Electronic Prescribing aka eRx Penalties Begin 2012

What is eRx?
CMS defines eRx as the transmission, using electronic media, of prescription or prescription-related information between a prescriber, dispenser, pharmacy benefit manager, or health plan either directly or through an intermediary, including an eRx network.  Electronic prescribing includes, but is not limited to, two-way transmissions between the point of care and the dispenser.

eRx is the abbreviation for the electronic prescription incentive program.

Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) authorizes a new and separate incentive program for eligible professionals (EPs) who are successful electronic prescribers as defined by MIPPA. This new incentive program, which began on January 1, 2009, is separate from and is in addition to the quality reporting incentive program authorized by Division B of the Tax Relief and Health Care Act of 2006 - Medicare Improvements and Extension Act of 2006 (MIEA-TRHCA) and known as the Physician Quality Reporting Initiative (PQRI). Eligible professionals do not need to participate in PQRI to participate in the Electronic Prescribing (eRx) Incentive Program.

Who can participate in the eRx?
Under the E-Prescribing Incentive Program, covered professional services are those paid under the Medicare Physician Fee Schedule (PFS) and have prescribing authority and are a Medicare physician, practitioner, and/or therapist. Below is a list of potential EPs (eligible professionals).

  • Doctor of Medicine
  • Doctor of Osteopathy
  • Doctor of Podiatric Medicine
  • Doctor of Optometry
  • Doctor of Oral Surgery
  • Doctor of Dental Medicine
  • Doctor of Chiropractic
  • 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
  • Audiologists (as of 1/1/2009)
  • Physical Therapist
  • Occupational Therapist
  • Qualified Speech-Language Therapist (as of 7/1/2009)

Who can NOT participate in the eRx?

  • Providers paid under the Medicare PFS billing Medicare fiscal intermediaries/MACs. The FI/MAC claims processing systems currently cannot accommodate billing at the individual physician or practitioner level:
  • Critical access hospital (CAH), method II payment, where the physician or practitioner has reassigned his or her benefits to the CAH. In this situation, the CAH bills the regular FI for the professional services provided by the physician or practitioner.
  • All institutional providers that bill for outpatient therapy provided by physical and occupational therapists and speech language pathologists (for example, hospital, skilled nursing facility Part B, home health agency, comprehensive outpatient rehabilitation facility, or outpatient rehabilitation facility).  This does not apply to skilled nursing facilities under Part A.

How is the registration done for the eRx system?
There is no registration required to participate in the eRx incentive program.

What is the first step to participate in the eRx incentive program?
The first step in order to participate in the eRx incentive program is to determine if you are an EP (eligible professional). (See question 2.) EPs must have adopted a "qualified" eRx system. 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 2010)
  • Providing information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient's drug plan, if available.

I have a qualified eRx system, what is the next step required to participate in the eRx program?
If any of the codes below are reported during a patient encounter, and at least one prescription was generated and transmitted through the qualified eRx system, report HCPCS code G8553 (or numerator code) as well on the claim.  G8553 attests that during the patient visit at least one prescription was electronically prescribed. Electronically generated refills do not count and faxes do not qualify as eRx. 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 25 unique eRx events. 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.

It's important to note that in order to avoid penalties in 2012, at least 10 unique encounters must be reported between January 1, 2011, and June 30, 2011. The additional 15 encounters may be reported during the rest of the year to receive incentive payments for 2011. For 2011, eRx measures must be reported via claims-based reporting, i.e. electronically or CMS-1500 claim form.

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, 99345, 99347, 99348, 99349, 99350, G0101, G0108, G0109

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

Note: Per CMS, prescriptions for diabetic supplies may be electronically prescribed. Some pharmacies may require additional documentation secondary to internal policies which may be mandatory in case of audits; others may require a signed copy of the order with signature to be kept for verification purposes.


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