2012 for small eRx GPRO participants (25-99 individual eligible professionals).

•      Submit a minimum of 2,500 denominator-eligible eRx events between January 1 and December 31, 2012 for large eRx GPRO participants (100 or more individual eligible professionals).

Detailed information regarding participating in the 2012 eRx Incentive Program for incentive payment can be found in the 2012 eRx Measure Specification document, available on the eRx website http://www.cms.gov/ERxIncentive , under the "E-Prescribing Measure" section.

2013 Hardship Codes & Exemption Requests
CMS may exempt individual eligible professionals and group practices participating in the eRx GPRO from the 2013 payment adjustment if it is determined that compliance with the requirement for being a successful electronic prescriber would result in a significant hardship.

Hardship Exemption Circumstances and Codes:

·        Inability to electronically prescribe due to state, or federal law, or local law or regulation;

·        The eligible professional prescribes fewer than 100 prescriptions during a 6–month payment adjustment reporting period;

·        The eligible professional practices in a rural area without sufficient high-speed Internet access (G8642); and

·        The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing (G8643).

2/17/2012
ICD-10 Delay & SGR Fix

CMS ANNOUNCES THEY WILL DELAY ICD-10 IMPLEMENTATION

In a press release yesterday, February 16, Health and Human Services (HHS) Secretary Kathleen G. Sebelius announced that HHS would initiate a process to postpone the ICD-10 compliance date. According to Secretary Sebelius, the postponement of the ICD-10 compliance date is in keeping with President Obama’s commitment to reducing regulatory burden.

The final rule adopting ICD-10 as a standard was published in January 2009 with a compliance date of October 1, 2013. Entities covered under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) will be required to use the ICD-10 diagnostic and procedure codes.

The American Medical Association (AMA) has been advocating for a delay in the implementation of ICD-10, citing high economic and administrative burdens at a time when physicians are also working to implement EHRs and electronic prescribing in order to avoid Medicare penalties. Furthermore, according to AMA Executive Vice President and CEO James L. Madara, requiring doctors to use ICD-10 would offer no direct benefit to patient care.

In a recent letter to House Speaker John Boehner, Madara, stated, “Stopping the implementation of ICD-10, and calling on appropriate stakeholders including physicians, hospitals, payers, national and state medical and informatics associations, to assess an appropriate replacement for ICD-9 will help to keep adoption of EMRs and physician participation in quality and health IT programs on track and reduce costly burdens on physician practices.”

In the February 16 press release announcing the ICD-10 postponement, Secretary Sebelius states, “ICD-10 codes are important to many positive improvements in our health care system. We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead.  We are committing to work with the provider community to reexamine the pace at which HHS and the nation implement these important improvements to our health care system.”

HHS gave no indication that they would consider an alternative to ICD-10.

CMS Acting Administrator Marilyn Tavenner said the agency will use the rulemaking process to establish the new ICD-10 implementation timeline.

ANOTHER TEMPORARY SGR FIX

On February 16, the U.S. Senate Committee on Finance published a press release announcing a payroll tax holiday bill, the Middle Class Tax Relief and Job Creation Act of 2012.  This bill would provide another temporary halt to the pending 27.4% cut to physician payments by extending the current Medicare payment rates through December 31, 2012. The bill would also extend the existing 1.0 floor on the physician work index through December 31, 2012.

The bill also contains offsets to pay for the Medicare spending in the bill including a reduction in hospital bad debt reimbursement, a 2% reduction in clinical lab payment rates in 2013 and a 1-year extension to the Affordable Care Act (ACA) Disproportionate Share Hospital (DSH) payment reductions.

The 27.4% cut to physician payments will go into effect on March 1, 2012 unless Congress acts prior to that date.

12/27/2011
Update - 5010 Transaction Standards

Important Alert – CMS Delays Enforcement Penalties of 5010

The compliance date for use of the new Version 5010 transaction standards remains Sunday, January 1, 2012, however on November 17, CMS’ Office of E-Health Standards and Services (OESS) announced that they would not initiate enforcement action for the use of the new standards until Saturday, March 31, 2012.

Nevertheless, providers are urged to continue preparation for the timely transition to the HIPAA 5010 standards as it is likely that many of your business partners (software vendors, payers, clearinghouses etc.,) will transition to 5010 by the compliance date of January 1, 2012, which would mean those providers who are still using 4010 would experience the rejection of their electronic transactions.  Therefore, it remains vitally important that you complete testing Version 5010 transactions and contact your vendors, payers and clearinghouse to determine when they will be implementing Version 5010.

The enforcement discretionary period is for 90 days after the January 1, 2012 compliance date. According to CMS, if a complaint is received by CMS after January 1, 2012, the entity against which the complaint has been filed will be evaluated to determine its level of compliance. An assessment will be made of the filed-against entity's efforts to test and become compliant. OESS will take appropriate actions as permitted under the authority of the HIPAA enforcement rule, but will not assess any penalties and/or civil monetary penalties during this 90-day period.

10/5/2011
OIG 2012 WORK PLAN

OIG PUBLISHES 2012 WORK PLAN – IDENTIFIES AUDIT & REVIEW ISSUES

The Office of Inspector General's (OlG) 2012 Work Plan is now available on the OIG Website. Each year the OIG publishes the Work Plan, which provides a brief description of audits and reviews they will be initiating or continuing during the fiscal year. Among the review issues listed by the OIG in their 2012 Work Plan are several new reviews that will be of interest to oncologists. The list below is a brief summary of the issue described in the 2012 OIG Work Plan.
  

Physicians and Other Suppliers: High Cumulative Part B Payments (New)
The OIG will review payment systems controls that identify high cumulative Medicare Part B payments to physicians and suppliers. The OIG will determine whether payment system controls are in place to identify such payments and assess the effectiveness of those controls. Medicare Part B services must be reasonable and necessary, adequately documented, and provided consistent with Federal regulations. A high cumulative payment is an unusually high payment made to an individual physician or supplier, or on behalf of an individual beneficiary, over a specified period. Prior OIG work has shown that unusually high Medicare payments may indicate incorrect billing or fraud and abuse.

Physicians: Incident-To Services (New)
The OIG will review physician billing for “incident-to” services to determine whether payment for such services had a higher error rate than that for non-incident-to services. They will assess CMS’s ability to monitor services billed as “incident-to.”  The OIG states that a previous report found that unqualified non-physicians performed 21% of the services that physicians did not perform personally. Incident-to services represent a program vulnerability in that they do not appear in claims data and can be identified only by reviewing the medical record.

Physician-Administered Drugs and Biologicals (New)

The OIG will compare Medicare and Medicaid payments for commonly used physician-administered drugs and biologicals to determine whether changes in the reimbursement methodologies for the Part B drug program would result in significant savings. Medicare Part B pays for most covered drugs and biologicals based on ASP plus 6%. Medicaid also covers physician-administered drugs and biologicals. However, under Medicaid, States have flexibility in determining reimbursement for covered drugs and biologicals as long as the ingredient cost approximates an estimated acquisition cost. In addition, manufacturers must provide rebates for Medicaid-covered drugs.

Medicare Payments for the Drug Herceptin (New)

The OIG will review payments associated with Medicare claims for the drug Herceptin to determine whether they were appropriate. For drug claims involving a single-use vial or package, if a provider must discard the remainder of a single-use vial or package after administering a dose/quantity of the drug or biological, Medicare provides payment for the amount discarded along with the amount administered, up to the amount of the drug or biological as indicated on the vial or package label. However, multiuse vials such as those used for supplying Herceptin are not subject to payment for discarded amounts of a drug or biological.

Medicare Outpatient Payments for Drugs (New)

The OIG will review Medicare outpatient payments to providers for certain drugs and the administration of those drugs (e.g., chemotherapy) to determine whether Medicare overpaid providers because of incorrect coding or overbilling of units. Prior OIG reviews have identified certain drugs, particularly chemotherapy drugs, as vulnerable to incorrect coding.

In addition to the new review issues listed above, the OIG will continue to review E/M claims for improper payments. They will review claims to identify trends in coding patterns, and the appropriate use of new or established patient codes, and they will review multiple E/M services for the same providers and beneficiaries, looking for medical records with identical documentation across services, to identify electronic health records (EHR) documentation practices associated with potentially improper payments.

The OIG is also continuing their review of payments for services ordered or referred by excluded providers and payments for off-label anticancer pharmaceuticals and biologicals.  

9/2/2011
Important eRx 2012 Payment Adjustment Changes

CMS FINALIZES eRx PROGRAM CHANGES

On August 31, CMS published the Medicare Program; Changes to the Electronic Prescribing (eRx) Incentive Program Final Rule. In the final rule, CMS finalizes their proposals to modify the eRx quality measure used for certain reporting periods in CY 2011, adopt additional hardship exemption categories for the 2012 eRx payment adjustment, and provide an extension to the deadline for submitting requests for exemptions from the 2012 eRx payment adjustment.

Summary of the significant changes in the final rule:

1. Revises the description of the 2011 eRx measure to indicate that the measure documents whether an eligible professional or group practice has adopted a "qualified" electronic prescribing system, that performs the four functionalities previously discussed, or Certified EHR Technology as defined at 42 CFR 495.4 and 45 CFR 170.102, regardless of whether the Certified EHR Technology has all four of the functionalities previously discussed.
   
   
2. Adds four new significant hardship exemption categories for the 2012 e Rx payment adjustment, bringing the total to 6 significant hardship exemptions:
   
   
   • The eligible professional or group practice practices in a rural area with limited high speed internet access;
   • The eligible professional or group practice practices in an area with limited available pharmacies for electronic prescribing;
   • Eligible professionals who register to participate in the Medicare or Medicaid EHR Incentive Program and adopt Certified EHR Technology;  New
   • The inability to electronically prescribe due to local, State, or Federal law; New
   • Limited prescribing activity; New
   • Insufficient opportunities to report the eRx measure due to limitations of the measure's denominator. New
     
     
3. Provides an extension of the deadline for submitting requests for exemptions from the 2012 eRx payment adjustment under the additional significant hardship exemption categories, as well as the two significant hardship codes established in the CY 2011 PFS final rule with comment period.
   
   The new deadline for submitting a hardship exemption request is November 1, 2011.
   
   
4. CMS also finalizes the process to request a significant hardship exemption from the 2012 eRx payment adjustment. Individual eligible providers will be required to submit significant hardship exemption requests using a Web-based tool only. CMS states that information on how to access the Web-based tool and detailed instructions for applying for a hardship exemption will be available on the eRx Incentive Program website at www.cms.gov/erxincentive.