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Medicare e-prescribing penalties


• The law requires a penalty phase for eligible physicians who do not e-prescribe during 2012 through 2014

• According to MIPPA, physicians who are eligible but choose not to participate in the 2012 or 2013 Medicare eprescribing incentive program and do not qualify for a significant hardship exemption would be subject to a one percent Medicare payment reduction based on their Medicare Part B allowed charges (1.5 percent in 2013)

• CMS is basing the 2012 penalties on e-prescribing activity that occurs during January 1, 2011 through June 30, 2011, and 2013 penalties on e-prescribing activity that occurs throughout 2011

How to avoid E-Prescription penalties

To avoid penalties in 2012, an eligible physician must e-prescribe and report the e-prescribing Gcode, G8553, at least 10 times for applicable Medicare office visits and services for the January 1, 2011 through June 30, 2011 reporting period on Medicare claim forms (report at least 25 times throughout 2011 to avoid penalties in 2013)

Code G8553 (called the numerator) must be reported on the same claim form as the denominator codes, for the same beneficiary, same date of service, by the same individual NPI who performed the covered service.

Denominator codes are reporting any ICD-9-CM diagnosis codes, and must include one of the CPT Category I or HCPCS codes. Please click here to view the denominator codes.

Code G8553 must be submitted with a line-item charge of zero dollars ($0.00). The charge field cannot be blank. If the system doesn’t allow zeroes in the charge field, use $0.01.

On the remittance advice notice, a standard remark code (N365) reads: “This procedure code is not payable. It is for reporting/information purposes only.” N365 indicates that the eRx G-code passed into the National Claims History database.

Claims may not be resubmitted for the sole purpose of adding or correcting an eRx code. Faxes do not qualify as electronic prescribing.

All claims for services furnished between January 1, 2011 and June 30, 2011 must be received and processed by no later than one month after the reporting period.

Exceptions

The 2012 e-prescribing penalty will NOT apply to:

• A professional who is not a physician, nurse practitioner, or physician assistant as of June 30, 2011;

• A physician for whom office visits and other services listed in the CMS e-prescribing measure specifications represent less than 10 percent of their allowed Medicare charges in the first six months of 2011; or

• A physician who has less than 100 claims for patient services containing visit and service codes that fall within the e-prescribing measure specifications for dates of service between January 1, 2011 through June 30, 2011

Please visit ERx, PQRI, EHR Updates for more information.

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