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Medicare’s eRx and EHR Incentive Programs─Clearing Up the Confusion for Anesthesiologists

MEDICARE'S eRx AND EHR INCENTIVE PROGRAMS─CLEARING UP THE CONFUSION FOR ANESTHESIOLOGISTS

August 15, 2011

Attestation to earn a bonus under the Medicare Electronic Health Record (EHR) Incentive program began on April 18, 2011.  As of July a total of 566 Eligible Professionals (EPs) had received a total of $18,432,000 in incentive payments,

Most anesthesiologists and pain physicians – but not all – will be unable to participate successfully in the electronic health record (EHR) incentive program, at least for now.  Neither specialty appears on CMS’ most recent report of eligible physicians by specialty.  You have until October 2012 to begin and still receive the full bonus, however.

Most readers will be also exempt from the Medicare requirement that they use e-prescribing (eRx) technology and will be ineligible for the corresponding bonus.  People are hearing different things from different sources, e.g., Medicare carriers, billing companies, IT vendors and the storied word of mouth, and we are encountering both unrealistic fears and unrealistic explanations.  A review of what each program requires or offers seems in order.

  eRx EHR

Statutory Source

Medicare Improvements for Patients and Physicians Act of 2008 (MIPPA) HITECH provisions of American Recovery and Reinvestment Act of 2009 (ARRA)
Regulations Proposed Rule, June 1, 2011

Proposed Fee Schedule Rule, 7/1/11

Final Rule, July 28, 2010

Proposed Fee Schedule Rule, 7/1/11

Bonus 2011-2012: 1.0% of total estimated Medicare allowed charges1

2013: 0.5%

2011 : 75% of allowed charges up to a maximum of $18,0002

Over 4 years, maximum of $44,000 total.

Can Earn Bonus Under Other Program Too EHR – No, not in same year

PQRS – Yes

eRx – No, because 1 core measure requires e-prescribing

PQRS – Yes

Penalty 2012:-1% if EP does not submit ≥10 claims with eRx modifier (G8553) between 1/1/2011 and 6/30/2011

(Proposed Rule would extend 6/30 deadline to 10/1/11, and create 6-month, 10-claim periods as well as the 12-month periods in 2013-2014)

2013: -1.5% if ≥25claims with G8553 by 12/31/2011.

2014: -2.0% if ≥25 claims with G8553 year ending 12/31/2012

2015: -1.0%

2016: -2.0%

2017 on: -3%

Eligibility Physicians, CRNAs, AAs et al. who adopt qualified eRx technology and who do not request/obtain hardship exemption
  • Physicians who provide ≤90% of their services on inpatient basis or in emergency department
  • 50% of your Medicare allowables must be in facilities with EHR
  • 80% of patients must have records in the certified EHR. The 2nd and 3rd requirements will disqualify most anesthesiologists
  100 outpatient visits & 10% of Medicare allowables must come from such visits Must register with CMS &
Major Action Required Report use of qualified eRx technology on x , y claims for outpatient (office) visits during measuring period.

x = 10 claims, 1/1/11 -6/30/11

y = 25 claims, 1/1/11-12/30/11; 25 claims, 1/1/12-12/31/12

Use certified EHR (with capabilities specified in regulations) to demonstrate meaningful use &
    Demonstrate “meaningful use” (MU) of EHR for (1) consecutive 90 days in 2011, i.e., start no later than October 1, and (2) full calendar year 2012 on.
    Stage 1 (through 2012) MU:15 required core objectives3 + 5 out of possible 10 "menu set" objectives 4
    1 core measure requires use of Clinical Quality Measures:5 3 required + 3 out of possible 386
Group Practice Reporting Option (GPRO) Groups participating in PQRS GPRO may also use GPRO for eRx program.

Proposed Rule would create new criteria + self-nomination process for eRx or PQRS incentive programs

 
Hardship Exemption Available upon request if: (1) rural area w/o internet or (2) insufficient pharmacies for e-prescribing

Proposed additional exemptions include one for MDs most of whose Rxs are for narcotics.7 Must apply by October 1, 2011.

 
Documentation HCPCS code G8553 Reporting may be yes/no or numerator/denominator
Reporting Methods Claims-based, EHR, Registry

 

2011: Attestation

 

2012: Attestation, or Proposed Rule: participate in PQRS-EHR Incentive Pilot and report electronically.

 

 

Key concepts in the eRx and EHR Incentive Programs are expanded in the linked documents and/or in the footnotes below. Additionally, by Wednesday, August 17, a set of source documents that includes much more detailed information on the requirements for reporting each measure in the EHR program will be available to clients on our website. We hope that this Alert will be helpful in clearing up some of the misunderstandings about the operation of the various CMS incentive programs discussed here.

Sincerely,
 

Tony Mira

President and CEO

1http://www.cms.gov/ERxIncentive/Downloads/erxintroeprescribing.pdf .

2 EHR Payment Schedule

Eligible Professionals may earn incentives based on an amount equal to 75% of their Medicare allowed charges, subject to the annual limits in the table below. Example: if your allowed charges are $20,000, your maximum bonus is $15,000.

Year 2011 2012 2013 2014 2015 2016 Total Penalty
2011 $18,000 $12,000 $8,000 $4,000 $2,000 $0 $44,000  
2012   $18,000 $12,000 $8,000 $4,000 $2,000 $44,000  
2013     $15,000 $12,000 $8,000 $4,000 $39,000  
2014       $12,000 $8,000 $4,000 $24,000  
2015               1%
2016               2%
2017+               3%

 

3 Eligible Professionals – 15 Core Objectives

  1. Computerized provider order entry (CPOE)
  2. E-Prescribing (eRx)
  3. Report ambulatory clinical quality measures to CMS/States
  4. Implement one clinical decision support rule
  5. Provide patients with an electronic copy of their health information, upon request
  6. Provide clinical summaries for patients for each office visit
  7. Drug-drug and drug-allergy interaction checks
  8. Record demographics
  9. Maintain an up-to-date problem list of current and active diagnoses
  10. Maintain active medication list
  11. Maintain active medication allergy list
  12. Record and chart changes in vital signs
  13. Record smoking status for patients 13 years or older
  14. Capability to exchange key clinical information among providers of care and patient-authorized entities electronically
  15. Protect electronic health information

4 Eligible Professionals – Choose 5 out of 10 Menu Set Objectives

  1. Drug-formulary checks
  2. Incorporate clinical lab test results as structured data
  3. Generate lists of patients by specific condition
  4. Send reminders to patients per patient preference for preventive/follow-up care
  5. Provide patients with timely electronic access to their health information
  6. Use certified EHR technology to identify patient-specific education resources and provide to patient
  7. Medication reconciliation
  8. Summary of care record for each transition of care/referrals
  9. Capability to submit electronic data to immunization registries/systems
  10. Capability to provide electronic syndromic surveillance data to public health agencies

5Clinical Quality Measures – Choose 3 CQMs from Core Set//Alternative Set plus 3 of 38 Additional CQMs

Core Set:

  1. Adult weight screening and follow-up
  2. Hypertension: blood pressure management
  3. Tobacco use assessment and intervention

Alternative Set:

  1. Childhood Immunization Status
  2. Influenza Immunization for Patients = 50 Years Old
  3. Weight Assessment and Counseling for Children and Adolescents

3 of 38 Additional CQMs

  1. Anti-depressant medication management (a) Effective Acute Phase Treatment, (b) Effective Continuation Phase Treatment
  2. Appropriate Testing for Children with Pharyngitis
  3. Asthma Assessment
  4. Asthma Pharmacologic Therapy
  5. Breast Cancer Screening
  6. Cervical Cancer Screening
  7. Chlamydia Screening for Women
  8. Controlling High Blood Pressure
  9. Colorectal Cancer Screening
  10. Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI)
  11. Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol.
  12. Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD
  13. Diabetes: Blood Pressure Management
  14. Diabetes: Eye Exam
  15. Diabetes: Foot Exam
  16. Diabetes: Hemoglobin A1c Control (<8.0%)
  17. Diabetes: Hemoglobin A1c Poor Control
  18. Diabetes: Low Density Lipoprotein (LDL) Management and Control
  19. Diabetes: Urine Screening
  20. Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
  21. Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy
  22. Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
  23. Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
  24. Pneumonia Vaccination Status for Older Adults
  25. Heart Failure (HF): Warfarin Therapy Patients with Atrial Fibrillation
  26. Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: (a) Initiation, (b) Engagement
  27. Ischemic Vascular Disease (IVD): Blood Pressure Management
  28. Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control
  29. Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic.
  30. Low Back Pain: Use of Imaging Studies
  31. Oncology Breast Cancer: Hormonal Therapy for Stage ICIIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer
  32. Oncology Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients
  33. Prenatal Care: Anti-D Immune Globulin
  34. Prenatal Care: Screening for Human Immunodeficiency Virus (HIV)
  35. Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation.
  36. Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients.
  37. Smoking and Tobacco Use Cessation, Medical assistance
  38. Use of Appropriate Medications for Asthma

See also http://www.ama-assn.org/ama1/pub/upload/mm/399/ehr-clinical-quality-measures.pdf

6 Although CMS requires all EPs to report core measures, there is no requirement to satisfy a minimum value for any of the numerator, denominator or exclusion fields for clinical quality measures. The value for any or all of those fields, as reported to CMS or the States, may be zero.

7 The proposed exemption for “Inability to electronically prescribe due to local, State or Federal law or regulation” will cover DEA and local prohibitions on electronic Rxs for narcotics. See June 6, 2011 Alert.