E-Prescribing Incentive Program - How To Get Started


It's not too late to start participating in the 2011 Electronic Prescribing (eRx) Incentive Program and potentially qualify to receive a full-year incentive payment for 2011. In addition, beginning 2012, CMS will apply payment adjustments to eligible professional who are not successful electronic prescribers under the eRx Incentive Program. To become successful electronic prescribers for purposes of avoiding the 2012 eRx payment adjustment, eligible professionals must report the eRx measure for a required minimum number of unique eRx events via claims between January 1, 2011 and June 30, 2011. This web site section is designed to lead you step by step through the process of becoming one of the growing number of eligible professionals who are participating in the program. You may also wish to investigate participating in a separate program known as the Physician Quality Reporting System (formerly known as the Physician Quality Reporting Initiative, or PQRI). For information on the Physician Quality Reporting System go to the "Related Links Inside CMS" section of this page and click on the link titled Physician Quality Reporting System.

Eligible professionals may begin reporting the eRx measure at any time throughout the 2011 program year of January 1-December 31, 2011 to be incentive eligible, but must do so prior to June 30, 2011 to be exempt from the 2012 eRx payment adjustment (click on "Payment Adjustment" link on the left for more information. Click on the "Eligible Professional" link on the left to see if you are an eligible professional. Eligible professionals must have adopted a "qualified" eRx system in order to be able to report the eRx measure. There are two types of systems.

1) a system for eRx only (stand-alone)

2) an electronic health record (EHR system) with eRx functionality.

Regardless of the type of system used, to be considered "qualified" it must be based on ALL of the following capabilities:

• Generating a complete active medication list incorporating electronic data received from applicable pharmacies and pharmacy benefit managers (PBMs) 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.

If you have not yet participated in the eRx Incentive Program, you can begin by reporting eRx data for January 1-December 31, 2011 using any of the following three options for purposes of qualifying for the 2011 incentive:

1. Claims-based reporting of the eRx measure. Report only one G-code (G8553) for 2011.

2. Registry-based reporting using a CMS-selected *registry to submit 2011 data to CMS during the first quarter of 2012.

3. EHR-based reporting using a CMS-selected *electronic health record product, submitting 2011 data to CMS during the first quarter of 2012

*Only registries and EHR vendors who have been vetted by CMS for the 2011 Physician Quality Reporting System/eRx Incentive Program and are on the posted list of registries/EHR vendors are eligible to be considered "qualified" for purposes of reporting the 2011 eRx Incentive Program. These registries/EHR vendors are qualified to report eRx information to CMS. However, please note that their systems have not been checked for eRx functionality as defined in the specifications of the measure. A list of EHR Vendors for the 2011 eRx Incentive Program is available in the "Downloads" section of this page. A list of qualified registries for the 2011 eRx Incentive Program will be available later this year.

For purposes of the 2012 payment adjustment, you need to report eRx data for January 1, 2011 through June 30, 2011 via claims. Before you report this measure, you should ask yourself the following questions:

QUESTION 1: Do I have an eRx system/program and am I routinely using it?

QUESTION 2: Is my system capable of performing the functions of a qualified system as described above?

QUESTION 3: Do I expect my Medicare Part B Physician Fee Schedule (PFS) charges for the codes in the denominator of the measure (as noted in List 1) to make up at least 10 percent of my total Medicare Part B PFS allowed charges for 2010?

If the answer to all three questions is YES, you may be eligible for an incentive payment equal to one percent as well as a one percent payment adjustment of your Medicare Part B PFS allowed charges for services furnished during the reporting period and you should report the eRx measure.

If the answer to the first two questions is YES, but the answer to the third question is NO, you may not be eligible for the incentive payment or the payment adjustment. However, we encourage you to report the eRx measure. In the event that your Medicare Part B PFS charges for the codes in the denominator of the measure (as noted in List 2) do make up at least 10 percent of your total Medicare Part B PFS allowed charges for 2010, you may be eligible for the incentive payment and payment adjustment.

If the answer to either of the first two questions is NO, you cannot report this measure unless you obtain and use a qualified eRx system as defined in List 1.

List 1: ERx Measure Denominator Codes (Eligible Cases)

Patient visit during the reporting period (Current Procedural Terminology [CPT] or Healthcare Common Procedure Coding System [HCPCS] G-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, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0101, G0108, G0109

CPT only copyright 2010 American Medical Association. All rights reserved.

Once You Have Decided That You Want to Participate in the eRx Incentive Program for 2011, You Should Take the Following Steps to Report the Measure:

STEP 1: Did you bill one of the CPT or HCPCS G-codes noted in List 1for the patient you are seeing?

NO: You do not need to report this measure for this patient for this visit.

YES: Proceed to Step 2.

STEP 2: You should report the following G-code (or numerator code) on the claim form that is submitted for the Medicare patient visit.

G8553 - At least one prescription created during the encounter was generated and transmitted electronically using a qualified eRx system.

We encourage you to report the G-code listed in Step 2 above on all of your patient visit claims along with one (or more) of the eligible denominator codes noted in List 1 above. An example of reporting the eRx measure on the Form CMS-1500 (Health Insurance Claim Form) is available in the "Downloads" section of this page. Click on the link titled "eRx Claims Based Reporting Principles".

STEP 3: To be a successful electronic prescriber and be eligible to receive an eRx incentive payment, you must generate and report one or more electronic prescriptions associated with a patient visit; a minimum of 25 unique visits per year. To avoid the 2012 eRx payment adjustment, you must report on a minimum of 10 unique visits via claims from January 1, 2011 through June 30, 2011. Each visit must be accompanied by the eRx G-code attesting that during the patient visit at least one prescription was electronically prescribed. Electronically generated refills do not count and faxes do not qualify as an electronic prescription. New prescriptions not associated with a code in the denominator of the measure specification are not accepted as an eligible patient visit and do not count towards the minimum unique eRx events.

STEP 4: Additionally, 10 percent of an eligible professional's Medicare Part B PFS charges must be comprised of the codes in the denominator of the measure to be eligible for an incentive or payment adjustment.

There is NO need to register to participate in this reporting program. Simply begin submitting the G-code on your claims appropriately, or, for eligible professionals attempting to quality for the incentive only, report the information required by the measure to a qualified registry, or submit the information required by the measure to CMS via a qualified EHR, if you satisfy the above requirements.

Other ways an eligible professional may avoid the 2012 payment adjustment are if the eligible professional:

• Is not a physician (MD, DO, or podiatrist), nurse practitioner, or physician assistant as of June 30, 2011, based on primary taxonomy code in the National Plan and Provider Enumeration System (NPPES);

• Does not have prescribing privileges and reports G-code G8644 (defined as not having prescribing privileges) at least one time on an eligible claim prior to June 30, 2011;

• Does not have at least 100 cases containing an encounter code in the measure denominator

• Does not meet the 10% denominator threshold

• Meets and reports a significant hardship exemption.

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