Title: Centers for Medicare
1Centers for Medicare Medicaid Services
- 2009 E-Prescribing Incentive Program
- 2008 MIPPA Legislation
- Michael T. Rapp, MD, JD, FACEP
- Director, Quality Measurement and Health
Assessment Group - Office of Clinical Standards and Quality
- Centers for Medicare Medicaid Services
- Baltimore, MD
2Overview
- E-Prescribing
- Electronic Prescribing Incentive Program
- Earning an incentive payment
- ERx system selection
- Getting more Information
3Background
- E-prescribing is the transmission, using
electronic - media, of prescription or prescription-related
- information between a prescriber, dispenser,
- pharmacy benefit manager (PBM), or health plan,
- either directly or through an intermediary,
including - an e-prescribing network
- E-prescribing includes, but is not limited to,
two-way - transmissions between the point of care and the
- dispenser
4Background
- Many potential benefits to e-prescribing
including safety, efficiency, formulary
adherence, drug surveillance, cost savings. - Limited adoption estimated only 5-18 of
prescribers e-prescribe
5Background
- The MMA and the creation of the Medicare
- Prescription Drug Benefit Program (Part D)
- promoted the use of electronic prescribing by
- requiring the adoption of interoperable Part D
- standards for Electronically prescribing Part
- D covered drugs prescribed to Part D
- eligible individuals.
6How eRx works
- An eligible professional decides to order a
prescription for a patient. - The prescription is entered into an eRx program
and is transmitted to the desired pharmacy. - Communication also occurs between the pharmacy
benefit manager and the physician.
7eRx Communication
8MIPPA Legislation - PQRI
- MIPPA enacted July 2008
- PQRI 2 incentive for 2009 and 2010 program
permanent - Electronic Prescriber
- Added separate incentive for a successful
electronic prescriber - 2009 and 2010 2
- 2011 and 2012 1
- 2013 0.5
- 2014 0
- Provided parallel future fee reduction penalty
- 2012 1
- 2013 1.5
- 2014 and beyond 2
9Future Penalties for Not Electronically
Prescribing
- Fee reduction is prospective based on
determination of successful electronic
prescribing based on prior date to be determined - This date will not be before 2010.
- Hardship exemption available for professionals
10MIPPA Legislation What is a Successful
Electronic Prescriber?
- MIPPA references 2008 PQRI electronic prescribing
quality measure (i.e. e-prescribing measure
125). - MIPPA requires E-Prescribing measure to be
removed from PQRI for 2009 - Measure 125 forms basis for 2009
- e-prescribing measure
112009 PFS Rule What is a Successful Electronic
Prescriber for 2009?
- Eligible professional
- Physicians and other eligible professionals under
PQRI - Prescribing authority
- Successful reporting of electronic prescribing
measure - Successful reporting is defined as reporting
measure in at least 50 of applicable cases - PQRI and Electronic Prescriber Incentive Program
implemented in 2009 PFS rule
122008 PQRI E-Prescribing Measure
- 2008 PQRI Electronic Prescribing Structural
Measure (measure 125) may be reported as one of
quality measures - 2008 PQRI Reportable at 80 of applicable cases
- 2008 No separate incentive
13Electronic Prescribing Measure
- Overall requirement to report measure that
eligible professionals (EPs) has adopted
qualified e-prescribing system. - Professionals who have not adopted a qualified
electronic prescribing system cannot report on
this measure
14Electronic Prescriber Measure
- PQRI Claims Based Measure Reporting System
- Reporting Denominator
- Determines applicable case when Numerator Codes
reportable - HCPCS Billing Codes (Generally Office Visit
Codes) - Reporting Numerator
- G Codes
- Reportable in each case of denominator codes
billed on claim - The secretary may change the measure
specifications until 12/31/08 (PFS Final Rule)
15Qualified Electronic Prescribing System
- As a qualified system, the program must be able
to perform the following tasks - Generate a complete active medication list
incorporating electronic data received from
applicable pharmacies and PBMs, if available - Allow eligible professionals to select
medications, print prescriptions, electronically
transmit prescriptions, and conduct alerts
(written or acoustic signals to warn 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). The ability of an electronic prescribing
system to receive tiered formulary information,
if available, would suffice for this requirement
for 2009 and until this function is more widely
available in the marketplace - Provide information on formulary or tiered
formulary medications, patient eligibility, and
authorization requirements received
electronically from the patients drug plan (if
available)
16Qualified eRx Systems and Part D Standards
- E-prescribing systems for 2009 are to be
compliant with the Medicare Part D standards for
required functionalities - The standards refer to the version of messaging
that the e-prescribing program uses to send the
information over the prescription network
17Reporting Deminator
- Patient services billed using one or more of
following encounter codes - CPT Service Codes or HCPCS Codes for 2008
measure 90801, 90802, 90804, 90805, 90806,
90807, 90808, 90809, 92002, 92004, 92012, 92014,
96150, 96151, 96152, 99201, 99202, 99203, 99204,
99205, 99211, 99212, 99213, 99214, 99215, 99241,
99242, 99243, 99244, 99245, 99381, 99382, 99383,
99384, 99385, 99386, 99387, 99391, 99392, 99393,
99394, 99395, 99396, 99397, G0101, G0108, G0109 - Professional who does not at least once bill such
a code has no - occasion to report or qualify as successful
electronic prescriber - Measures codes may be updated for 2009
- PFS Rule indicates that will not be expanded
outside professional office or - outpatient setting for 2009
- Further limitation for incentive payment (but not
reporting) that Part B - allowed charges for the reporting denominator
codes must make up at least 10 of - professionals total Part B allowed charges
(January 1-December 31, 2009)
18Reporting Numerator Codes
- G CODE OPTIONS
- All prescriptions in connection with the visit
billed were electronically prescribed using a
qualified e-prescribing system - No prescriptions were generated during the visit
but professional does have access to a qualified
e-prescribing system - Some or all prescriptions were written or phoned
in due to patient request, State or Federal law,
the pharmacys system being unable to receive the
data electronically OR because the prescription
was for a narcotic or other controlled substance.
19Selection of a System
- Functionalities for Qualified System
- Compliance with Part D Standards for required
functionalities - EHR vs. Standalone Systems
- EHR systems with 2008 CCHIT Certification meeting
qualifications - CCHIT expects to review stand-alone systems for
certification in 2009
20Part D Standards
- As part of SureScripts-RxHubs vetting process,
all vendors who are listed on the SureScripts
website http//www.surescripts.com/get-connected
.aspx?ptypephysician meet the 2009 Part D
standards for the functions they provide. - If an eRx system is not on the SureScripts
network, a potential customer should look at the
Part D standards on the CMS website and check
with the products vendor.
21Additional Information
- CMS plans to have an eRx section on the PQRI
website at www.cms.hhs.gov/pqri - This section will contain information on
- The MIPPA legislation
- A Fact Sheet describing the MIPPA E-Prescribing
Incentive Provisions - Part D standards
- e-Prescribing Made Simple
22Future Alternative to Determining Successful
Electronic Prescriber
- MIPPA authorizes Secretary to change future
requirements for successful E-Prescriber - May base limitation on number of Part D
prescriptions rather than particular Part B
services as in current measure - Authorizes use of Part D data to determine
successful e-prescribing
23Implementation Schedule for 2009 PQRI and
e-Prescriber Incentive
- 2009 Electronic Prescribing Incentive
- 2009 PFS Rule placed on display October 30,
2008 - Detailed information on Electronic Prescribing
Incentive -
24Additional PQRI Resources
- For more information on PQRI and eRxing please
visit our website at http//www.cms.hhs.gov/pqri
- 2009 PFS Final Rule with Electronic Prescriber
Incentive Implementation - http//www.cms.hhs.gov/physicianfeesched/downloads
/CMS-1403-FC.pdf?agreeyesnextAccept - Thank you!
- Michael T. Rapp, MD, JD