The Centers for Medicare and Medicaid Services (CMS) developed the Electronic Prescribing (eRx) Incentive Program to encourage physicians, NPs and PAs to incorporate e-prescribing into their practices. The eRx program consists of a ‘carrot and stick’ system of incentives for successful eRx participants and penalties for those who fail to meet the program's requirements.
If you participate successfully in eRx in 2013, you can earn a 0.5% bonus payment. Note that the 2013 eRx six-month reporting period (Jan. 1, 2013 - June 30, 2013) is the reporting period to avoid the 2014 eRx payment adjustment.
The Basics of eRx
Any health care professional who prescribes medications is subject to the requirements of the eRx program. CMS refers to these individuals, including DOs, MDs, PAs, NPs, podiatrists, etc., as "eligible professionals."
If you are participating in eRx, remember that:
A visit in which a patient is given several prescriptions counts as one eRx event.
A face-to-face visit in which a patient refills a prescription electronically counts as one eRx event.
Phone prescription refills do not qualify.
New and repeat patient visits qualify for the program.
CMS requires claims submission to avoid the penalty. Electronic health record or registry submissions are accepted to qualify for the incentive.
It's a good idea to submit a few more eRx events than are required for a given time period; that way, even if a few claims are rejected, you'll still be covered.
Controlled substances, as defined by the Drug Enforcement Agency, may not be electronically prescribed.
You do not need to participate in eRx if:
You do not have at least 100 claims containing an E/M code between Jan. 1 – June 30, 2013. CMS will calculate this and will automatically exempt physicians from the penalty. Physicians do not need to report anything.
Less than 10% of your total allowed charges are comprised of E/M codes between Jan. 1 – June 30, 2013. CMS will calculate this and will automatically exempt physicians from the penalty. Physicians do not need to report anything.
You do not have prescribing authority. In this case, report G8643 at least once by June 30, 2013.
Qualifying for the Incentive in 2013
To qualify for the eRx incentive in 2013, eligible professionals must submit 25 eRx events by Dec. 31, 2013. Claims must be submitted using G8553 and the applicable E/M code.
Avoiding the Penalty in 2014
Even if you were not a successful e-prescriber in 2012, you can avoid the 2% 2014 eRx penalty if you met the specified reporting requirements between Jan. 1 and June 30, 2013:
Individual eligible professionals – 10 eRx events; it is suggested you submit at least 15 eRx events to ensure that 10 go through. Claims must be submitted using G8553, but it's not necessary to report the denominator E/M code.
Group practices with 2-24 eligible professionals - 75 eRx events
Group practices with 25-99 eligible professionals: 625 eRx events
Group practices with 1,000 or more eligible professionals: 2,500 eRx events
To learn more about the group practice reporting option (GPRO), view the GPRO resources on the CMS website.
2014 Exclusion Criteria
CMS will automatically exclude individual eligible professionals from the 2014 eRx penalty if:
The eligible professional was a successful e-prescriber during the 2012 eRx 12- month reporting period (Jan. 1, 2012– Dec. 31, 2012). However, even if you meet this qualification, it may be wise to e-prescribe 10 times between Jan. 1 and June 30, 2013, to prevent the possibility of being erroneously penalized 2% in 2014.
The eligible professional is not a DO, MD, podiatrist, nurse practitioner, or physician assistant by June 30, 2013, based on primary taxonomy code in the National Plan and Provider Enumeration System (NPPES).
Significant Hardship Exemptions and Codes for 2014
CMS may exempt individual eligible professionals from the 2014 eRx payment adjustment if it is determined that complying with the requirements for being a successful electronic prescriber would result in a significant hardship. Significant hardship exemption requests must have been filed online between March 1 and June 30, 2013. These hardship exemption categories have been approved for 2014.
The eligible professional is unable to electronically prescribe due to local, state, or federal law or regulation. This exemption may apply to surgeons, physicians who administer pain clinics, orthopedic physicians and others who predominantly prescribe narcotics.
The eligible professional has or will prescribe fewer than 100 prescriptions during a six-month reporting period (Jan. 1 – June 30, 2013). Osteopathic manipulation practices may seek this exemption.
The eligible professional practices in a rural area without sufficient high-speed internet access (G8642). Submit this G code on at least one claim between Jan. 1 – June 30, 2013.
The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing (G8643). Submit this G code on at least one claim between Jan. 1 – June 30, 2013. Note that DOs who practice in nursing homes without eRx capabilities would use this exemption.
Eligible professionals within a group practice (GPRO) who achieve meaningful use under the Medicare or Medicaid EHR Incentive Program during the 12-month eRx reporting period (Jan. 1, 2012 – 12/31/2012) or the 6-month reporting period (Jan. 1 - June 30, 2013).
Eligible professionals within a group practice (GPRO) who demonstrate their intent (must register the certified EHR system with CMS) to participate in the Medicare or Medicaid Electronic Health Record (EHR) Incentive Program by June 30, 2013.
How to Request a Significant Hardship Exemption
If you qualify for an exemption, you should have submitted a significant hardship exemption request through the Quality Reporting Communication Support Page between March 1 and June 30, 2013. Here's what's needed to request an exemption:
Identifying information including tax identification number (TIN), national provider identification (NPI), name, mailing address and email address.
A justification statement describing how the exemption category applies. For example, if a physician is requesting the hardship exemption related to narcotics prescribing, the justification must cite the applicable law and state how the law restricts the ability to e-prescribe. If a physician is claiming the limited prescribing activity hardship, the justification must provide the number of prescriptions generated. This would mean fewer than 100 prescriptions in 2013, which is the requirement to avoid the penalty in 2014.
An attestation as to the accuracy of the information provided. CMS may request additional supporting documentation if there is insufficient information. This could happen if the physician’s NPI or TIN does not match the Medicare claims, if a certification number for the certified EMR technology does not appear on the ONC list, or if there is incomplete justification to support the significant hardship exemption requested.
CMS reviews hardship exemption requests on a case-by-case basis and all decisions are final.
Tips for Requesting a Significant Hardship Exemption
When entering your identifying information, you will be prompted to enter the last six digits of the TIN used to bill Medicare; this may be an employee ID number (EIN) or a Social Security number, whichever is used by the individual provider as the federal tax ID number on Part B claims.
If you are a solo practitioner requesting a hardship exemption but are incorporated (LLC or PC), use the individual NPI.
If a physician in a five-person group practice is filing for a hardship, each practitioner still should use their individual NPI.
The group practice option is only for those group practices who are CMS-recognized GPRO. Eligible professionals requesting a hardship exemption for themselves should select “Health Care Provider” in the requestor relationship field. Note that office staff can request a hardship exemption on behalf of the physician.
Significant hardships associated with a G code may be submitted via the communication support page or on at least one claim during the 2013 eRx reporting period (Jan. 1 – June 30, 2013). If you are submitting a significant hardship G code via claims, it is not necessary to request the same hardship through the Quality Reporting Communication Support Page.
Physicians can begin reporting on their CMS 1500 claim form with the appropriate numerator G code, G8553. The Form CMS-1500 is the standard paper claim form used by healthcare professionals and suppliers to bill Medicare Carriers or Part A/B and Durable Medical Equipment Medicare Administrative Contractors. The G8553 code must be reported with an ambulatory care visit with the denominator code (CPT or HCPCS): 90801, 02, 90804-09, 90862, 92002, 92004, 92012, 92014, 96150-52, 99201-05, 99211-15, 99304-10, 99315-16, 99324-28, 99334-37, 99341-45, 99347-50, 60101, 60108, 60109.
Adding a Nominal Amount to the Claim
The G code must be submitted with a line-item charge of $0.00 at the time the associated covered service is performed. However, the CMS claims processing system cannot accept a claim with a total charge of $0.00, so you will need to add a nominal amount, such as $0.01. Your patient will not be charged this nominal amount; it is only used to ensure the claim goes through and your eRx event is accepted.
Questions and Additional Information
If you have questions regarding the eRx Incentive Program, eRx payment adjustments, or need assistance submitting a hardship exemption request, please contact the QualityNet Help Desk at 866-288-8912 (TTY 877-715-6222) or via email at email@example.com. Help desk hours are Monday through Friday from 7 a.m. to 7 p.m.