Medicare Electronic Prescribing Incentive Program

Eligible physicians can participate in the eRx incentive program (and are subject to the payment adjustment) if the encounter codes they bill to Medicare fall within the encounter codes listed on page 2 of the Centers for Medicare & Medicaid Services (CMS) measure specifications document. Eligible Professionals must have at least 10% of their Medicare Part B charges comprised of the codes in the denominator of the measure to be incentive eligible. Additionally, if the physician does not have at least 100 cases containing an encounter code in the measure denominator, then he or she is exempt.

An eligible professional's analysis is performed at the Tax Identification Number/National Provider Number (TIN/NPI) level. Eligible professionals practicing under multiple TINs must report the eRx measure under each of their TINs.

Eligible professionals must have adopted a "qualified" eRx system in order to be able to report the eRx measure. Regardless of the type of system used, to be considered "qualified" it must be based on ALL of the following capabilities:

• Generating a complete active medication list incorporating electronic data received from applicable pharmacies and pharmacy benefit managers (PBMs) 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, would meet this requirement for 2011)
• Providing information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient's drug plan, if available.

If a provider does not meet the minimum eligibility requirements, no further action is required and the provider DOES NOT need to alert CMS. CMS will make the determination after the reporting period is over, based on claims data.

Electronic Prescribing Incentive Program Incentive Details
Year	Incentive Amount	Applicable Reporting Dates	Reporting Instances	Reporting Method
2011	1.0%	1/1/11–12/31/11	25	Claims, Registry, EHR
2012	1.0%	1/1/12–12/31/12	25	Claims, Registry, EHR
2013	0.5%	1/1/13–12/31/13	25	Claims, Registry, EHR
2014	N/A	N/A	N/A	N/A

Reporting the eRx Measure

For successful reporting under the 2011, 2012, 2013 eRx Incentive Program, neurologists must generate at least one eRx associated with a patient visit on 25 or more unique events during the reporting period. See below on how to report successfully to Medicare.

Electronic Prescribing Incentive Program Penalty Details
Year	Penalty Amount	Applicable Reporting Dates	Reporting Instances	Reporting Method
2011	N/A	N/A	N/A	N/A
2012	–1.0%	1/1/11–6/30/11	10	Claims
2013	–1.5%	1/1/11–12/31/11	25	Claims, Registry, EHR
2013*	–1.5%	1/1/12–6/30/12	10	Claims
2014	–2.0%	1/1/12–12/31/12	25	Claims, Registry, EHR
2014*	–2.0%	1/1/13–6/30/13	10	Claims

*The 6–month reporting period option is for eligible professionals who DID NOT already meet the 12–month reporting period for the relevant payment adjustment year. The 6–month reporting option no longer requires eligible professionals to report on an eRx event tied to a denominator–eligible encounter (as required for the 2012 payment adjustment and also the 12–month reporting options). Rather, eligible professionals may submit the G8553 code for any visit if there was an eRx event, regardless of what claim they are submitting it with.

2012 eRx Payment Adjustment

The 2012 eRx payment adjustment is a 1% reduction in 2012 to the physician fee schedule amount for covered professional services furnished by the eligible neurologist who is not a successful e–prescriber. The reporting period for the 2012 eRx payment adjustment was January 1, 2011 through June 30, 2011.

2013 eRx Payment Adjustment

The 2013 eRx payment adjustment is a 1.5% reduction in 2013 to the physician fee schedule amount for covered professional services furnished by the eligible neurologist who is not a successful e–prescriber. The reporting period for the 2013 eRx payment adjustment is January 1, 2011, through December 31, 2011. A neurologist who successfully e–prescribes in the 2011 eRx Incentive Program will be considered exempt from the 2013 payment adjustment.

Eligible neurologists who did not meet the 12–month reporting deadline in calendar year 2011 have the option of a 6–month reporting period from 1/1/12–6/30/12 to avoid the 2013 eRx payment adjustment. The 6–month reporting must be claims–based, and the G8553 code can be submitted for any visit if there was an eRx event.

Example: An EP who did not meet the 12–month reporting period during the 2011 CY to avoid the 2013 payment adjustment can now fulfill the 6–month reporting period requirements from 1/1–2012–6/30–2012 to avoid the 2013 payment adjustment of 1.5%.

2014 eRx Payment Adjustment

The 2014 eRx payment adjustment is a 2.0% reduction to the physician fee schedule amount for covered professional services furnished by the eligible neurologist who is not a successful e–prescriber. There are two options for the 2014 payment adjustment reporting period, both a 12–month option (1/1/2012–12/31/2012) and a 6–month claims–based only option (1/1/2013–6/30/2013). A neurologist who successfully e–prescribes in the 2012 eRx Incentive Program will be considered exempt from the 2014 payment adjustment.

Claims–Based Reporting:

Submit both a denominator CPT code and the numerator G–code on the claim. All measure–specific coding should be reported on the claim(s) representing the eligible encounter. Eligible neurologists must identify the encounter code being reported on line 1 of the claim form. On the second line the G8553 code must be reported for the amount of $0.00. The G8553 code must be included on the original claim form; you cannot claim only the G8553 code or add it to an already reported claim. Medicare will keep track of the claims being reported and determine if the requirements have been met to avoid the penalties and earn incentives. Medicare has provided a claims–based reporting principles document for more details and an example claim form.

Claims that are resubmitted for the sole purpose of adding or correcting an eRx code will NOT be accepted.

Note: Medicare Advantage (MA) and other private insurance claims do not count as part of the Medicare eRx Incentive Program, only traditional Medicare.

Registry Reporting:

Must use a CMS–selected registry to submit 2012 data to CMS. Those participating in a registry that self–nominates and meets the qualifications to submit data for a particular program year should plan on receiving more information from the registry on participating in the Medicare eRx Incentive Program.

Click here to view a list of qualified registries for the 2012 eRx Incentive Program.

A denominator CPT code and an electronically generated and transmitted prescription (not faxed) are required to report the measure.

EHR–Based Reporting:

Must use a CMS–selected electronic health record (EHR) product, to submit 2012 data. EHR vendors must be qualified to report and must have already submitted a self–nomination letter.

Click here to view a list of qualified EHR Direct Vendors for the 2012 Medicare eRx Incentive Program.

There is no formal way to track your eRx and Medicare does not provide any up–to–date feedback on if an eligible professional is correctly reporting, However, when a claim with the G8553 code is submitted, the eRx line item (with the G8553 code) will be denied for payment but passed through the claims processing system to the National Claims History database (NCH). Eligible professionals will receive a Remittance Advice (RA) that includes a standard remark code, N365. The N365 remark code that states the code is for information/reporting purposes indicates that the eRx G–code passed into NCH.

Note that the N365 remark code does NOT indicate whether the eRx G–code is accurate for that claim or for the measure the eligible professional is attempting to report.

If an entire claim is rejected, the eRx G8553 code will not be processed or tracked.

The Centers for Medicare & Medicaid Services (CMS) re–opened the Quality Reporting Communication Support Page on November 1, 2012 to allow hardship exemption requests for the 2013 payment adjustment.

The deadline to submit a hardship request to avoid the 2013 payment adjustment is January 31, 2013. For more information on submitting a hardship exemption for the 2013 eRx payment adjustment, click here.

Hardship exemption categories for the 2013 payment adjustment include:

• The EP or group practice practices in a rural area with limited high speed internet access
• The EP or group practice practices in an area with limited available pharmacies for eRx
• Inability to eRx due to local, state, or Federal law or regulation
• EP who prescribe fewer than 100 prescriptions during a 6–month, payment adjustment reporting period (1/1/2012–6/30/2012)

The Communication Support Page is not currently accepting exemption requests for the 2014 payment adjustment.

All hardship Exemptions can be submitted through the Communications Support Page at https://www.qualitynet.org/portal/server.pt/community/communications_support_system/234

1. Clinicians Guide to E–Prescribing
2. CMS document listing the encounter codes that fall under the Medicare eRx Incentive Program. See “Who is Eligible for the Program” for details.?
3. CMS document detailing how to report electronic prescriptions (using the G8553 code) and providing an example claim form.

Contact CMS for inquiries regarding the Medicare eRx Incentive Program, including incentive payments, feedback reports, and IACS registration.

QualityNet Help Desk – 7:00am –7:00pm CST
Phone: 1–866–288–8912
TTY: 1–877–715–6222
Email: Qnetsupport@sdps.org