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Centers for Medicare

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All prescriptions in connection with the visit billed were electronically ... Some or all prescriptions were written or phoned in due to patient request, ... – PowerPoint PPT presentation

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Title: Centers for Medicare


1
Centers 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

2
Overview
  • E-Prescribing
  • Electronic Prescribing Incentive Program
  • Earning an incentive payment
  • ERx system selection
  • Getting more Information

3
Background
  • 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

4
Background
  • 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

5
Background
  • 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.

6
How 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.

7
eRx Communication
8
MIPPA 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

9
Future 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

10
MIPPA 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

11
2009 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

12
2008 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

13
Electronic 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

14
Electronic 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)

15
Qualified 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)

16
Qualified 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

17
Reporting 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)

18
Reporting 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.

19
Selection 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

20
Part 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.

21
Additional 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

22
Future 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

23
Implementation 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

24
Additional 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
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