Published 3/1/2003
Toya M. Sledd, MPH, MBA

E-prescribing: The clock is ticking

The sooner you start, the more you can earn

If you don’t already use an e-prescribing system, now is the perfect time to start. The sooner you begin participating in the 2009 e-Prescribing Incentive Program, the greater your potential incentive payment will be.

Physicians who e-prescribe and participate in Physician Quality Reporting Initiative (PQRI) for 2009 could see up to 4 percent in incentive payments next year. No sign-up or preregistration is required to participate in the program, but the Centers for Medicare and Medicaid Services (CMS) has established certain limitations for participation.

Qualified systems
Eligible professionals must have and use a qualified e-prescribing system—either a “stand-alone” system for e-prescribing only or an electronic health record system with e-prescribing functionality. The system must be able to do the following:

  • Generate a complete medication list that incorporates data from pharmacies and pharmacy benefit managers (PBM)
  • Select medications, print prescriptions, transmit prescriptions electronically using the applicable standards, issue alerts, and warn the prescriber of possible undesirable or unsafe situations
  • Provide information on lower-cost, therapeutically appropriate alternatives, if any (For 2009, a system that can receive tiered formulary information, if available, from the PBM meets this requirement. A tiered formulary organizes the prescription drugs covered by a PBM into generic, formulary brand, and nonformulary brand, each associated with a set copayment amount.)
  • Provide information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient’s drug plan.

Although CMS does not provide a vendor list of qualified systems, information can be found on the SureScripts Web site (www.surescripts.com).

Coding requirements
At least 10 percent of eligible professionals’ Medicare Part B covered services must be made up of Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System codes that appear in the denominator of the e-prescribing measure. Orthopaedic surgeons could report the following codes in the denominator of the measure:

  • Office, New Patient – 99201, 99202, 99203, 99204, 99205
  • Office, Established Patient – 99211, 99212, 99213, 99214, 99215
  • Consultations – 99241, 99242, 99243, 99244, 99245
  • Screening and Diabetic Training – G0101, G0108, G0109

Orthopaedic surgeons will need to report the appropriate G-codes (G8443, G8445, or G8446) in the numerator of the e-prescribing measure on at least 50 percent of the Medicare claims that include one of the codes linked to e-prescribing. If one of the denominator codes (such as CPT code 99213–office/outpatient visit, established) is included on a claim for Part B services, one of the numerator reporting codes must be included on the same claim to meet the reporting requirement.

Using the G-codes
The first G code, G8443, refers to all prescriptions created during the encounter that were generated using a qualified e-prescribing system.

The second code, G8445, states that no prescriptions were generated during the encounter, but the eligible professional has access to a qualified e-prescribing system.

The third G code, G8446, states that the eligible professional has access to a qualified e-prescribing system, but that some or all of the prescriptions generated during the encounter were printed or phoned in because of state or federal law regulation or patient request, because the pharmacy system was unable to receive the electronic transmission, or because the physician prescribed a narcotic or other controlled substance to the patient.

Narcotics or other controlled substances
Orthopaedic surgeons who prescribe narcotic or controlled substances can still report on the e-prescribing quality measure by using G code G8446. The Drug Enforcement Administration (DEA) has authority through the Controlled Substances Act over e-prescribing of controlled substances and does not currently allow it. Although the DEA published a notice in June 2008 of proposed regulatory changes to allow for e-prescribing of controlled substances, a final determination on this issue has not been made.

Getting paid
All incentive payments are determined at the individual professional level and payment will always be made to applicable tax identification number (TIN) of the practice.

Penalties for nonparticipation
Beginning in 2012, physicians who do not participate in e-prescribing will be subject to a differential payment (penalty). As a result of this penalty, the physician would receive 99 percent of the total allowed charges in 2012, 98.5 per­cent in 2013, and 98 percent in 2014.

CMS has published Medicare’s Practical Guide to the E-Prescribing Incentive Program; the online version of this article contains a link to the guide.

In addition, AAOS members should visit the online Practice Management Center (www.aaos.org/pracman) for more information on e-prescribing, PQRI, and national and state programs and initiatives.

Toya M. Sledd, MPH, MBA, is the clinical quality improvement coordinator in the department of medical affairs. She can be reached at sledd@aaos.org