CMS ePrescribing Incentive Program
What Physicians Need To Know About the 2012 E-Prescribing Penalty Program and the Processing of Exemption Requests
The AMA has been in constant communication with CMS to ensure that physicians who applied for an exemption to avoid the 2012 e-prescribing penalty are notified as soon as possible on whether their exemption request has been honored by CMS. Here is the latest information on the 2012 e-prescribing penalty program.- CMS is in the process of notifying physicians via email whether their exemption request with respect to the 2012 Medicare e-prescribing penalty will be honored. Any questions regarding the status of a physician's request for an exemption should be directed to CMS' Quality Net Help Desk. The Quality Net Help Desk may be contacted via telephone at (866) 288-8912 or via email at Qnetsupport@sdps.org. Further information on the QualityNet Help Desk is available on CMS' website.
- As noted in earlier communications, due to the volume of hardship exemptions requested and CMS' case by case review process, CMS was unable to process each hardship exemption request by January 1, 2012. As of the beginning of March, CMS has told us they have completed their review of all the hardships and that every physician who filed for a hardship exemption should have received a letter from CMS.
- Many physicians who applied for an exemption last year have received this month or will receive an email from CMS in the next several weeks indicating that their exemption request has been honored. Unfortunately, some physicians whose exemption request has been honored may still see a 1 percent payment reduction in their 2012 Medicare Part B payments. Please be advised that CMS will reprocess these claims as soon as they can but it may take a month or so to credit physicians who should not have received a penalty.
- Please retain the email from CMS notifying you that they have honored your exemption request for your records.
- Important Note: Until now, physicians who filed for a hardship exemption but experienced a financial penalty anyway, may now have a recourse to have this penalty removed. As a direct result of AMA advocacy, CMS has agreed to review situation such as these. Examples of these sorts of problems physicians are experiencing include:
- Physicians who applied for an exemption were required to submit their individual National Provider Identifier (NPI). Some physicians have seen the penalty applied as a result of submitting their group NPI rather than their individual NPI. CMS is reviewing this issue.
- There have been some cases where vendors/billers/clearinghouses have inappropriately removed the G code - G8553 - from a physician's Medicare Part B claims thinking that the G-code was reported in error. Please make sure your vendors/billers/clearinghouses understand why you are including the G8553 code on your claims and make sure that they do not remove the G8553 code from your Medicare Part B claims. Remember to review your remittance advice regularly to ensure you receive the N365 code when submitting the G8553 codes on your Medicare Part B claims. The N365 code is your indication that the G8553 code passed into the Medicare National Claims History (NCH) database
- Physicians who have been unsuccessful in resolving their Medicare e-prescribing concerns after contacting the Quality Net Help Desk can complete the ePrescribing incentive complaint form and email it back directly to CMS or fax to the AMA who will forward it onto CMS.
Review an updated frequently asked questions (FAQ) sheet.
In January 2009 the Centers for Medicare & Medicaid Services (CMS) began offering eligible providers incentive payments for their use of an electronic prescribing (ePrescribing) system to prescribe for Medicare patients. For 2009 and 2010, ePrescribing incentive amounts were 2 percent of a provider’s total estimated allowed charges for covered professional services during the reporting period (one calendar year). The incentive amount reduced to 1 percent in 2011 and 2012 and finally to 0.5 percent in 2013.
Eligible professionals who were successful electronic prescribers received an average bonus payment of just over $3,000 (and $14,501 per practice) from the ePrescribing Incentive Program in 2009.
To be eligible for the incentive, you must use qualified ePrescribing technology. A qualified ePrescribing system is one that is capable of all of the following:
- 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 the availability of lower cost, therapeutically appropriate alternatives (if any)
- Providing information on formulary or tiered formulary medications, patient eligibility and authorization requirements received electronically from the patient’s drug plan
Eligible professionals must report prescribing activity using a qualified ePrescribing system. Follow these three steps to report ePrescribing activity and receive the incentive:
- Step 1: Determine the eligibility of the patient encounter. Consider the list of Current Procedural Terminology (CPT®) codes. A list of codes is included in the CMS ePrescribing Measure Specifications, which identifies applicable services.
- Step 2: Document the patient encounter on the Medicare Part B claim. All measure-specific coding should be reported on the same claim.
- Step 3: Report G-code G8553 when a patient visit results in placing at least one electronic prescription.
Incentive payment is equal to 1 percent of total Medicare Part B allowed charges (Eprescribing incentive not available to professionals receiving incentives from EHR Incentive Program for 2012).
- The CMS ePrescribing program has two reporting periods: penalty (January 1 to June 30, 2012) and incentive (January 1 - December 31, 2012).
- Eligible professionals need only report 25 separate electronic prescribing events during the reporting period (2012 calendar year) to receive the incentive and just 10 times before June 30, 2012 to avoid the 2013 penalty.
- Data may be reported in three ways: 1) to CMS via Medicare Part B claims; 2) to a qualified registry; or 3) to CMS via a qualified electronic health record (EHR) product. CMS has posted a list of qualified registries and qualified EHR vendors and products for the 2012 Electronic Prescribing Incentive Program on its website.
The penalty
Individual eligible professionals may be subject to a 1.5 percent payment adjustment (penalty) in 2013 unless they:
- Are successful ePrescribers before June 30, 2012 (i.e., 10 unique ePrescribing events for CPT codes reported on Medicare Part B claims with the G8553 code)
- Are not a physician, nurse practitioner or physician assistant as of June 30, 2012
- Do not have at least 100 cases containing an encounter code in measure denominator
- Less than 10 percent of their Medicare Part B charges during the first six months of 2012 are for office visits and other services listed in the 2012 CMS ePrescribing measure specifications
An eligible professional who is a successful ePrescriber for the 2012 eRx incentive (i.e., transmitting and reporting on 25 electronic prescriptions in the calendar year) would also be considered a successful ePrescriber for purposes of avoiding the 2014 eRx penalty (a 2 percent payment adjustment). Note: Eligible professionals who successfully transmitted and reported 25 electronic prescriptions in 2011are already exempted from the 2013 penalty.
Hardship exemption
Eligible professionals and group practices can submit an exemption form to avoid the 2013 penalty. Use the following hardship categories to determine eligibility:
- Physician is unable to electronically prescribe due to local, state, or federal law or regulation (e.g., state law prohibits ePrescribing of controlled substances)
- Physician prescribes fewer than 100 prescriptions between January 1, 2012 and June 30, 2012
- Physician is located in a rural area without high-speed Internet access
- Physician practice is located in an area without sufficient available pharmacies for ePrescribing
Exemption form.
This frequently asked questions (FAQ) flier will help providers determine their eligibility for the incentive program and learn more about the reporting requirements. Providers may also consult the following resources:
- Claims-based reporting principles for eRx incentive program
- Instructions to obtain PQRS feedback reports, MLN Matters, October 2009
- Sample CMS-1500 claim form
- List of Medicare allowed frequency and charges by specialty from 2007
