A Brief Primer to Electronic Prescribing (eRx)

By Neil A. Pence, OD, FAAO

As a part of the effort to encourage the use of electronic health records, the use of e-prescribing for medication prescriptions is being strongly encouraged. If a qualified system is used, there is an incentive program for Medicare patients. If the incentives are met, the payment from all allowable Medicare Part B charges for the year will be increased by 2 percent in 2010; 1 percent in 2011 and 2012; and 0.5 percent in 2013. Penalties will begin in 2012 for those not adopting eRx; they will see their amounts decreased by 1 percent in 2012; 1.5 percent in 2013; and 2 percent in 2014 and years after.

Qualified systems must:

• Generate an active medication list, and access information from the patients PBM (pharmacy benefit management) plan if possible
• Select, print and transmit prescriptions electronically, and warn the prescriber of possible undesirable or unsafe situations
• Provide information on lower cost alternatives
• Provide formulary or tiered benefit, patient eligibility, and authorization requirements for the patients drug plan

2010 Incentive Requirements

For individual practitioners, to meet the minimum requirement for E-prescribing in 2010, they must generate and report a minimum of 25 electronic prescribing events during the 2010 calendar year. There is no sign-up or registration required.

Reporting Requirements

• For a Medicare patient, an E/M encounter code must be billed with a professional fee ( i.e. 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215 or 92002, 92004, 92012, 92014)
• The code above used must represent at least 10% of all the Medicare allowed charges from that provider (i.e. you cannot use a code rarely reported, and have it count)
• A G8553 code must be billed in order to have the eRx event be reported and tracked.
• The G8553 means “at least one prescription created during the encounter was generated and transmitted electronically using a qualified eRx system”
• The G8553 is billed as $0.00 (if a practice management system does not allow 0.00, then bill as $0.01 but it is not collected); the charges column cannot be left blank
• The total charge on the claim form cannot be $0.00
• The G8553 code cannot be billed later, or the claim amended, etc.
• It must be the same provider (same NPI) for the reported professional service and the G-code

Note: The eRx incentive is not available if the eligible provider earns an incentive payment under the HITECH provisions for those qualifying as “meaningful EHR users.”

Second Note: The eRx incentive program for 2010 is significantly different from 2009. In 2009, the criteria was to report the eRx 50% of the time. The G-codes used were also different (G8443, 8445, and 8446). Be sure to use the G8553 code in 2010, and not the 2009 codes.

Case Scenario

A Medicare patient reports to your office. It is their first visit, and the encounter results in you sending two Rxes via eRx. You might bill a 92004 encounter code with the appropriate fee for you office, and on the next line bill the quality-data code G8553 at a charge of $0.00. This would count as one eRx event (not two) toward your minimum 25 needed.

If the same patient returned two weeks later and you wrote one new Rx and sent it via eRx to the pharmacy, you might bill a 92012 for the visit with a fee, and then G8553 at $0.00. This would again count as one event, even though it is the same patient. Refills or prescriptions sent without an accompanying visit charge on the same day do not count as new events.

The visit fees for the scenario above might just as well have been a 99204 on the first day, and 99213 on the second visit along with the G8553 with each, as an example if you chose to use the 99000 codes instead of the 92000s. The visit record must reflect that you met the requirements for the individual code chosen, as with all Medicare coding.

E-Prescribing Background and Comments

The national eRx network linking providers, pharmacies and insurance or benefit management systems is called Surescripts. They are essentially the portal that all the various computer software providers go through. Ratings of various eRx systems can be found on their web site (www.surescripts.com). There are several major companies that do the majority of eRx services. These include: RxNT, Allscripts, DrFirst, and New Crop.

These can be stand alone programs, or accessed through various practice management software systems (OfficeMate, Compulink, etc.). Your eRx is sent to them, and they then transmit it to the pharmacy electronically, or if the pharmacy is not set up to receive it (the vast majority are), then they send it via fax.

There may well be a fee over and above your business management costs to use the eRx. This may be a monthly fee (around $30 for some using New Crop), an annual fee, (RxNT is $650/year as a license fee for one doctor and staff), a one-time purchase fee, or it may be free (Allscripts Basic). Allscripts Basic is a web based system provided by the National ePrescribing Patient Safety Initiative (NEPSI). To use it from a PDA or with various options, there may be a fee but the basic is free (www.nationalerx.com).

A list of plans and their ratings can be found at http://www.eprescribing.info/eprescribe/companylist. A second free basic web based program can be found on this list (iScribe), with the PDA version again available for a charge. This did not receive quite as high a rating, so you would need to be sure it can do all the things you need to qualify for the incentive program.

Cautions about eRx

It might seem reasonable that the input screen of your eRx system would be similar to what then shows up on the pharmacist’s computer. Be advised that this is not the case, and some are widely different in format. After selecting the drug and instructions, there is often a comments box next just below this. What gets ultimately sent to the pharmacist will at times have this comment box buried way at the bottom, and in some cases it is in much smaller print. This can look very much like the standard disclaimers that are often found at the bottom of faxes or documents, and are easy to miss or ignore. For a Medicaid Rx to be filed with a brand name in some states, (Indiana for example), the prescription must have wording like “Brand name medically necessary” hand written on the Rx. Checking the “no substitutions box” on the screen is probably not sufficient, so it needs to be written in the comments (and then hope the comment will see it).

When beginning to send eRxs, it might be useful to have a pharmacist print off what they receive so you can see what they are working from, or you could arrange ahead of time to send a “test” Rx and maybe stop in and see what the screen looks like. This will be different with each of the different systems, but also may be different based on the software that the individual pharmacy or pharmacy chain is using.

Reference Resources

www.cms.hhs.gov/eprescribing/
www.eprescribing.info/
www.nationalerx.com

Attached references

• Claims-BasedReportingPrinciplesforeRx122209 (CMS explanation of the Incentive Program)
• 2010 eRx_Measure_Specification_111309 (CMS short guideline for qualified systems)
• MIPPA Incentive Program Fact Sheet (from Surescripts)
• eRx_Buyer’s_Guide_ (questions to ask of a prospective eRx software vendor)
• E-Prescribing_Guide (for providers from Surescripts)
• Eprescribing_info Your Number 1 Resource on E-Prescribing and EMR (from eprescribing.info)

Neil A. Pence, OD, FAAO, is a faculty member at theIndiana University School of Optometry in Bloomington, Indiana. He serves as Director of the Contact Lens Research Clinic. Contact: pence@indiana.edu.