Information on eRx Incentive Program

Who Is Eligible to Participate?

Eligible professionals must have prescribing authority and include the following:

• Medicare physicians
  --Doctor of Medicine
  --Doctor of Osteopathy
  --Doctor of Podiatric Medicine
  --Doctor of Optometry
  --Doctor of Oral Surgery
  --Doctor of Dental Medicine
  --Doctor of Chiropractic
• Therapists
  --Physical Therapist
  --Occupational Therapist
  --Qualified Speech-Language Therapist
• Practitioner
  --Physician Assistant
  --Nurse Practitioner
  --Clinical Nurse Specialist
  --Certified Registered Nurse Anesthetist (and Anesthesiologist Assistant)
  --Certified Nurse Midwife
  --Clinical Social Worker
  --Clinical Psychologist
  --Registered Dietician
  --Nutrition Professional
  --Audiologist
  

What Is the Reporting Period?

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.

Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) authorizes CMS to apply this payment adjustment whether or not the eligible professional is planning to participate in the eRx Incentive Program.

Reporting Qualifications

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:

• Claims-based reporting of the eRx measure. Report only one G-code (G8553) for 2011.
• Registry-based reporting using a CMS-selected *registry to submit 2011 data to CMS during the first quarter of 2012.
• EHR-based reporting using a CMS-selected *electronic health record product, submitting 2011 data to CMS during the first quarter of 2012.
  

What Are the Requirements?

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.
  

Payment Adjustments

From 2012 through 2014, the eRx payment adjustment will increase each Calendar Year:

• In 2012, the payment adjustment for not being a successful electronic prescriber will result in an eligible professional or group practice receiving 99% of their Medicare Part B PFS amount that would otherwise apply to such services.
• In 2013, an eligible professional or group practice will receive 98.5% of their Medicare Part B PFS amount for covered professional services for not being a successful electronic prescriber in 2011 or as defined in future rule making.
• In 2014, the payment adjustment for not being a successful electronic prescriber is 2%, resulting in an eligible professional or group practice receiving 98% of their Medicare Part B PFS amount for covered professional services.

The 2012 payment adjustment does not apply if less than 10% of an eligible professional’s (or group practice’s) allowed charges for the January 1, 2011, through June 30, 2011, reporting period are comprised of codes in the denominator of the 2011 eRx measure. The payment adjustment also does not apply if the eligible professional has less than 100 cases containing an encounter code in the measure’s denominator for the same January 1, 2011, through June 30, 2011, reporting period.

Please note that earning an eRx incentive for 2011 will NOT necessarily exempt an eligible professional or group practice from the payment adjustment in 2012 – but it will exempt an eligible professional or GPRO from a 2013 payment adjustment.

Avoiding the 2012 eRx Payment Adjustment

An eligible professional can avoid the 2012 eRx Payment Adjustment if he or she:

• 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’s denominator;
• Becomes a successful electronic prescriber (submits required number of electronic prescriptions (10 for individual) via claims and reports this to CMS before June 30, 2011); or
• Claims a hardship as described below.

A group practice that is participating in eRx GPRO I or GPRO II during 2011:

• MUST become a successful electronic prescriber (submit required number of electronic prescriptions via claims before June 30, 2011);
  --Depending on the group’s size, the group practice must report the eRx measure for 75-2,500 unique eRx events via claims for patients in the denominator of the measure.

If an eligible professional or selected group practice wishes to request an exemption to the eRx Incentive Program and the payment adjustment, there are two “hardship codes” that can be reported via claims if one of the following situations apply:

• G8642 - The eligible professional practices in a rural area without sufficient high speed internet access and requests a hardship exemption from the application of the payment adjustment under section 1848(a)(5)(A) of the Social Security Act.
• G8643 - The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing and requests a hardship exemption from the application of the payment adjustment under section 1848(a)(5)(A) of the Social Security Act.
  

How Is the eRx Incentive Program Related to the Electronic Health Record (EHR) Incentive Program?

• Medicare eligible professionals (EPs) may not earn incentives under the eRx and EHR Incentive Programs at the same time. However, EPs can receive payment from both the eRx and Medicaid EHR Incentive Programs for the same year.
• The EHR Incentive Program has a Core Objective related to generating and transmitting permissible prescriptions electronically (eRx).
  --This objective requires that more than 40% of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology.
  --Any EP who writes fewer than 100 prescriptions during the EHR reporting period is excluded from meeting the 40% threshold.