American Academy of Family Physicians
Friday Jun 07, 2013

eRx: It's not too late, but just barely

As mentioned in a previous post, June 30 is the end of the six-month reporting period for physicians to avoid having their Medicare Part B fees cut next year under the federal Electronic Prescribing (eRx) Incentive Program.

The 2 percent 2014 eRx payment adjustment, which affects covered professional services on or after Jan. 1, 2014, only applies to certain individual eligible professionals and group practices. The Centers for Medicare and Medicaid Services (CMS) will automatically exclude those who meet the criteria listed in the eRx Incentive Program: 2014 Payment Adjustment Fact Sheet.

For everyone else, avoiding the cut requires submitting 10 eRx events via claims between Jan. 1 and June 30, 2013. The requirements for CMS-selected group practices participating in the eRx group practice reporting option (GPRO) are as follows:

•    eRx GPRO of 2-24 eligible professionals – 75 eRx events via claims,
•    eRx GPRO of 25-99 eligible professionals – 625 eRx events via claims,
•    eRx GPRO of 100+ eligible professionals – 2,500 eRx events via claims.
CMS may exempt individual eligible professionals and group practices participating in the eRx GPRO from the payment adjustment if CMS determines that compliance with the requirements for becoming a successful electronic prescriber would result in a significant hardship. The significant hardship categories are also listed in the fact sheet referenced above.

You can submit your significant hardship exemption requests through the Quality Reporting Communication Support Page no later than June 30, 2013. Alternatively, significant hardships associated with a G-code may be submitted via the Communication Support Page or on at least one claim between Jan. 1 and June 30, 2013. If submitting a significant hardship G-code via claims, it is not necessary to request the same hardship through the Communication Support Page. The hardship exemptions for achieving meaningful use or demonstrating intent to participate by registering in the Medicare or Medicaid Electronic Health Record Incentive Program by June 30, 2013, will be automatically processed by CMS and therefore will not need to be entered as a hardship exemption request through the Communication Support Page. CMS will review hardship exemption requests on a case-by-case basis, and all decisions on significant hardship exemption requests will be final.

For more information on how to navigate the Communication Support Page, please see the following documents:

•    Quality Reporting Communication Support Page User Guide,
•    Tips for Using the Quality Reporting Communication Support Page.
Additional information and resources are available through the fact sheet and the eRx Incentive Program website. If you have questions regarding the eRx Incentive Program or eRx payment adjustments, or if you need assistance submitting a hardship exemption request, please contact the QualityNet Help Desk at 866-288-8912 (TTY 1-877-715-6222) or via They are available Monday through Friday from 7am-7pm CT.

 – Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Wednesday Feb 22, 2012

E-Prescribing codes for 2012

Wondering what codes to report to demonstrate e-prescribing in 2012? If you electronically prescribed during the eligible patient visit, submit code G8553, which denotes that at least one prescription created during the encounter was generated and transmitted electronically using a qualified e-prescribing system. Eligible patient visits are those reported with any of the following CPT or HCPCS codes:

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, 99344, 99345, 99347, 99348, 99349, 99350, G0101, G0108, G0109.

To demonstrate that you are exempt from e-prescribing, submit code G8642, which connotes that "the eligible professional practices in a rural area without sufficient high-speed Internet access" and G8643, "The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing. There are no codes to report exemptions resulting from the inability to electronically prescribe due to state, federal, or local law or regulation" or as an "eligible professional who prescribes fewer than 100 prescriptions during a six-month payment adjustment reporting period." These exemptions must be requested by the physician through

A Remittance Advice (RA)/Explanation of Benefits (EOB) with the denial code N365 is your indication that the e-prescribing G-code was received by Medicare.

Saturday Jun 11, 2011

CMS proposes to align eRx and EHR incentive programs

We have previously posted that even though physicians who are participating in the Centers for Medicare & Medicaid Services (CMS) EHR Incentive Program in 2011 are not eligible to receive an incentive under the CMS eRx Incentive Program, they could be subject to a penalty for not participating in the eRx Incentive Program (1 percent for 2012, 1.5 percent for 2013, and 2 percent for 2014). In a proposed rule published in the June 1, 2011, Federal Register, CMS has noted their desire to better align the two programs. This proposed rule is complex but has key provisions of importance to any physician who may be subject to a penalty for failure to participate in the CMS eRx Incentive Program but who intends to participate in the EHR Incentive Program this year.

CMS proposes that use of an EHR meeting the certification requirements for meaningful use will qualify for a hardship exemption under the CMS eRx Incentive Program. CMS is proposing that the eligible professional  must: 

1. Have registered for either the Medicare or Medicaid EHR Incentive Program (for instructions on how to register for one of the EHR Incentive Programs, see the registration page of the EHR Incentive Programs section of the CMS web site); and 

2. Provide identifying information as to the certified EHR technology (as defined at 45 CFR 170.102) that has been adopted for use no later than October 1, 2011, for a hardship exemption to be submitted, which then would be reviewed on a case-by-case basis.

In requesting a significant hardship exemption of the type CMS is proposing, physicians would be attesting to having purchased certified EHR technology (as identified by the certification number and/or serial number) or having the specified certified EHR technology available for immediate use with the intention of using it to qualify for a Medicare or Medicaid EHR incentive payment for 2011.

Because this proposed change would not be finalized before June 30, 2011 (the end of the 2012 eRx payment adjustment reporting period), it would not apply for purposes of reporting the eRx measure for the 2012 eRx payment adjustment. In other words, meeting this new hardship exemption could qualify you for the 1 percent incentive in 2011 and exempt you from the 1.5 percent penalty in 2013, but you will still need to submit 10 claims indicating your use of a qualified eRx system before June 30, 2011 to avoid the off-setting 1 percent penalty for 2012.

In the proposed rule, CMS has suggested additional exemptions for the eRx program. If the rule is implemented, physicians would be able to request consideration for a significant hardship exemption from the 2012 eRx payment adjustment if one of the following circumstances applies:

• The practice is located in a rural area without high speed Internet access.

• The practice is located in an area without sufficient available pharmacies for electronic prescribing.

• The physician has registered to participate in the Medicare or Medicaid EHR Incentive Program and adoption of certified EHR technology.

• The physician lives in an  area where a local, state or federal law or regulation prevents e-prescribing (e.g., such as those prohibiting paperless prescriptions for narcotics). (Must cite law/regulation.)

• The physician has limited prescribing activity. (Must submit number of prescriptions written.)

• The physician has insufficient opportunities to report the electronic prescribing measure due to limitations of the measure's denominator.

The proposed rule would require that you provide the following to CMS by Oct. 1, 2011, to request an exemption:

1. Identifying information such as the TIN, NPI, name, mailing address, and e-mail address of all affected eligible professionals.

2. The significant hardship exemption category(ies) above that apply.

3. A justification statement describing how compliance with the requirement for being a successful electronic prescriber for the 2012 eRx payment adjustment during the reporting period would result in a significant hardship to the eligible professional or group practice.

4. An attestation of the accuracy of the information provided.

CMS proposes to have an online tool for submission of exemptions by Oct. 1, 2011, but should that fail to happen, requests for exemption would need to be submitted by mail and postmarked no later than that date. We will keep you posted on how this works out.

CMS is requesting comments on this proposed rule and particularly on whether the serial number of the EHR product should be required for identification of the certified EHR technology the physician has purchased and adopted to meet the requirements for the EHR incentive program. The AAFP will submit a comment letter about this still overly complex process. You too can provide comments online at (enter ID CMS-3248-P to bring up this docket). The rule is open for public comment until July 25, 2011.

Thursday Apr 21, 2011

Performance measurement and reporting: Finding a method in the madness

As if it wasn't already hard enough for physicians to provide care and get paid by Medicare, many physicians and their staffs are now documenting and reporting data to demonstrate "meaningful use" of electronic health record (EHR) systems, quality (for the Physician Quality Reporting System, or PQRS, formerly PQRI), successful e-prescribing and more. The seeming (and sometimes glaring) lack of coordination across these programs has created barriers to successful participation that may actually detract from the intended increases in quality and coordination of care. 

I hope I have stumbled onto something that might help family physicians and their staff members who are considering how to report the required measures while still having the time and sanity to provide patient care. In developing information on the new Medicare annual wellness visit and the documentation necessary to be paid for that newly covered benefit, I researched the extent to which documentation of preventive services might also be used to support both the PQRS and the meaningful use reporting requirements.

The following table identifies areas of overlap and notes regarding the frequency with which Medicare will pay for the preventive services.

Preventive service

2011 Medicare PQRS measure

EHR “meaningful use” incentive measure

Medicare benefit

Blood pressure


included in annual wellness visit benefit 

BMI screening and follow-up

yes yes

included in annual wellness visit benefit

Tobacco use screening and cessation intervention

yes yes

covered – up to 8 sessions in 12 months

Influenza immunization for patients 50 years and over

yes yes

covered once per season 

Pneumonia vaccination for patients 65 years and over



covered once

Screening mammography

yes yes

covered annually

Colorectal cancer screening

yes yes

covered – schedule depends on screening type

Alcohol use screening



national coverage analysis in progress

Osteoporosis screening or therapy



bone mass measurement covered for estrogen-deficient or clinically at-risk patients

Urinary incontinence screening for women 65 years and over





Of course each of the programs has its own measure specifications and reporting methodologies, so it may provide much relief to use one measure to meet multiple reporting requirements. However, the table might help you to better organize your efforts.

For instance, is your EHR approved by CMS for use in reporting data to the PQRS program? If not, have you considered using a registry for this purpose? If you are providing annual wellness visits or otherwise documenting your patients' preventive care, registry-based reporting, which requires reporting data for only 30 Medicare patients, might be more easily accomplished. Do you have other ideas for participating in these initiatives with the least amount of administrative burden? If so, I hope you'll share your comments below. Others will appreciate your help.

Monday Dec 06, 2010

Not e-prescribing in 2011 may cost you in 2012

By law, Medicare must apply a 1-percent reduction to Medicare Physician Fee Schedule (MPFS) payments in 2012 for those physicians who do not successfully participate in the Medicare e-prescribing (eRx) incentive program in 2011. This applies to all physicians who provide at least 100 evaluation and management (E/M) and/or other services designated by the Centers for Medicare & Medicaid Services (CMS) as eRx denominator codes and receive at least 10 percent of their MPFS income from these. To avoid the fee reduction, covered physicians must adopt a "qualified" eRx system and report its use during at least 10 distinct encounters for services represented by a denominator code in the first six months of 2011 to avoid a 1-percent decrease in MPFS payments in 2012. The code to report is G8553, "At least one prescription created during the encounter was generated and transmitted electronically using a qualified eRx system," and it must be reported on the same claim as the associated denominator code.

The denominator codes are 90801, 90802, 90804-90806, 90807-90809, 90862, 92002, 92004, 92012, 92014, 96150-96152, 99201-99205, 99211-99215, 99304-99310, 99315, 99316, 99324-99328, 99334-99337, 99341-99343, 99345, 99347-99350, G0101, G0108, G0109.

CMS does allow for two hardship exceptions. These require reporting one of the following codes once during the period from Jan. 1, 2011, to June 30, 2011. The exceptions and codes are as follows:

• 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.

For a physician or nonphysician provider who would otherwise be required to participate in the eRx program but does not have prescribing privileges, a one-time reporting of code G8644, "Eligible provider does not have prescribing privileges," is required to be granted an exception.

On the up-side of this, successful eRx for the entire year in 2011 (reporting 25 encounters) will earn a bonus of 1 percent of all MPFS allowed charges for 2011. Also, it is not too late to claim a bonus of 2 percent for 2010 if you have been using an eRx system that qualifies for the incentive. Here's how:

1. Determine if you are using a qualified eRx system. There are two types of systems. You may use either a stand-alone eRx system or an electronic health record (EHR) system with eRx functionality. Your system must be able to perform the following tasks:

• Generate a complete active medication list incorporating electronic data received from applicable pharmacies and pharmacy benefit managers (PBMs), if available.

• Select medications, print prescriptions, electronically transmit prescriptions, and provide all alerts.

• Provide 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.)

• Provide information on formulary or tiered-formulary medications, patient eligibility, and authorization requirements received electronically from the patient's drug plan, if available.

2. Submit code G8553 on at least 25 of your claims for E/M services with dates of service in 2010. Alternatively, you may choose to report a minimum of 25 patient encounters through a qualified registry or qualified EHR. CMS also offers a group reporting option for practices that also participate as a group in the Physician Quality Reporting System (PQRS, formerly PQRI).

The opportunity for a bonus will continue through 2013 but is reduced by .5 percent each year. I hope you can take advantage of the opportunities to receive a bonus while they exist and avoid the penalties that are scheduled to increase by .5 percent in each year through 2014.

Friday Jul 16, 2010

Looking ahead to the 2011 Medicare physician fee schedule

While the fate of the 2010 Medicare physician fee schedule is temporarily settled, it is time to look ahead to 2011. 

On July 13, the Centers for Medicare and Medicaid Services (CMS) published its proposed rule on the 2011 Medicare physician fee schedule in the Federal Register. The proposed rule covers a wide array of topics, including changes in Medicare fees, updates to existing Medicare programs (like the Physician Quality Reporting Initiative and e-prescribing incentive payments), and implementation of some provisions of the Patient Protection and Affordable Care Act

The bottom-line, good news in the proposed rule is that CMS estimates family physicians will see a 1 percent increase in their Medicare allowed charges in 2011 as a result of changes proposed in the rule, all other things being equal. That is not much, but it is better than the decreases estimated for many other specialties. Of course, any gains could be washed away if Congress and the President do not act to avert the scheduled cut of 21 percent in the Medicare payment rate that will be effective Dec. 1, 2010, under current law.

As in any proposed federal regulation, "the devil is in the details," and I and other AAFP staff are poring over those details in preparing an AAFP response to the proposed rule.  I'll share more on those details in a future post. 

In the meantime, feel free to peruse the proposed rule yourself and share your comments here.

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