2014 Medicare E-Prescribing Program Toolkit

There have been no changes since 2013.

MEDICARE Electronic Prescribing (eRx) Program:
Avoid the reimbursement cut in 2014 by e-prescribing beginning January 2013

2013 is the second year in which CMS will be implementing a 0.5% payment incentive to successful eRx providers as well as a 1.5% payment cut for those eligible Medicare providers failing to participate in the eRx program during the first stage of the reporting period (January – June). To qualify as a “successful eRx provider” in 2013, CMS retains the same reporting requirements and specifications as in 2012.

In the 2013, CMS establishes new requirements to be considered a successful electronic prescriber for small group practices (2-24) using the eRx GPRO web-interface. This was previously available to larger group practices. CMS states that its establishment of different eRx reporting thresholds for smaller groups (2-24), as compared to the reporting thresholds for larger groups (25+) under the traditional GPRO, reflects the understanding that these smaller practices may not have the resources to meet the more robust reporting option. Please note that the self-nomination deadline to participate in the eRx GPRO program in January 31, 2013.

For more information on the Medicare eRx Group Reporting Option for larger practices, please click here:
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/Group-Practice-Reporting-Option.html

The 2012 Medicare Physician Fee Schedule final regulation sets forth the requirements for the Medicare electronic prescribing program’s incentive payments as well as reimbursement cuts. These incentive payments and reimbursements cuts are based on total Medicare Part B fee for service charges.

The applicable Medicare eRx incentive amounts are as follows:

2013 .5%
2014 and beyond There are no incentives schedule for 2014 and beyond

The applicable Medicare eRx “payment adjustments” are as follows:

2013 1.5% (based on 2012 e-prescribing data)
2014 2% (based on 2012 and 2013 e-prescribing data)
2015+ There are no payment adjustments scheduled past 2014

Criteria for being a “successful” electronic prescriber in 2013 Incentive Program (1% Incentive Payment)**

Reporting Period Reporting Mechanism Reporting Criteria
January – December 2013 Claims Report G code: G8553 for at least 25 unique “dominator eligible” visits
January – December 2013 Registry Report at least 25 unique “dominator eligible” visits
January – December 2013 EHR Report at least 25 unique “dominator eligible” visits
January – December 2013 GPRO (practice size: 2-24) Report the measure at least 75 times

** Providers successfully reporting these requirements in 2012 also avoided the 2014 payment adjustment

Criteria for avoiding the 2014 eRx Payment Adjustment are as follows:

Reporting Period Reporting Mechanism Reporting Criteria
January – December 2012 Claims, Registry, or EHR If a provider successfully reported in 2012 the criteria for the 2011 eRx incentive payment  
January – June 2013 Claims Report G code: G8553 for at least 10 unique visits

These visits do not need to be “dominator eligible visits.

January – June 2013 GPRO (practice size: 2-24) Report the measure 75 times

The “denominator eligible” visits include the following base codes:

90801 90808 96150 99204 99215 99309 99326 99337 99348
90802 90809 96151 99205 99304 99310 99327 99341 99349
90804 90862 96152 99211 99305 99315 99328 99342 99350
90805 92002 99201 99212 99306 99316 99334 99343 G0101
90806 92004 99202 99213 99307 99324 99335 99345 G0108
90807 92014 99203 99214 99308 99325 99336 99347 G0109

It is important to note that providers resubmitting any Medicare claim cannot add the eRx codes on this revised Medicare claims form. 

CMS allows six “hardship exemptions” to avoid the 2014 payment penalty (EPs as well as GPRO participants:

  • Provider is in an area with limited high speed internet access
  • Provider is in an area with limited e-prescribing ready pharmacies
  • Provider cannot e-prescribe to due local or state laws/regulations
  • Provider prescribed fewer than 100 prescriptions during the 6 month reporting period. 
  • Eligible professionals or group practices who achieve “meaningful use” during certain eRx payment adjustment reporting periods; and
  • Provider Eligible professionals or group practices who demonstrate the intent to participate in the Medicare “meaningful use” incentive program and adopt HHS-certified health IT.
    • For the 2013 payment adjustment: this hardship exemption applies to EPs (and eRx GPRO participants) who demonstrated the intent to participate in “meaningful use” from January 2, 2012 – January 31, 2013.  Those EPs who have demonstrated “meaningful use” on or before June 30, 2012 are ineligible for this hardship exemption
    • For the 2014 payment adjustment: this hardship exemption applies to EPs (and eRx GPRO participants) who demonstrate intent to participate in “meaningful use” from January 1, 2013 – June 30, 2013.  Those EPs who have achieved “meaningful use” on or before June 30, 2013 are ineligible for this hardship exemption.

CMS also establishes an informal review process for the eRx program. This will be modeled after the informal review process established under PQRS. The informal review process would only be available for the 2012 and 2013 eRx incentive payments and the 2013 and 2014 eRx payment adjustment. EPs wishing to request an informal review must do so by email.

  • Re the 2012 eRx incentive and 2013 eRx incentive, EPs must submit this request for an informal review within 90 days of receiving the feedback reports.
  • Re the 2012 and 2013 eRx payment adjustments, EPs must submit their request for an informal review by February 28, 2013.
  • Re the 2014 eRx payment adjustment, EPs must submit their request for an informal review by February 28, 2014.    

Please click on the following link to learn more on this informal review process:
http://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/erxincentive/index.html?redirect=/erxincentive