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ePrescribe by June 30 to Avoid Payment Reduction

April 13, 2011:

This means that providers who have not reported that at least 10 prescriptions were eRxed by June 30, 2011, ARE SUBJECT to the negative payment adjustment. It also appears that group practices using the group practice reporting options (GPRO) must report that ALL prescriptions were eRxed.

There are two exemptions:

1.Providers in a rural area that does not have high-speed internet connections

2.Providers in an area that does not have a sufficient number of pharmacies that accept eRX

There are two types of eRx systems eligible providers can use: a stand-alone eRx system or an electronic health record (EHR) with eRx capabilities. Systems must be able to:

  • 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 conduct all alerts (defined below)
  • Provide information related to lower cost and therapeutically appropriate alternatives (if any)
  • Provide information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient’s drug plan (if available)

The system must employ, for the capabilities listed, the eRx standards adopted by the secretary of the Department of Health and Human Services for Part D under the 2003 Medicare Modernization Act (MMA).

Eligible providers are the same as those eligible for the physician quality reporting system (PQRS). There is a special G code for those providers who are not allowed to prescribe (physical and occupational therapists, for example). There are also several types of eligible providers who are exempted for different reasons:

  • Professionals paid under or based upon the physician fee schedule billing Medicare carriers/ Medicare administrative contractors (MACs) who do not bill directly
  • Professionals paid under the physician fee schedule billing Medicare fiscal intermediaries (FIs) or MACs. The FI/MAC claims processing systems currently cannot accommodate billing at the individual physician or practitioner level:
    1. 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.
    2. 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.

The reporting options that may be used to report eRx quality data information are the same options that are used under PQRS:

  • Claims-based (paper or electronic)
  • Registry based
  • EHR reporting
  • Group practice

The following are the quality data codes used:

G8553At least one prescription created during the encounter was generated and transmitted electronically using a qualified eRx system
G8642The 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
G8643The 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
G8644Eligible professional does not have prescribing privileges


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