What you should know about the Medicare E-Prescribing Incentive Program

Background

The Electronic Prescribing (eRx) Incentive Program is a reporting program that uses a combination of incentive payments and payment adjustments (penalties) to encourage electronic prescribing by eligible professionals. The program provides an incentive payment to practices with eligible professionals (identified on claims by their National Provider Identifier [NPI] and Tax Identification Number [TIN]) who successfully e-prescribe for covered Medicare Physician Fee Service Schedule (MPFS) services for Medicare Part B Fee-for-Service (FFS) beneficiaries. Below is information on the following:

Click on links below for related information

I) Eligibility Criteria for Physicians and Group Practice

II) Mechanisms for Reporting the eRx Measure

III) Incentives and Penalties

IV) Hardship Exemptions

V) Participating in the EHR, PQRS, and eRx Programs Simultaneously

E-Prescribing in 2012: What You Need to Do to Comply 

2012 is the first year of the Electronic Prescribing (eRx) Incentive Program that features both incentive payments and adjustments (penalties). Eligible professionals that successfully reported eRx measures in 2011 will receive a bonus payment from Medicare in 2012 equal to 1 percent (1%) of their total Medicare Part B payments in 2011. 

If a physician fails to report one of the following, they will be subject to a 1 percent payment penalty for all Medicare payments in 2012, which will be assessed in 2013.

• at least 25 prescriving events via claims for at least 10 unique denominator eligible eRx events for serivces provided January 1, 2012 through June 30, 2012
• or report the G8553 code via claims for at least 10 unique denominator eligible eRx events for services provided January 1, 2012 through June 30, 2012
• or apply for an exemption

I) Eligibility Criteria for Physicians and Group Practice

To be eligible to participate in the 2012 Medicare (eRx) Incentive Program, office visits should represent at least 10 percent of your total Medicare Part B Physician Fee Schedule charges from January 1, 2012 to June 30, 2012. You can only report the eRx measure for office visits that are separately listed on your Medicare claims and separately payable by Medicare.

In order to be eligible to receive an eRx incentive payment in 2012, you must generate and report one or more electronic prescriptions associated with a minimum of 25 unique patient visits per year. Each visit must be accompanied by the electronic prescribing G-code (G8553 - At least one prescription created during the encounter was generated and transmitted electronically using a qualified ERX System) attesting that during the patient’s visit at least one prescription was electronically prescribed. The Centers for Medicare and Medicaid Services (CMS) requires that you use a "qualified" electronic prescribing system (stand-alone or an electronic health record system (EHR) with eRx functionality), which has all of the following capabilities:

• Generating a complete active medication list incorporating electronic data received from applicable pharmacies and pharmacy benefit managers, if available
• Selecting medications, printing prescriptions, electronically transmitting prescriptions, and conducting all alerts
• Providing information related to lower cost, therapeutically appropriate alternatives (if any). The availability of an eRx system to receive tiered formulary information, if available
• Providing information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient's drug plan, if available

The eRx measure (G8553) only qualifies for the incentive bonus when submitted with one of the following exam codes: 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90862, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99345, 99347, 99348, 99349, 99350, G0101, G0108, G0109

II) Mechanisms for Reporting the eRx measure

There is no pre-registration required to participate in the eRx program. To participate in the 2012 eRx Incentive program, you may choose to report on your adoption and use of a qualified eRx system by submitting information on one eRx measure, G8553 to:

• CMS on your Medicare part B claims
  - Submit both a denominator CPT code and numerator G-code on the claim. All    measure-specific coding should be reported ON THE SAME CLAIM (Faxes do not qualify as eRx)
  - Claims may not be resubmitted only to add or correct the eRx measure
  - View sample paper claim form
  - View more instructions on submitting the eRx measure via your Medicare part B claims
• A qualified registry (list of qualified registries)
  - A denominator CPT code and an electronically generated and transmitted prescription (not faxed) are required to report the measure
  - The e-prescribing incentive amount is based on an estimate of the allowed charges for all  Medicare Physician Schedule covered professional services you provided  during the reporting period (minus durable medical equipment, facility and injectable)
• CMS via a qualified electronic health record (EHR) product

According to the Health Resources and Services Administration (HRSA), “Generally a stand-alone e-prescribing system program ranges from free  (offered by the National ePrescribing Patient Safety Initiative) to about $2,500 per physician annually.”

III) Incentives and Penalties

If you successfully e-prescribe medications and report the eRx measure in 2012 (by generating and reporting one or more electronic prescriptions associated with a minimum of 25 unique patient visits from January 1, 2012- December 31, 2012) you will earn incentives (in 2013) equal to 1 percent of your total Medicare payments for 2012. (You will obtain payment bonuses after the conclusion of the calendar year in which you e-prescribed for your Medicare patients, not as an immediate payment). The incentive payment decreases to .5% of your total Medicare Part B payments for calendar year 2012.

This table shows the incentives and penalties in the eRx program through 2014:

Group Practice Reporting Option (GPRO): Groups are also eligible for incentive payments based on 2012 e-prescribing. Information on group reporting measures can be found here.

2012 is the first year that penalties were assessed for unsuccessful participation. These penalties continue to increase every year of unsuccessful participation.To avoid penalties in 2013, an eligible physician needs to report the ePrescribing G-code, G8553, at least 10 times for Medicare office visits or services for the January 1, 2012 through June 30, 2012 reporting period on your Medicare Part B claim forms. All claims for services furnished between January 1, 2012, and June 30, 2012 needed to be received and processed by CMS no later than one month after the reporting period. Please note that electronically generated refills and faxes do not qualify as electronic prescriptions. Office visits provided as part of a global surgical package will not count towards the calculation of penalties for not adopting e-prescribing.

The eRx penalty will not apply to you, if you do not:

• Have at least 100 cases containing an encounter code in the measure denominator
• Meet the 10% denominator threshold
• Do not have prescribing privileges (report G8644 - Eligible professional does not have prescribing privileges at least once on your Medicare claims)

Eligible Professionals can avoid penalties in 2014 by reporting G-code (G8553) 25 times in 2012 on Part B claims.

IV) Hardship Exemptions

Eligible Professionals may apply for a hardship exemption from CMS that would exempt them from penalties in 2013 based on 2012 claims. Physicians have to apply for the exemption from the 2013 penalty by June 30th, 2012. Visit the CMS web tool to apply.

As a result of the advocacy of the Academy and several specialty societies, CMS, on August 31, 2011, issued a final rule, added new exemption categories to enable physicians to avoid the 1% Medicare E-Rx penalty in 2013 (based on 2012).

The newly finalized exemption groups are:

• Practice in a rural area without adequate high-speed internet access,
• Practice in a location without enough available pharmacies for e-prescribing,
• Physicians who are already registered to participate in the Medicare or Medicaid EHR Incentive Program and who have adopted certified EHR technology, or
• Physicians who are unable to electronically prescribe due to local, State, or Federal law or Regulation (e.g., prescribes controlled substances), or
• Physicians who infrequently prescribe (e.g., prescribe fewer than 10 prescriptions between January 1, 2011 – June 30, 2011), or
• Insufficient opportunities to report the e-prescribing measure due to program limitations.

The eligible professional (EP) must be the person completing and submitting the hardship exemption form; office staff may not complete the form on the EPs behalf. For a GPRO, the hardship exemption must be provided by the GPRO member designated during the time of the self nomination process. For more information on the self-nomination process, please visit visit the GPRO website.

CMS and the QualityNet Help Desk have been receiving calls from physicians who are having difficulty with accessing the Communication Support Page. CMS is asking physicians to take the step below if they are unsuccessful in accessing the Communication Support Page when trying to submit their Hardship Exemption Request:

• After going to the QualityNet portal (link provided below Hardship Exemptions Banner), select Tools/Internet Options/ Advanced.
• Scroll down toward the bottom and locate the "Use TLS 1.0" choice.
• Place a checkmark in the "Use TLS 1.0."
• Click OK. Attempt to access the site again.

If you are still having trouble accessing the site, the QualityNet Help Desk may be reached at 1-866-288-8912 or email at gnetsupport@sdps.org from 7 am to 7 pm CT, Monday through Friday. Due to the high volume of calls that the QualityNet Help Desk has been receiving, there may be a waiting period.

V) Participating in the Medicare Electronic Health Records (EHR), Physician Quality Reporting System (PQRS) and eRx Programs Simultaneously

You are not able to obtain incentives from both the Medicare eRx and the Medicare EHR incentive programs simultaneously. However, you may participate in the PQRS and eRx programs at the same time. Also, you may participate in the Medicaid EHR incentive program and still qualify for incentives under the eRx program.

Information from the Academy on:
Medicare EHR Incentive Program
Physician Quality Reporting System

If you have more questions on the eRx program, contact healthpolicy@entnet.org or visit the CMS Electronic Prescribing Incentive Payment website.