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Medicare 2011 E-Prescribing Incentive Program

The Centers for Medicare and Medicaid Services (CMS) offers an incentive program for eligible professionals to facilitate the use of electronic prescribing (eRx). The incentive program was authorized under the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) and was implemented in 2009 and 2010. The following changes were made to the program for 2011 in comparison to 2010

• The amount of the incentive has changed from 2 % to 1% of total allowed charges for professional services covered by the Medicare Part B Physician Fee Schedule during 2011.
• A payment adjustment (penalty) has been introduced for eligible professionals that have not implemented and employed a qualified eRx system by the end of the first 6-months of 2011. The penalty is 1 % of total allowed charges submitted throughout 2012. Eligible professionals who have not implemented and employed a qualified eRx system by the end of 2011 will face a 1 ½ % penalty for charges submitted in 2013.
• Practices that successfully participate in the Medicare and Medicaid “Meaningful Use” EHR incentive program will not be eligible for the eRx incentive, but will still be eligible for imposition of the eRx payment adjustment.

Eligible Professionals

Eligible professionals (EP) include physicians and other recognized practitioners under the Medicare Act who have prescribing authority within their scope of practice.

The incentive is limited in 2011 to eligible professionals whose estimated allowed charges for “e-prescribing measure” procedural codes (defined below) are at least 10% of their total Medicare Part B Physician Fee Schedule allowed charges for the reporting period. Most office-based general internal medicine physicians and subspecialists should easily meet this 10% threshold.

Patient Eligibility

This incentive only applies to services provided to patients within the Medicare Part B Fee-For-Service program. It does not apply to patients covered under a Medicare Advantage program.

Reporting Periods

Reporting periods are from January 1 through December 31 each year. Providers who are successful electronic prescribers in 2011 are eligible to receive an incentive payment for 2011 charges submitted by no later than February 28, 2012.

Incentive Amounts

The eRx incentive for eligible, successful e-prescribers in 2011 is 1 % of their total allowed charges for professional services covered by the Medicare Part B Physician Fee Schedule.

Qualified E-prescribing System

Eligible professionals must use a “qualified” eRx system defined as a system that meets the following criteria. The system must be able to:

• Generate a complete active medication list incorporating electronic data received from applicable pharmacies and benefit managers (PBMs). (if available).
• Select medications, print prescriptions, electronically transmit prescriptions, and conduct all alerts defined as “written or acoustic signals to warn prescribers of possible undesirable or unsafe situations including potentially inappropriate dose or route of administration of a drug, drug-drug interactions, allergy concerns, or warnings and cautions.”Provide information on lower-cost, therapeutically-appropriate alternatives if there are any. (The availability of an eRx system to receive tiered formulary information would meet this requirement.
• Provide information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient’s drug plan. (if available).
• Convey the above information using the messaging and interoperability standards currently in effect for the Medicare Part D eRx program.

Eligible professionals should assess whether a particular eRx system is qualified by asking the system’s vendor and obtaining assurance that the system is capable of doing all of the required functionalities. Free standing e-prescribing systems and e-prescribing functions found in EHR systems that meet the requirements of the Certification Commission for Health Information Technology (CCHIT) will all qualify. CCHIT recognized products can be found at http://www.cchit.org/products.

Successful Electronic Prescriber Defined

A successful e-prescriber is one who meets all eligibility requirements and generates and reports at least one eRx during 25 or more unique patient visits during the reporting year.

A successful eRx reporting event consists of submitting the G-code (G8553) when performing one of the service codes defined below during the patient visit. This G-code reflects that at least one prescription created during the encounter was generated and transmitted using a qualified eRx system.

The applicable service codes for the electronic prescribing measure are 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, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, , and G Codes: G0101, G0108, G0109. The measure has no diagnosis codes or age/gender requirements in order to be included in the denominator.

Alternative Means of Reporting E-prescribing Incentive Data

Successful e-prescribing encounters that qualify for the incentive can be reported in 2011 through any of the following means:

Claims

Submit both the service and G-code code on the claim. The “G” code must be on the same claim form as the related service and should have a charge of $0.00.

Registry

Only registries qualified to submit quality measure results on behalf of eligible professionals for the 2011 Physician Quality Reporting System (PQRS) incentive (formerly PQRI) will be qualified to submit data on the eRx measure. A list of qualified registries for the 2011 E-Prescribing Incentive Program will be placed on the CMS Web site at http://www.cms.hhs.gov/ERXIncentive sometime in 2011.

Electronic Health Record (EHR)

EHR venders must self-nominate and have their systems vetted and approved by CMS for direct reporting of data to fulfill the requirements for the eRx incentive. Discuss with your vendor whether their system has been approved or is in the process of receiving approval, CMS will also post a list of approved vendors at http://www.cms.gov/ERxIncentive/08_Alternative%20Reporting%20Mechanism.asp#TopOfPage.

Group Practice Reporting Option (GPRO)

CMS requires that in order for a group practice to participate in the 2011 eRx GPRO, a group practice must also participate in the 2011 PQRS GPRO. A group practice that wishes to participate in both the PQRS GPRO and in the eRx GPRO must notify CMS of its desire to do so through self-nomination. The requirements and instructions for submitting the self-nomination letter can be found at: http://www.cms.hhs.gov/ERxIncentive/Downloads/GPRO_SelfNominationRequirements_111009.pdf.

For 2011, CMS has adopted a two tiered Group Practice Reporting Option. GPRO1 is geared for group practices with at least 200 eligible professionals; GPRO II for group practices of less than 200 eligible professionals. Practices approved under the GPRO1 option will have to report that at least 1 prescription during an applicable service encounter was generated and transmitted electronically using a qualified eRx system in at least 2,500 instances during the year-long reporting period. Practices approved under the GPRO II option will be considered successful eRx prescribers if they report at least 1 prescription during an applicable service encounter was generated and transmitted electronically using a qualified eRx system for the number of instances (based on practice size) specified in the following table.

Group size (Number of Eligible Professionals)	Required Number of Unique Visits Where an Electronic Prescription was Generated to be a Successful Electronic Prescriber
2-10	75
11-25	225
26-50	475
51-100	925
101-199	1875

Payment Adjustment—2012

A payment adjustment (penalty) has been introduced for 2011, which will affect payments in 2012. More specifically, eligible professionals will be penalized if they do not report a minimum of 10 successful eRx reporting events during the 6 month period of January 1, 2011 to June 30, 2011. Group practices approved to submit under GPRO1 or GPRO2, in order to avoid the penalty, will need to report the full minimal number of successful eRx encounter defined above under the incentive criteria within the first 6 months of 2011—e.g. for practices reporting under GPRO1, that means all 2500 required successful eRx encounter will need to be reported in the first 6 months of 2011. There is no proration under the GPRO option. A penalty of 1 % will be assessed for all allowed charges during the 2012 year for eligible professionals or groups that do not meet these requirements.

Due to CMS data processing limitations, all EPs will need to submit at least 10 successful eRx encounters in the first 6 months of 2011 through the claims process to avoid the penalty. This does not preclude these practices from also submitting their required incentive eRx data through registry or EHR methods at the same time. Group practices submitting under one of the GPRO alternatives will also need to report the required number of successful eRx encounter through the claims process to avoid the penalty. The College is aware that this is an unfortunate burden to many practices, and is strongly advocating for the elimination of this claims-only reporting requirement.

The penalty will be applied in 2012 for an individual EP or group unless one of the following is met:

• The EP is not a physician (includes MDs, DOs, and podiatrists), nurse practitioner or physician assistant as of June 30, 2011
• The EP does not have at least 100 cases (that is, claims for patient services) that contains the applicable eRx service code (as defined above) for dates of service January 1, 2011 through June 30, 2011.
• The EP is a successful electronic prescriber as defined by reporting a minimum of 10 successful eRx events during the 6 month period of January 1, 2011 to June 30, 2011.
• The EP’s (or group practice) claims reflect that less than 10 percent of their estimated total allowed charges for the January 1, 2011 through June 30, 2011 reporting period are comprised of applicable eRx service codes.

In addition, an EP (or group practice) can be considered for a “Significant Hardship Exemption” from the penalty if during January 1, 2011 through June 30, 2011, one of the following circumstances applies:

• The EP or group practice practices in a rural area with limited high speed internet access. (G8642)
• The EP or group practice practices in an area with limited available pharmacies for electronic prescribing. (G8643)

An EP or group practice must submit one of the related G codes indicated above during the first 6 months of 2011 to be considered for this hardship exemption.

Payment Adjustment—2013

A penalty has also been introduced for 2011, which will affect payments in 2013. More specifically, EP will be penalized if they do not report a minimum of 25 successful eRx reporting events during the12 month period of January 1, 2011 to December 31, 2011. Group practices approved to submit under GPRO1 or GPRO2, in order to avoid the penalty, will also need to report at least the minimal number of successful eRx encounters defined above under the incentive criteria within 2011—e.g. for practices reporting under GPRO1, that means all 2500 required successful eRx encounter will need to be reported by the end of 2011. A penalty of 1.5 % will be assessed for all allowed charges during the 2013 year for eligible professionals or groups that do not meet these requirements.

Successful E-Prescriber Determination and Payment Procedure

Determination of professionals who are successful e-prescribers for 2011 will be at the individual professional level, based on their National Provider Identifier (NPI). However, payment will be made to the practice represented by the Tax Identification Number (TIN) to which payments are made for the individual’s professional services. For providers associated with more than one practice, determination of a successful e-prescriber for 2011 will be made for each unique NPI-TIN combination. Incentive payments for 2011 will be made by mid-year 2012.

For Further Information:

The ACP E-Prescribing website that contains many helpful informational tools at http://www.acponline.org/running_practice/technology/eprescribing/index.html#links

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