Medicare E-Prescribing Incentive Program
To promote the adoption of e-prescribing systems, the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) authorized a five-year program of incentive payments for eligible professionals who electronically prescribe for the Medicare patients they treat. This program began on January 1, 2009, and will end in 2014. Eligibility Criteria To be eligible to participate in the 2011 eRx Incentive Program, office visits should represent at least 10 percent of your total Medicare Part B Physician Fee Schedule charges. 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, 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 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, 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. While free software and hardware e-prescribing programs are available, generally, the cost of stand-alone e-prescribing systems, including software and training, ranges from $500 to $2,500. Mechanisms for Reporting the eRx Measure There is no pre-registration required to participate in the eRx program. To participate in the 2011 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, G code, G8553 to: 1. CMS on their Medicare part B claims, 2. A qualified registry, (for a list of qualified registries, visit http://www.cms.gov/ERxIncentive/08_Alternative%20Reporting%20Mechanism.asp#TopOfPage) or, 3. CMS via a qualified electronic health record (EHR) product Though you may begin reporting the eRx measure at any time from January 1, 2011, to December 31, 2011, to avoid accruing penalty payment adjustments in 2012, you must start reporting the eRx measure by June 30, 2011. Incentives and Penalties If you successfully e-prescribe medications and report the eRx measure in 2011, you will earn incentives equal to 1 percent of your total Medicare payments for that year. (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.) Table 1 shows the incentives and penalties in the eRx program. Table 1. Incentive and penalty percentages Calendar Year of E-Prescribing Incentive Amount (%) Penalty Amount (%) 2011 1.0 – 2012 1.0 -1.0 2013 0.5 -1.5 2014 – -2.0 To avoid the 2012 eRx penalty payment adjustment, you must report on a minimum of 10 unique visits using claims-based reporting from January 1, 2011, through June 30, 2011. Please note that electronically generated refills do not count and faxes do not qualify as electronic prescriptions. Office visits provided as part of a global surgical package will not count toward the calculation of penalties for not adopting e-prescribing. To avoid the 2013 eRx penalty, you will need to report the 25 electronic prescriptions through a single method using claims-based reporting, registry-based submission, or EHR-based submission. Note that future rule-making from CMS may further define application of the 2013 eRx Payment Adjustment. 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 percent denominator threshold June Update: More Exemption Categories Based on the House of Medicine’s urging, CMS issued a proposed ruling on June 1 that makes significant changes to the e-prescribing penalty program by adding more exemption categories so that physicians are not unfairly penalized for failing to meet the requirements under the 2012 e-prescribing penalty program. Physicians are still required to e-prescribe using a qualifying e-prescribing system and report the G8553 code on at least 10 Medicare Part B claims from January 1, 2011, through June 30, 2011, to avoid the 2012 e-prescribing penalty. In order to avoid the 2012 e-prescribing penalty, physicians will have the opportunity to attest through an online web portal that they should be eligible for one of the following exemptions: • Physician’s practice is located in a rural area without high-speed internet access • Physician’s practice is located in an area without sufficient available pharmacies for electronic prescribing • Physician is registered to participate in the Medicare of Medicaid EHR Incentive Program and has adopted certified EHR technology • Physician is unable to electronically prescribe due to local, state, or federal law or regulation (e.g., prescribes controlled substances) • Physician infrequently prescribes (e.g. prescribe fewer than 10 prescriptions between January 1, 2011, and June 20, 2011) • There are insufficient opportunities to report the e-prescribing measure due to program limitations Physicians will have to apply for an exemption from the 2012 e-prescribing penalty via the web portal tool by October 1, 2011. Participation You will not be able to obtain incentives from both the Medicare eRx and the Medicare EHR incentive programs simultaneously. However, you may participate in the Physician Quality Reporting System and the eRx program at the same time. Also, you may participate in the Medicaid EHR incentive program and still qualify for incentives under the eRx program. If you have more questions on the eRx program, contact Healthpolicy@entnet.org or visit http://www.entnet.org/eRx.
Eligibility Criteria
To be eligible to participate in the 2011 eRx Incentive Program, office visits should represent at least 10 percent of your total Medicare Part B Physician Fee Schedule charges. 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, 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 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, 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. While free software and hardware e-prescribing programs are available, generally, the cost of stand-alone e-prescribing systems, including software and training, ranges from $500 to $2,500. |
Mechanisms for Reporting the eRx Measure
There is no pre-registration required to participate in the eRx program. To participate in the 2011 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, G code, G8553 to:
1. | CMS on their Medicare part B claims, |
2. | A qualified registry, (for a list of qualified registries, visit http://www.cms.gov/ERxIncentive/08_Alternative%20Reporting%20Mechanism.asp#TopOfPage) or, |
3. | CMS via a qualified electronic health record (EHR) product |
Though you may begin reporting the eRx measure at any time from January 1, 2011, to December 31, 2011, to avoid accruing penalty payment adjustments in 2012, you must start reporting the eRx measure by June 30, 2011.
Incentives and Penalties
If you successfully e-prescribe medications and report the eRx measure in 2011, you will earn incentives equal to 1 percent of your total Medicare payments for that year. (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.) Table 1 shows the incentives and penalties in the eRx program.
Table 1. Incentive and penalty percentages | ||
Calendar Year of E-Prescribing |
Incentive Amount (%) |
Penalty Amount (%) |
2011 | 1.0 | – |
2012 | 1.0 | -1.0 |
2013 | 0.5 | -1.5 |
2014 | – | -2.0 |
To avoid the 2012 eRx penalty payment adjustment, you must report on a minimum of 10 unique visits using claims-based reporting from January 1, 2011, through June 30, 2011. Please note that electronically generated refills do not count and faxes do not qualify as electronic prescriptions. Office visits provided as part of a global surgical package will not count toward the calculation of penalties for not adopting e-prescribing.
To avoid the 2013 eRx penalty, you will need to report the 25 electronic prescriptions through a single method using claims-based reporting, registry-based submission, or EHR-based submission.
Note that future rule-making from CMS may further define application of the 2013 eRx Payment Adjustment.
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 percent denominator threshold |
June Update: More Exemption Categories
Based on the House of Medicine’s urging, CMS issued a proposed ruling on June 1 that makes significant changes to the e-prescribing penalty program by adding more exemption categories so that physicians are not unfairly penalized for failing to meet the requirements under the 2012 e-prescribing penalty program. Physicians are still required to e-prescribe using a qualifying e-prescribing system and report the G8553 code on at least 10 Medicare Part B claims from January 1, 2011, through June 30, 2011, to avoid the 2012 e-prescribing penalty.
In order to avoid the 2012 e-prescribing penalty, physicians will have the opportunity to attest through an online web portal that they should be eligible for one of the following exemptions:
• | Physician’s practice is located in a rural area without high-speed internet access |
• | Physician’s practice is located in an area without sufficient available pharmacies for electronic prescribing |
• | Physician is registered to participate in the Medicare of Medicaid EHR Incentive Program and has adopted certified EHR technology |
• | Physician is unable to electronically prescribe due to local, state, or federal law or regulation (e.g., prescribes controlled substances) |
• | Physician infrequently prescribes (e.g. prescribe fewer than 10 prescriptions between January 1, 2011, and June 20, 2011) |
• | There are insufficient opportunities to report the e-prescribing measure due to program limitations |
Physicians will have to apply for an exemption from the 2012 e-prescribing penalty via the web portal tool by October 1, 2011.
Participation
You will not be able to obtain incentives from both the Medicare eRx and the Medicare EHR incentive programs simultaneously. However, you may participate in the Physician Quality Reporting System and the eRx program at the same time. Also, you may participate in the Medicaid EHR incentive program and still qualify for incentives under the eRx program.
If you have more questions on the eRx program, contact Healthpolicy@entnet.org or visit http://www.entnet.org/eRx.