Q: What is e-prescribing and when will it come to ophthalmology?


A: E-prescribing is the adoption of an electronic prescribing system that transmits prescriptions directly from the prescriber to a desired pharmacy. Electronic medical record systems typically have the capability to submit prescriptions electronically, but an EMR system is not required to E-prescribe, as stand-alone systems exist. Some systems are free to providers while others must be purchased. It is worthwhile to check with your existing practice-management vendor and ask if they have an E-prescribe module.


Q: What is the bonus program offered by Medicare?

A: The Medicare Improvements for Patients and Providers Act authorized a new financial bonus beginning in 2009 for eligible professionals who successfully implement E-prescribing. Eligible eye-care providers include ophthalmologists, optometrists, osteopaths, physician assistants, nurse practitioners, anesthesiologists, CRNAs, among others. 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 for the bonus program.


Q: Do I need to enroll?

A: No. Once an eligible provider has a qualified E-prescribing system in place, you begin participating by submitting appropriate codes from the E-prescribing quality measure on your claims to Medicare. While this program is specific to traditional Medicare, some commercial payers may also offer bonuses for E-prescribing. Check your larger commercial payers for additional information on bonus programs.


Q: Are all eligible providers entitled to a 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 percent of your total allowed charges for Medicare Part B covered services. Success is defined as reporting the measure with the appropriate "G" code on at least 50 percent of eligible claims.

Eligible providers may qualify for a 2 percent bonus in 2009 and 2010, a 1 percent bonus for 2011 and 2012, and a 0.5 percent 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. This is a calendar year program; there is no cap on the amount of bonus payment.


Q: Am I required to participate in this program?

A: No. But, 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 percent for 2012, 1.5 percent for 2013, and 2 percent for 2014 and beyond. Exceptions may be made by CMS on a case-by-case basis, and reviewed annually.


Q: In a group practice, must all physicians participate and be successful in order to receive the bonus?

A: No. Similar to the Physician's Quality Reporting Initiative program, the transmissions are tracked and bonus calculated by individual NPI numbers. But, the bonus payment will be a lump sum paid to the holder of the tax ID number.

As of January 1, 2009, this measure was removed from the PQRI program and is a stand-alone measure with a separate bonus program. As such, you are eligible to receive bonuses in both. If you are successful with both programs, you could receive a 4-percent bonus. If you are successful with one program and not the other, you would receive a 2-percent bonus.


Q: What must the system be capable of to be considered 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;

   • 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; and

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

"Conduct all alerts" refers to circumstances in which a written or acoustic signal warns 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. (2009 Electronic Prescribing Incentive Program, Version 1.0 – 11/7/08)


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, known as denominator codes, include the following: 90801-90809, 92002-92014, 96150-96152, 99201-99205, 99211-99215, 99241-99245, G0101, G0108, G0109.

When a claim is filed with a qualified denominator code (as noted above), one of the following G-codes must be added to the claim to count toward the incentive 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); or

   • 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 or other controlled substance).


Q: Is it too late to consider the E-prescribing bonus program?

A: No. Because the success threshold is 50 percent of eligible encounters, you could start later in the year and still be successful. The longer you wait though, the less likely you will succeed in 2009.  


Ms. McCune is vice president of Corcoran Consulting Group. Contact her at http://DMcCune@corco ran ccg.com.