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Overview of the Medicare 2013 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. The following bullets summarize major elements of and changes made for the 2013 program.

  • The amount of the incentive is reduced to 0.5% of total allowed charges for professional services covered by the Medicare Part B Physician Fee Schedule during 2013.
  • Eligible professionals who did not become successful e-prescribers by the end of 2011 or were unable to successfully submit at least 10 eRx through claims during the first 6-months of 2012 will face a 1 ½ % penalty for charges submitted in 2013. Hardship exemptions are available.
  • Eligible professionals who do not become successful e-prescribers by the end of 2012 or are unable to successfully submit at least 10 eRx through claims during the first 6-months of 2013 will face a 2 % penalty for charges submitted in 2014. Hardship exemptions are available.
  • Two additional hardship exemptions from the payment adjustment for unsuccessful eRx implementers were extended through 2014. These are:
    • Inability to electronically prescribe due to local, state, or Federal law or regulation.
    • Eligible professionals who prescribe fewer than 100 prescriptions during a 6-month payment adjustment reporting period.
  • A hardship exemption for participants in the Medicare or Medicaid EHR Incentive program to avoid the 2013 payment adjustment was approved through January 31, 2013.

Eligible Professionals

Eligible professionals (EP) include physicians and other recognized practitioners under the Medicare Act who have prescribing authority within their scope of practice. There is no registration process; submission of the required documentation automatically enrolls the EP into the program.

The incentive is limited in 2013 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 for the incentive are from January 1 through December 31 each year. Providers who are successful electronic prescribers in 2013 are eligible to receive an incentive payment for 2013 charges submitted by no later than February 28, 2013.

Incentive Amounts

The eRx incentive for eligible, successful e-prescribers in 2013 is 0.5 % of their total allowed charges for professional services covered by the Medicare Part B Physician Fee Schedule.

Practices that successfully participate in the Medicare “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.

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.

The definition of a qualified system was expanded to include ONC Certified EHR Technology.

Members should also be aware that there are free eRx programs available that meet CMS requirements. For example, the National ePrescribing Patient Safety Initiative, offers a free, basic e-prescribing system that meets the CMS e-prescribing qualifications for all interested physicians and medication prescribers.

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.

An 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

E-prescribing encounters that qualify for the incentive can be reported in 2012 through any of the following means. The EP or group practice must report through only one of these options---CMS will not combine data reported through different options.

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 that self nominate and are qualified by CMS to submit quality measure results on behalf of eligible professionals participating in the 2013 Physician Quality Reporting System (PQRS) incentive (formerly PQRI) can be used to submit data on the eRx measure. EP and group practices choosing this registry eRx reporting option must also participate in the PQRS program and use registry reporting within that program. A list of qualified registries for the 2013 E-Prescribing Incentive Program will be placed on the CMS Web site.

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. EP and group practices choosing this EHR eRx reporting option must also participate in the PQRS program and use EHR reporting within that program. 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.

Group Practice Reporting Option (GPRO)

CMS requires that in order for a group practice to participate in the 2013 eRx GPRO, a group practice must also participate in the 2013 PQRS as a 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.

For 2013, CMS has adopted a definition of practices eligible to participate in the GPRO to include at least 25 eligible professionals Practices approved under the GPRO 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 for the number of instances (based on practice size) as specified in the following table.

Group Size* Required Minimum Number of Unique Visits**
25 – 99 625
100 or more 2500

*Number of Eligible Professionals
**Where an Electronic Prescription was Generated to be a Successful Electronic Prescriber


Payment Adjustment—2013-2014

A payment adjustment (penalty) was introduced in 2011.

In 2012, EP and groups who did not become successful e-prescribers by the end of 2011 or are unable to successfully submit at least 10 eRx during the first 6-months of 2012 face a 1 ½ % penalty for charges submitted in 2013. Hardship exemptions are available.

Eligible professionals who do not become successful e-prescribers during the 12 months of 2012 or are unable to successfully submit at least 10 eRx during the first 6-months of 2013 will face a 2 % penalty for charges submitted in 2014. Hardship exemptions are available. Also, EP using the 6 month qualifying period to avoid the payment adjustment can submit their qualifying e-prescribing encounters only through claims and they can be submitted for any Medicare Part B Physician Fee Schedule code—not just the applicable codes defined for the incentive.

The penalty is applied to 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.
  • 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 between January 1 through June 30 of the 2012 for the 2013 penalty and January 1 through June 30, 2013 for the 2014 penalty.
  • The EP or group becomes a successful electronic prescriber during the defined time period.
  • The EP’s (or group practice) claims reflect that less than 10 percent of their estimated total allowed charges for the January 1, 2012 through June 30,2012 (for the 2013 penalty) and January 1, 2013 through June 30, 2013 (for the 2014 penalty) reporting periods are comprised of defined, applicable eRx service codes.

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

  • The EP or group practice practices in a rural area with limited high speed internet access— report through any of the reporting options code G8642 at least once.
  • The EP or group practice practices in an area with limited available pharmacies for electronic prescribing---report through any of the reporting options code G8613 at least once.
  • The EP or group obtained or registered for participation in the Medicare or Medicaid HER “Meaningful Use” program by January 31, 2013.
  • The EP or group practice is inability to electronically prescribe due to local, state, or Federal law or regulation.
  • The EP prescribes fewer than 100 prescriptions during a 6-month payment adjustment reporting period.

Any of the above exemptions can also be submitted via the Medicare Web Portal tool. All hardship exemptions must be submitted by June 30, 2013 to avoid the 2014 payment adjustment

Successful E-Prescriber Determination and Payment Procedure

Determination of professionals who are successful e-prescribers for 2012 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 2012 will be made for each unique NPI-TIN combination. Incentive payments for 2013 will be made by Fall of 2014.

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