The Medicare program for eligible professionals only applies to physicians, dentists or dental surgeons, podiatrists, optometrists and chiropractors who are not hospital-based. Non-physician practitioners and other members of the care team are not eligible for incentive payments under this program. This is a major area of differentiation between the Medicare and Medicaid incentive programs.

EHR availability

In addition to not being hospital-based, physicians must also furnish at least 50 percent of their patient encounters in a location equipped with an EHR. This means, if you work for multiple practices and one has an EHR and another does not, at least 50 percent of your patient encounters must occur in the practice with an EHR. Otherwise, you will not be eligible for the incentive payment. The same is true if you substitute the word “location” for practice, even if the two locations are part of the same practice.

Hospital-based status

To determine if you are eligible for the Medicare EHR incentive program, you must first determine if you are hospital-based. Physicians who furnish 90 percent or more of their services in the inpatient setting or emergency department are considered hospital-based physicians, making them ineligible for the incentive program. Place of service codes submitted on Medicare claims will be used to determine eligibility, rather than employment status or ownership. Therefore, those working in hospital-owned practices are eligible for the incentive payments.

The definition of a hospital-based physician has changed twice since the proposed rule for Stage 1 was released. Originally, services provided in a hospital outpatient department - also referred to as a provider based clinic - were considered hospital services. This also included physician practices owned by hospitals and academic practices affiliated with hospitals. Before the final Stage 1 rule could be released, Congress passed new legislation limiting hospital services to those furnished in the inpatient setting or emergency department, and the Stage 1 rule was changed to reflect that. More recently, as part of the Stage 2 rulemaking process, CMS agreed to change the regulations to allow eligible professionals who might otherwise be considered hospital-based to fall outside of that definition if they demonstrate that they fund the acquisition, implementation and maintenance of their certified EHR, including supporting hardware and interfaces necessary for meeting the program’s requirements without reimbursement from an eligible hospital, and use that certified EHR in the inpatient or emergency department of a hospital, rather than the hospital’s certified EHR.

The determination of hospital-based status will be made based on claims filed during the preceding fiscal year. CMS intends to alert physicians of their status by the beginning of each calendar year.

Many cardiologists have asked if they can participate in the program. The answer is yes. While CMS has been explicit in its interest in including primary care physicians in the program, specialists will not be excluded. Based on the requirements, most cardiologists should qualify, though certain subspecialties such as electrophysiology, may have difficulty if those physicians spend most of their time in an inpatient setting or if their office visits are generally included in a global billing package unless they can demonstrate that they meet the new criteria regarding eligible professional EHR funding. Cardiac surgeons may also face difficulty qualifying for the incentive payments unless they fit the new criteria because they also spend a majority of their time in the inpatient setting or performing office visits included in global billing packages. Ultimately, eligibility will be driven by a physician’s exact mix of services during the preceding fiscal year.

Eligible professionals will be able to determine the nature of their status upon registering for the EHR program. If they are designated as hospital based, there will be a process for providing documentation and seeking a non-hospital based status determination on a case-by-case basis should hospital-based physicians fully fund and use their own certified EHR. An attestation to the accuracy of this information will need to be made annually. More information on this process will be made available in the future. Should physicians be successful in obtaining a non-hospital based determination, they will be required to meet the same requirements as traditional non-hospital based physicians.

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