CMS E-Prescribing Penalty:  Less Than 2 Months to Avoid
By: Justin Vaughn, M.Div, CPC
Director of Compliance

5/7/2011

With less than 60 days available to avoid the government’s e-prescribing penalty, pain practices should seriously consider whether or not they will participate in the “incentive” program.

In order to avoid the penalty—to be assessed in 2012, and which amounts to a 1% reduction in one’s total annual Medicare “allowable”—an eligible provider (EP) must electronically and successfully prescribe 10 times, on behalf of Medicare patients, before June 30, 2011, indicating such via claims-based reporting. 

The only way EPs can avoid the e-prescribing penalty is if they fall under one or more of the following exceptions:

• Not a physician (which includes an MD, DO, or podiatrist), nurse practitioners, or physician assistants as of June 30, 2011, based on their primary taxonomy code in the National Plan and Provider Enumeration System.

• No prescribing privileges—in which case the EP must report code G8644 at least one time on a denominator-eligible claim prior to June 30, 2011.

• Practice is in a rural area without sufficient high speed internet access—in which case the EP must report G8642 at least one time on a denominator-eligible claim prior to June 30, 2011.

• Practice is in an area without sufficient available pharmacies for electronic prescribing—in which case the EP must report G8643 at least one time on a denominator-eligible claim prior to June 30, 2011.

• Less than 10% of an EP’s allowed charges for the January 1, 2011 through June 30, 2011 reporting period are comprised of codes in the e-prescribing “denominator.”  (In general, the denominator includes such evaluation and management codes as inpatient visits or outpatient/office visits—which most pain physicians submit on a regular basis.)  (This bulleted exception is one reason why most anesthesiologists may NOT be eligible for the e-prescribing program, and thus not subject to the penalty.)

• EP has less than 100 cases containing an encounter code in the measure’s denominator for the January 1, 2011 through June 30, 2011 reporting period.

The Medical Group Management Association (MGMA), which has a strong lobby in Washington, has urged CMS to modify its policy on the e-prescribing penalty.  However, until CMS or Congress acts to revise that section of the regulations, chronic pain providers should seriously and expeditiously consider whether it is time to begin their participation in this program.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.