E-prescribing


eRx Payment Adjustments, Exclusions and Hardship Exemptions

Under Section 1848(a)(5)(A) of the Social Security Act, for years 2012 through 2014, a Medicare Physician Fee Schedule (MPFS) payment adjustment applies to eligible professionals who are not successful electronic prescribers at an increasing rate through 2014. Specifically, if the eligible professional is not a successful electronic prescriber for the respective reporting period for the appropriate program year, the MPFS amount for covered professional services during the year shall be a percentage less than the MPFS amount that would otherwise apply. 

The applicable electronic prescribing percent for payment adjustments under the eRx Incentive Program are as follows:

  • 1.0% adjustment in 2012 (eligible professional will receive 99% of their Medicare Part B PFS amount that would otherwise apply to such services);
  • 1.5% adjustment in 2013 (eligible professional will receive 98.5% of their Medicare Part B PFS amount for covered professional services); and 
  • 2.0% adjustment in 2014 (eligible professional will receive 98% of their Medicare Part B PFS amount for covered professional services).

Exclusion Criteria for Individual Eligible Professionals is as follows:

  • An individual eligible professional (regardless of participation in other CMS incentive programs) will not be included in analysis for the payment adjustment if one of the payment adjustment exclusion criteria (listed in the table below) applies. 
  • CMS will determine whether an individual eligible professional (defined by individual rendering National Provider Identifier, or NPI) is subject to future payment adjustments for each Tax Identification Number (TIN).
2013 Payment Adjustment Exclusion Criteria
2014 Payment Adjustment Exclusion Criteria

The eligible professional is a successful electronic prescriber during the 2011 eRx 12-month reporting period (1/1/11-12/31/11).

The eligible professional is a successful electronic prescriber during the 2012 eRx 12-month reporting period (1/1/12-12/31/12).

The eligible professional is not an MD, DO, podiatrist, Nurse Practitioner, or Physician Assistant by June 30, 2012, based on primary taxonomy code in the National Plan and Provider Enumeration System (NPPES).

The eligible professional is not an MD, DO, podiatrist, Nurse Practitioner, or Physician Assistant by June 30, 2013, based on primary taxonomy code in the NPPES.

The eligible professional does not have at least 100 MPFS cases containing an encounter code in the measure's denominator for dates of service from 1/1/12-6/30/12.

The eligible professional does not have at least 100 MPFS cases containing an encounter code in the measure's denominator for dates of service from 1/1/13-6/30/13.

The eligible professional does not have 10% or more of their MPFS allowable charges (per TIN) for encounter codes in the measure's denominator for dates of service from 1/1/12-6/30/12.

The eligible professional does not have 10% or more of their MPFS allowable charges (per TIN) for encounter codes in the measure's denominator for dates of service from 1/1/13-6/30/13.

The eligible professional does not have prescribing privileges and reported G8644 on a billable Medicare Part B service at least once on a claim between 1/1/12-6/30/12.

The eligible professional does not have prescribing privileges and reported G8644 on a billable Medicare Part B service at least once on a claim between 1/1/13-6/30/13.

Avoiding the 2013 eRx Payment Adjustment

Individual eligible professionals participating in the eRx GPRO who were not successful electronic prescribers in 2011 can avoid the 2013 eRx Incentive Program payment adjustment by reporting code G8553 for at least 10 fee-for-service encounters on Medicare Part B services rendered from 1/1/2012-6/30/2012.

For group practice submissions (GPRO) the number of encounters reported should be at least 625 and for practices of 25-99 eligible professionals, and at least 2,500 for practices with 100 or more eligible professionals.

Avoiding the 2014 eRx Payment Adjustment

Individual eligible professionals can avoid the 2014 eRx payment adjustment by either becoming a successful electronic prescriber for the 2012 reporting period (1/1/12-12/31/12), which entails reporting code G8553 at least 25 for fee-for-service encounters, or, reporting code G8553 for at least 10 fee-for-service encounters rendered from 1/1/2013-6/30/2013. 

For group practice submissions (GPRO) the number of encounters reported should be at least 625 and for practices of 25-99 eligible professionals, and at least 2,500 for practices with 100 or more eligible professionals.

2013 Hardship Codes and Hardship Exemption Requests

CMS may exempt individual eligible professionals and group practices participating in the eRx GPRO from the 2013 payment adjustment if it is determined that compliance with the requirement for being a successful electronic prescriber would result in a significant hardship.  The deadline for submitting hardship exemptions is July 2, 2012.

Hardship Exemption Circumstances and Codes:  
  • Inability to electronically prescribe due to state, or federal law, or local law or regulation;
  • The eligible professional prescribes fewer than 100 prescriptions during a 6-month payment adjustment reporting period;
  • The eligible professional practices in a rural area without sufficient high-speed Internet access (G8642); and
  • The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing (G8643).
Submitting a Hardship Request

CMS established the Quality Reporting Communication Support Page at http://www.qualitynet.org/pqrs for eligible professionals to submit hardship requests, including those associated with a G-code. For more information detailing how to navigate the Quality Reporting Communication Support Page, please reference the following documents: 

A hardship G-code may also be submitted at least once on a claim during the 6-month 2013 eRx payment adjustment reporting period, if applicable.

  • The hardship G-code must be submitted on a claim with a billable Medicare Part B service. 
  • The hardship G-code does not need to be submitted on a claim that contains eRx measure denominator codes. 
eRx Participation Feedback

Refer to the Remittance Advice (RA) to determine whether or not eRx quality-data codes submitted to the Medicare Carrier or A/B Medicare Administrative Contractor (MAC) are processed into the National Claims History database (NCH). CMS uses the NCH data for eRx program analysis. Take the following steps to ensure the eRx Quality-Data Codes (QDCs) are processed into the NCH:

  • The eRx line items will be denied for payment, but are passed through the claims processing system to the NCH used for eRx claims analysis.
  • The RA will include a standard remark code (N365). N365 reads: "This procedure code is not payable. It is for reporting/information purposes only." The N365 remark code does NOT indicate whether the eRx G-code is accurate for that claim or for the reported measure. N365 only indicates that the eRx G-code passed into the NCH. 
  • If the entire claim is rejected, please review claim for errors before re-submitting, since eRx G-codes will NOT be processed or tracked if the claim is rejected. 
  • Claims may NOT be resubmitted for the sole purpose of adding or correcting QDCs. 

Eligible professionals reporting eRx via claims can find additional information about claims submission and claims processing in the "2012 eRx Claims-Based Reporting Principles" document on CMS website at www.cms.gov/ERxIncentive under the "E-Prescribing Measure" section on the CMS website.

(The information above was taken from Noridian Administrative Services website - Medicare B News Issue 277 April 3 2012)

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Background

The Electronic Prescribing (eRx) Incentive Program is a reporting program that uses a combination of incentive payments and payment adjustments to encourage electronic prescribing by eligible professionals. The program provides an incentive payment to practices with eligible professionals (identified on claims by their individual National Provider Identifier [NPI] and Tax Identification Number [TIN]) who successfully e-prescribe for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries (including Railroad Retirement Board and Medicare Secondary Payer). Beginning in 2012, the program also applies a payment adjustment to those eligible professionals who are not successful electronic prescribers on their Medicare Part B services. This website serves as the primary and authoritative source for all publicly available information and CMS-supported educational and implementation support materials for the eRx Incentive Program.

No Sign Up or Pre-Registration: There is no sign-up or pre-registration for individual eligible professionals to participate in the eRx Incentive Program. However, there are certain limitations on who can qualify for an eRx incentive payment. First, an eligible professional must have and use a qualified eRx system and report on his or her adoption and use of the eRx system. Second, the eligible professional must meet the criteria for a successful electronic prescriber specified by CMS for a particular reporting period. Finally, at least 10% of a successful electronic prescriber's Medicare Part B covered services must be made up of codes that appear in the denominator of the eRx measure.

Eligible and Able to Participate: Below is a list of 20 professionals who are eligible to participate in the eRx Incentive Program for the incentive payment. Eligible professionals must have prescribing authority in order to participate in this incentive program.

1. Medicare physicians

  • Doctor of Medicine (MD) – subject to payment adjustment
  • Doctor of Osteopathy (DO) – subject to payment adjustment
  • Doctor of Podiatric Medicine (DPM) – subject to payment adjustment
  • Doctor of Optometry
  • Doctor of Oral Surgery
  • Doctor of Dental Medicine
  • Doctor of Chiropractic

2. Practitioner

  • Physician Assistant (PA) – subject to payment adjustment
  • Nurse Practitioner* (NP) – subject to payment adjustment
  • Clinical Nurse Specialist*
  • Certified Registered Nurse Anesthetist* (and Anesthesiologist Assistant)
  • Certified Nurse Midwife*
  • Clinical Social Worker
  • Clinical Psychologist
  • Registered Dietician
  • Nutrition Professional
  • Audiologists

*Includes Advanced Practice Registered Nurse (APRN)

3. Therapists

  • Physical Therapist
  • Occupational Therapist
  • Qualified Speech-Language Therapist

(The information above was taken the CMS Electronic Prescribing Incentive Program website section)

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Additional Information

For more information on the CMS eRx Incentive Program, go to www.cms.gov/ERxIncentive on the CMS website.

For more information on future payment adjustments, go to www.cms.gov/ERxIncentive/20_Payment_Adjustment_Information.asp on the CMS website.

CMS has provided the following resource to answer inquiries regarding the Physician Quality Reporting System and eRx Incentive Program, incentive payments, feedback reports, and Individuals Authorized Access to CMS Computer Services (IACS) registration:

QualityNet Help Desk - 7:00 AM - 7:00 p.m. CST. This desk can help with:

  • General CMS Physician Quality Reporting System and eRx Incentive Program information;
  • Portal password issues;
  • Feedback report availability and access;
  • Physician Quality Reporting-IACS registration questions; and 
  • Physician Quality Reporting-IACS login issues.

Phone: (866) 288-8912  TTY: (877) 715-6222     Email: Qnetsupport@sdps.org

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Attached Documents:

v2 2016