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CMS Proposes Additional Hardship Exceptions to Electronic Prescribing

June 7, 2011:

Deborah C. Hall, Clinical/Technical Editor

A recently released proposed rule would allow eligible providers to get an exemption from the 2012 ePrescribing payment adjustment if they have a significant hardship.

In the rule, published June 1, the Centers for Medicare and Medicaid Services proposed providing additional exemption categories for professionals and group practices who want to request an exemption during 2011 from the 2012 payment adjustment because of significant hardship.

Currently, to avoid the 2012 penalty the physician practice must indicate that it is eligible for one of the following exemptions:

  • The eligible provider is located in a rural area without high-speed internet access.
  • The eligible provider is located in an area without sufficient available pharmacies for electronic prescribing.

The new rule proposes adding four additional exemption categories:

  • The eligible provider is registered to participate in the Medicare or Medicaid Electronic Health Records (EHR) Incentive Program and has adopted certified EHR technology. (This is included because such a provider may have delayed adopting eRx technology while it waited for the list of certified EHR technology to be released.)
  • The eligible provider is unable to electronically prescribe because of local, state, or federal law or regulation (such as prescribing controlled substances).
  • The physician infrequently prescribes (such as prescribing fewer than 10 prescriptions from January 1 to June 30).
  • There are insufficient opportunities to report the ePrescribing measure because of eRx program limitations.

For the currently established hardships, physicians are required to report one of two “hardship codes” on claims. Claims without these codes could be paid less, resulting in a significant loss in Medicare revenue.

G8642—The eligible professional practices in a rural area without sufficient high speed internet access and requests a hardship exemption from the application of the payment adjustment under section 1848(a)(5)(A) of the Social Security Act.

G8643—The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing and requests a hardship exemption from the application of the payment adjustment under section 1848(a)(5)(A) of the Social Security Act

For the newly proposed hardship exemptions, CMS is proposing that providers or group practices report the following to the agency:

  • Identifying information such as the TIN, NPI, name, mailing address, and email address of all affected eligible professionals
  • The significant hardship exemption category or categories above that apply
  • A justification statement describing how compliance with the requirement for being a successful electronic prescriber for the 2012 eRx payment adjustment during the reporting period would result in a significant hardship to the eligible professional or group practice
  • An attestation of the accuracy of the information provided

The justification statement should be specific to the category under which the eligible professional or group practice is submitting its request and must explain how the exemption applies to the professional or group practice. Once the rule is finalized, it is assumed that more detailed reporting instructions will be made available.

The payment adjustment will change during the years of 2012 through 2014, increasing each calendar year. In 2012, the payment adjustment for not being a successful ePrescriber will result in an eligible professional or group practice’s receiving a 1 percent adjustment in the Medicare Part B allowed physician fee schedule amount. In 2013, an eligible professional or group practice will receive a 1.5 percent adjustment to the Medicare Part B allowed physician fee schedule amount, and in 2014, the payment adjustment will be 2 percent.

To transition providers to electronic prescribing, CMS introduced a Medicare ePrescribing Incentive Program January 1, 2009. Section 132 of the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 authorized a new and separate incentive program for eligible professionals who are successful electronic prescribers (ePrescribers).

This incentive is separate from and is in addition to the quality reporting incentive program authorized by division B of the Tax Relief and Health Care Act of 2006—Medicare Improvements and Extension Act of 2006 (MIEA–TRHCA), known as the Physician Quality Reporting System (PQRS). Successful reporting under the ePrescribing Incentive Program results in 1 percent bonus payments for 2011 and 2012 and a 0.5 percent bonus payment in 2013.

In general, an eligible professional is one of the following:

  • Physician
  • Physical or occupational therapist
  • Qualified speech-language pathologist
  • Nurse practitioner
  • Physician assistant
  • Clinical nurse specialist
  • Certified registered nurse anesthetist
  • Certified nurse midwife
  • Clinical social worker
  • Clinical psychologist
  • Registered dietitian
  • Nutrition professional
  • Qualified audiologist

To qualify as a “successful ePrescriber,” the eligible professional must report the ePrescribing quality measure through Medicare Part B claims on at least 50 percent of applicable cases during the reporting year.

There are two types of systems an ePrescriber can use. The first is a stand-alone system or one that is used for ePrescribing only. The second is an electronic health record system with ePrescribing functionality. Either of these systems may be used for the incentive program, as long as it can do the following:

  • Generate a complete medication list that incorporates data from pharmacies and benefit managers (if available)
  • Select medications; transmit prescriptions electronically using the applicable standards, and warn the prescriber of possible undesirable or unsafe situations
  • Provide information on lower-cost, therapeutically appropriate alternatives
  • Provide information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient’s drug plan


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