Medicare Electronic Prescribing

Medicare Electronic Prescribing
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. 

*New Document*- 2014 Electronic Prescribing One Page Fact Sheet

E-Prescribing in 2014:  How it differs from eRx in 2013

The 2013 reporting year was the last year to report for the eRx program and 2014 will be the last year of eRx payment adjustments.  In other words, EPs had the opportuniatey to avoid the 2014 eRx penalty by meeting certain criteria which is highlighted below.  Physicians should note that because 2013 was the last year to report, there is no replacement code for the G8553 for 2014.  G8553 was a means to show that a particular EP was in fact adopting and using a qualified eRx, to participate and earn an incentive under the Incentive Program.  Howevermembers should be aware that e-prescribing is still an aspect of Meaningful Use (MU) reporting, so members should ensure that they are meeting the requirement of the MU Incentive Program.  (Please visit the Academy's Electronic Health Records page, which can be found here, for more information on the MU Incentive Program.)

How do I know if I avoided the 2014 eRx Payment Adjustment?

If you are an individual EP then you may be subject to a -2% penalty (“payment adjustment”) for covered professional services rendered from January 1, 2014 to December 31, 2014, if you did not meet one of the following:

  • Become a successful electronic prescriber during the 2012 eRx 12-month reporting period, which was from January 1, 2012 to December 31, 2012; OR
  • Become a successful electronic prescriber during the 2013 eRx 6-month reporting period, which was from January 1, 2013 to   June 30, 2013; OR 
  • Qualified and requested a 2013 eRx significant hardship exemption, or submit a lack of prescribing privileges G-code request. *
  • If you are a group practice then you may be subject to a -2% penalty for covered professional services rendered from January 1, 2014 to December 31, 2014, if the group did not meet one of the following:
  • Become successful electronic prescribers during the 2012 eRx 12-month reporting period, which was from January 1, 2012 to December 31, 2012 via the reporting method provided during self-nomination; OR
  • Become successful electronic prescribers during the 2013 eRx 6-month reporting period, which was from January 1, 2013 to June 30, 2013 via claims; OR 
  • Qualified and requested a 2014 eRx significant hardship exemption.*

REMEMBER:  While there is no more reporting for the year 2014 or thereafter, there is still the eRx penalty for 2014 if EPs did not report the required 10 e-prescriptions or file a hardship in the time period listed above.  

2014 eRx Penalty Feedback Reports 

2014 eRx Penalty Feedback Reports are now available for EPs who have participated in the eRx Incentive Program.  The feedback reports are interim reports based on partial-year reporting of 2012, thus allowing providers to determine their status in meeting the requirements of the program.  It is important to bear in mind that the reports do not provide final determination on whether the EP is eligible for the incentive payment.  

For more information, please visit the CMS website

Members with specific questions can contact the CMS QualityNet Help Desk at qnetsupport@sdps.org.  The QualityNet Help Desk is an excellent resource for members looking for step by step review/discussion of specific requirements.  The QualityNet Help Desk can provide individualized guidance on 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.

Other Related Information

Title: 
Eligibility Criteria for Physicians and Group Practice
Body: 

To be eligible to participate in the 2013 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, 2013 to June 30, 2013. 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 2013, 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(CPT or HCPCS): 90791, 90792, 90832, 90834, 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.

All groups participating in the 2013 eRx Group Practice Reporting Option (GPRO) need to notify CMS of their desire to do so as well as the reporting method they plan to use for each calendar year. If a group plans on participating in both the PQRS GPRO and eRx GPRO, this information maybe submitted via the web. If, however, they are part of an Accountable Care Organization (ACO) or wishes to participate solely in the eRx GRPO, they cannot self-nominate via the web and must submit an email. 

GPROs participating in the eRx GPRO for the 2013 incentive payment must report the eRx measure's numerator for at least 75 unique visits (groups 2-24 EPs), 625 unique visits (groups sized 25-00 EPs), or 2,500 unique visits (groups sized 100 or more EPs) by December 31st, 2013.

Title: 
Mechanisms for Reporting the eRx measure
Body: 

Individual EPs are not required pre-register to participate in the eRx program. As noted above, groups must register with CMS in the appropriate manner. To participate in the 2013 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
  • 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.” If you utilize an Electronic Health Record system, speak to your vendor about eRx capabilities.

Title: 
Incentives and Penalties
Body: 

If you successfully e-prescribe medications and report the eRx measure in 2013 (by generating and reporting one or more electronic prescriptions associated with a minimum of 25 unique patient visits from January 1, 2013- December 31, 2013) you will earn incentives (in 2014) equal to .5 percent of your total Medicare payments for 2013. (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). 

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

Calendar Year of E-Prescribing Incentive Amount (%)

Penalty Amount (%)

2013

.5

-1.5

2014

N/A

-2

Group Practice Reporting Option (GPRO): Groups are also eligible for incentive payments based on 2013 e-prescribing. Information on group reporting measures can be found here.

Penalties for not participating in the eRx continue to increase every year of unsuccessful participation.To avoid a 2 percent penalty in 2014, 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, 2013 through June 30, 2013 reporting period on your Medicare Part B claim forms.All claims for services furnished between January 1, 2013, and June 30, 2013 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)
Title: 
Hardship Exemptions
Body: 

Eligible Professionals may apply for a hardship exemption from CMS that would exempt them from penalties in 2014 based on 2013 claims. Physicians have to apply for the exemption from the 2014 penalty by June 30th, 2013. Visit the CMS web tool to apply.

As a result of the advocacy of the Academy and several specialty societies, CMS, has continued to add new exemption categories to enable physicians to avoid the 2 percent Medicare E-Rx penalty in 2014 (based on 2013).

The 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
  • Physicians who are unable to electronically prescribe due to local, State, or Federal law or Regulation (e.g., prescribes controlled substances)
  • Physicians who infrequently prescribe
  • Insufficient opportunities to report the e-prescribing measure due to program limitations
  • *New*- Successfully achieving Meaningful Use in the CMS Electronic Health Record (EHR) Meaningful Use Incentive Program
  • *New*- Demonstrating intent to participate in the EHR Incentive Program for the first time by registering for the program and adopting certified EHR technology.

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.

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

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.