Chiropractic News

Electronic Health Record Incentive Program

March 8, 2010, 2:10 pm

The American Chiropractic Association (ACA) is a professional society composed of doctors of

chiropractic (DC) whose goal is to promote the highest standards of ethics and patient care,

contributing to the health and well-being of millions of patients. The ACA currently has over 15,000

members, making it the primary representative of the chiropractic community. Below are ACA’s

comments regarding CMS Proposed Rule 0033-P.

First, the ACA would like to applaud the work that has been done thus far by CMS, the HIT

Standards Committee and the HIT Policy Committee in developing the proposed regulations for

achieving meaningful use in HIT. This is an ambitious undertaking with an equally ambitious

timeline for implementation. It is clear that more time and attention will be needed to revise and

adjust the regulations and ACA appreciates CMS’ acknowledgement of the areas in the proposed

rule that need additional refinement to accommodate all relevant healthcare provider groups.

At this time the ACA has strong concerns regarding two of CMS’ twenty five objectives for achieving

meaningful use. Currently CMS proposes to require eligible professionals (EP) to generate and

transmit permissible prescriptions electronically. According to the proposed requirements EPs

would be required to submit at least 75 percent of all permissible prescriptions using certified EHR

technology. CMS goes on to state that “an EP must utilize this capability as part of the daily work

process.” This objective would prohibit eligible providers who do not prescribe medications as part

of their scope of practice, from meeting meaningful use criteria.

The ACA understands the benefit of having providers who prescribe medication to transmit

prescriptions electronically. However, providers who do not write prescriptions should not be

precluded from achieving other meaningful use benchmarks. The ACA supports the requirement

that any EHR system have the ability to transmit prescriptions electronically, however, the ACA

suggests that CMS revise the EP measure for achieving this objective. The measure for this

objective currently states, “At least 75 percent of all permissible prescriptions written by the EP are

transmitted electronically using certified EHR technology.” CMS goes on to indicate, “The

numerator for this objective is the number of prescriptions for other than controlled substances

generated and transmitted electronically during the EHR reporting period. The denominator for

this objective is the number of prescriptions written for other than controlled substances during

the EHR reporting period.” ACA suggests CMS revise the measure for this objective to read, “At

least 75 percent of all permissible prescriptions written by the EP are transmitted electronically

using certified EHR technology. Those providers reporting zero in the numerator and zero in the

denominator for this objective will be required to demonstrate the functionality of the electronic

health record to achieve this objective but will not be required to meet the 75% measure

threshold.”

The second issue that will preclude some DCs from achieving meaningful use is the requirement to

“Perform medication reconciliation at relevant encounters and each transition of care.” CMS’

measure for this objective states, “Perform medication reconciliation for at least 80 percent of

relevant encounters and transitions of care.” As there are a number of eligible providers who do

not prescribe medication, performing medication reconciliation is not a typical function within

their practice. As such, the ACA requests that those eligible providers who do not prescribe

medication be exempt from this objective.

Our final issue of concern pertains to the reporting of core measures and specialty measures. CMS

has proposed to require that all EPs treating Medicare and Medicaid patients in the ambulatory

setting report on all of the core measures as applicable for their patients. The measures in the core

measures group include inquiry regarding tobacco use, blood pressure measurement and

recognition of drugs to be avoided in the elderly. The ACA supports CMS’ belief that these measures

are of great importance to the general population and they fall within the scope of practice for

doctors of chiropractic. However, the limited coverage for chiropractic services under Medicare

adversely impacts the ability of DCs to report on these measures.

While only one of the proposed core measures is currently a PQRI measure, it is presumed that CMS

will follow the PQRI model for developing further measures specifications. If so, the work described

in these measures will essentially fall under evaluation and management (E/M) services, with E/M

codes listed as the primary denominators codes. In this case, DCs will be unable to satisfy this

measure and achieve meaningful use of an EHR as we are currently restricted from billing CMS for

these codes.

CMS has indicated that for PQRI, providers may only report on measures for covered Medicare

services for their provider type. Under Medicare, only the Chiropractic Manipulation Treatment

(CMT) codes are covered services for DCs. E/M services are not covered by Medicare when

performed by a DC. It would not be appropriate to address this issue by simply adding the CMT

codes to the denominators for these core measures as this would force DCs to use CMT codes to

report on E/M level services, compromising the integrity of the reporting and the codes.

It is the request of the ACA that CMS examine how it reimburses DCs for the provision of services

and expand coverage to include the full scope of services DCs currently provide to their Medicare

patients. This coverage issue has long created a burden on patients and now creates a significant

barrier for fully participating in federal programs which are intended to support the provision of

quality care.

The ACA appreciates the fact that CMS’ already recognizes that the current outline of specialty

measures is not all inclusive and that adjustments and an option for specialties to opt out is

necessary. The ACA would like to request that DCs be exempt from reporting on a specific specialty

measures group, due to the restrictions in reimbursement under Medicare outlined above . As an

alternative, we recommend that DCs be required to report on those PQRI measures for which we

are currently eligible to report. These measures include #124. Adoption/use of health information

technology, #131. Pain assessment prior to initiation of patient treatment and #182. Functional

Outcome Assessment in Chiropractic Care.

The ACA is committed to participaton in quality care initiatives to the fullest extent that CMS will

allow and stands ready to assist CMS is addressing the issues delineated above regarding coverage

issues and the barriers that those issues create for patients and providers alike. Thank you for this

opportunity to provide comments on the proposed rule.

Rick McMichael, DC

ACA President

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