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American Association of Oral and Maxillofacial Surgeons

Practice Management & Allied Staff News & Materials

Electronic Prescribing (e-Rx)

August 5th, 2013

Overview
The Electronic Prescribing (e-Rx) Incentive Program is a reporting program that provides a combination of incentive payments and payment adjustments to encourage the use of electronic prescribing by eligible professionals. The incentive is a bonus payment equal to a percentage of the total part B Medicare payments for the year. The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) established a five-year program of incentive payments along with payment adjustments to eligible professionals – including Doctors of Oral Surgery (DDS) and Doctors of Dental Medicine when they electronically prescribe for Medicare patients seen in their offices. It is widely believed that e-prescribing (e-Rx) will encourage electronic health record (EHR) adoption. No sign-up or registration is necessary to begin e-Rx.

Important note: Eligible professionals may not earn incentives under the Medicare e-Rx and EHR incentive programs at the same time. A provider reporting under both incentive programs would receive the EHR incentive program bonus only.

Eligible Professionals
Doctors of Oral Surgery (DDS) and Doctors of Dental Medicine are included within the list of eligible professionals provided on the Centers for Medicare and Medicaid Services (CMS) website. There is no sign-up or registration for an eligible professional to begin participation within the e-Rx program, however not all providers are eligible to join the program.

Qualified e-Rx System
Also in order to qualify for the program, eligible providers must have adopted a “qualified” e-Rx system. There are two types of systems that will meet this definition:

  1. a system for e-prescribing only (stand-alone) or
  2. An EHR system with e-Rx 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 e-prescribing system to receive tiered formulary information, if available, would meet this requirement)
  • Providing information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient’s drug plan, if available.

Reporting options
There are two reporting methods: individually or as a group. Eligible physicians (individual reporting) or groups (defined as more than 200 doctors) must report e-prescribing activity via a qualified e-prescribing system.  The eligible provider may report use of a qualified e-prescribing system via 1) Medicare claims, 2) report to a qualified registry, or 3) report via a qualified electronic health record.

Individual reporting: Providers must report the e-prescribing G-code G8553 (“at least one prescription created during the encounter was generated and transmitted electronically using a qualified E-prescribing system”) at least 25 times for Medicare Part B services for the calendar year to be eligible for the incentive payment (issued to the provider the following year). To avoid the payment adjustment, eligible professionals with at least 100 cases containing an encounter code in the measure denominator (I.E. 99201-99205) are required to report the e-prescribing measure for at least 10 unique e-prescribing events within the first 6 months of the previous calendar year.  Eligible professionals that do not have at least 100 cases within the first 6 months of the previous calendar year containing an encounter code in the measure denominator may be exempt from the payment adjustment.

Group Reporting: Groups reporting electronically must report the e-Rx measure for a minimum of 2,500 unique denominator-eligible visits per year. Attempts to report the measure for visits not associated with a denominator eligible patient visit do not count towards the minimum of 2,500 cases. A denominator eligible patient is a patient whose visit could be documented using a code from CMS’s list of e-Rx eligible denominator codes.  In addition to meeting the criteria for "successful electronic prescriber" above, at least 10% of the group practice's Medicare Part B charges must be comprised of the codes in the denominator of the measure in order for the group practice to be incentive eligible.

Penalties
The program also provides penalties for eligible providers who fail to e-prescribe in the first 6 months of a reporting year. Eligible professionals with at least 100 cases within the first 6 months of the previous calendar year containing an encounter code in the measure denominator are required to report the e-Rx measure for at least 10 unique e-prescribing events or face the penalty. For these individuals, the incentive is reduced each year that a physician chooses not to participate.  Single degreed oral and maxillofacial surgeons appear to be exempt from the penalty, at least for the current reporting period, but this may or may not be the case in the future. It is important to note that earning an e-Rx incentive for the reporting year does not exempt an eligible professional or group practice from the payment adjustment. Eligible professionals that do not meet the necessary number of cases may be exempt from the payment adjustment.

Avoiding the Penalty
All eligible professionals have the opportunity to avoid the e-Rx payment adjustment by meeting the criteria for becoming a successful electronic prescriber either:

  1. During a specified 12-month reporting period (January 1–December 31), or
  2. During a specified 6-month reporting period (January 1–June 30, 2013). 

Individual eligible professionals need to have been a successful electronic prescriber in the reporting year (2 years prior to the current year), need to report the G8553 code via claims for at least 10 billable Medicare Part B PFS services provided during the 6-month (January-June) reporting period during the reporting year, OR request an e-Rx significant hardship exemption.

Hardship Codes:
CMS introduced new codes for use beginning in 2011, referred to as hardship codes, to be reported at least one time on a claim with a CMS approved denominator code during the payment adjustment reporting period(January 1 through June 30). These codes are to be used ONLY when an eligible professional wishes to request a significant hardship exemption from the application of the payment adjustment because the professional is unable to submit prescriptions electronically due to a system hardship.  (e.g., rural without internet, limited available pharmacies for electronic prescribing, or does not have prescribing privileges).The three hardship codes are provided below for your reference.

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.

G8644: the eligible professional does not have Prescribing privileges. If this code is utilized, the eligible professional may not be considered for a payment adjustment.

ADMINISTRATIVE NOTE: The e-prescribing G-code must be submitted with a line-item charge of zero dollars ($0.00) at the time the associated covered service is performed.

Individual eligible professionals can also request on of the final four hardship exemptions (not G-codes) by submitting their request via the CMS Quality Reporting Communication Support Page.

  1. The eligible professional or e-Rx GPRO practices in an area with limited high-speed internet access;
  2. The eligible professional or e-Rx GPRO practices in an area with limited available pharmacies for electronic prescribing;
  3. The eligible professional or e-Rx GPRO is unable to electronically prescribe due to local, state or federal law or regulation;
  4. The eligible professional or e-Rx GPRO has limited prescribing activity, as defined by an eligible professional generating fewer than 100 prescriptions during a 6-month reporting period

Requests and supporting rationale for the e-Rx payment adjustment significant hardship exemption may be submitted through the Quality Reporting Communication Support Page.  The deadlines for the exemption from the 2015 penalty will be announced shortly and providers are encouraged to check the CMS Web site for this information.

Program Bonus & Penalty Schedule
Calendar year of e-prescribing                  Incentive amount            Penalty amount
2010                                                                       2.0%                                      ----
2011                                                                       1.0%                                      -1.0% for those unsuccessful
in the first 6 months of the year
2012                                                                       1.0%                                      -1.0%
2013                                                                       0.5%                                      -1.5%
2014                                                                       -----                                        -2.0%