Coding & Reimbursement

Prepare for E-Prescribing

By Suzanne L. Corcoran, COE

In 2009, Medicare initiates a new program that will enable practices to qualify for bonus payments for successfully participating in its electronic prescription (E-Prescribing) program. I'll address some commonly asked questions about the program.

Q. What is Medicare's E-Prescribing incentive program?

A. E-Prescribing is the adoption of an electronic prescribing system that transmits prescriptions ordered by the provider to a desired pharmacy. The Medicare Improvements for Patients and Providers Act (MIPPA) authorizes a new financial bonus for eligible professionals who successfully implement E-Prescribing.

Eligible professionals are defined in the Social Security Act. Eligible eyecare providers include ophthalmologists, optometrists, osteopaths, physician assistants, nurse practitioners, anesthesiologists and CRNAs. Eligibility is restricted by scope of practice to those professionals who have prescribing authority. All Medicare-enrolled eligible professionals, whether participating or non-participating, are eligible.

No enrollment is needed to participate in the E-Prescribing program. Once eligible providers have adopted qualified E-Prescribing systems, they begin submitting appropriate codes from the E-Prescribing quality measure on their claims.

Q. How do I qualify for the E-Prescribing bonus?

A. To be eligible for a bonus, your total Medicare-allowed charges for the specific CPT codes (exams and consultations) must be more than 10% of your total allowed charges for Medicare Part B covered services. This is obviously not a problem for ophthalmic practices. Success is defined as reporting the measure with the appropriate "G" code on at least 50% of eligible claims.

Q. How is the bonus calculated?

A. Eligible providers may qualify for a 2% bonus in 2009 and 2010, a 1% bonus for 2011 and 2012, and a 0.5% bonus in 2013. The bonus applies to all allowed charges, including the beneficiary's co-payments and deductible, not just those services associated with the E-Prescribing measure. There is no cap on the amount of bonus payment.

Penalties for non-compliance are anticipated. In 2012 and beyond, eligible professionals who are not successful E-prescribers will see a reduction in their fee schedule amounts. The reduction is 1% for 2012, 1.5% for 2013 and 2% for 2014 and beyond.

Q. What capabilities are required for a qualified E-Prescribing system?

A. Qualified systems must be able to:

► generate a complete active medication list

► select medications, print prescriptions, electronically transmit prescriptions and conduct all alerts (An alert is a written or audible signal warning the prescriber of possible undesirable or unsafe situations, including potentially inappropriate dose or route of administration of a drug, drug-drug interactions, allergy concerns or warnings and cautions.)

► provide information related to lower-cost, therapeutically appropriate alternatives (if any)

► provide information on formulary or tiered formulary medications, patient eligibility and authorization requirements received electronically from the patient's drug plan

► comply with Medicare Part D standards to the extent possible.

Electronic medical records are not required for E-Prescribing; standalone E-Prescribing systems exist. The American Academy of Ophthalmology publishes a list of qualified systems on its Web site.

Q. What codes do we add to the claim to report E-Prescribing?

A. When a claim is filed with a qualified code (as noted below), one of the following G-codes must be added to the claim to count toward the bonus:

► G8443: prescriptions generated via qualified E-Prescribing system

► G8445: E-Prescribing system available but no prescription(s) were generated due to patient/system reasons (no Rx generated)

► G8446: E-Prescribing system available, but not used for one or more prescriptions due to patient/system reasons (no access to system; state or federal law requires written or phoned-in Rx; patient request; pharmacy unable to receive electronic Rx; narcotic/other controlled substance).

Q. How is the E-Prescribing information reported to Medicare?

A. The reporting measure (i.e., G-code) is listed on the claim for each eligible patient visit in addition to the applicable visit code. Eligible visit codes include the following: 90801-90809, 92002-92014, 96150-96152, 99201-99205, 99211-99215, 99241-99245, G0101, G0108, G0109. OM