American College of Cardiology

Claims-Based Participation in Medicare’s
Electronic Prescribing Incentive Program
What You Need to Know in 2009
Prepared by the American College of Cardiology

What is Medicare’s Electronic Prescribing Incentive Program?
Is participation in E-Rx mandatory as a condition of payment under Medicare?
How is the incentive payment calculated?
How long is the 2009 E-Rx reporting period?
Do I have to participate in PQRI if I want to participate in the E-Rx Incentive Program?
Are there incentive limitations?
How do I know if I have a qualified e-prescribing system?
How do I register to participate in the program?
What is the process for reporting in 2009?
Can I get a bonus payment if I do not have an e-prescribing system?
What are the reporting requirements?
When will I get my bonus payment?
Can a physician assistant receive a bonus payment for participation?
What should I do right now?
Who can I contact for help at the ACC?

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Q1: What is Medicare’s Electronic Prescribing Incentive Program?

A: The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) authorized a new incentive program for eligible professionals who are successful electronic prescribers (E-Prescribers). This program will give physicians a bonus equal to 2% of allowed charges in 2009. This new incentive program is in addition to the quality reporting incentive program known as the Physician Quality Reporting Initiative (PQRI).

The e-prescribing (E-Rx) incentive is similar to the PQRI incentive in that reporting periods are one year in length and the incentive is based on the covered professional services furnished by the eligible professional during the reporting year.

Q2: Is participation in E-Rx mandatory as a condition of payment under Medicare?

A: Physicians will not be required to use electronic prescribing as a result of this program. Instead, the program will pay physicians a bonus for the use of a qualified e-prescribing system. The legislation that created the program mandated a gradually decreasing bonus incentive followed by a penalty program. The bonuses and penalties are listed below, but for almost every year, e-prescribers will be paid 2% more than those who are not:

Q3: How is the incentive payment calculated?

A: The e-Rx incentive amount is based on the allowed charges for all Physician Fee Schedule services furnished by the eligible professional during the year. This would generally include all cardiologist services, but would exclude services such as labs and part B drugs that are not priced on the physician fee schedule.

Q4: How long is the 2009 E-Rx reporting period?

A: The 2009 reporting period is from January 1 through December 31, 2009.

Q5: Do I have to participate in PQRI if I want to participate in the E-Rx Incentive Program?

A: No.

Q6. Are there incentive limitations?

A: Eligible professionals must have and use a qualified e-prescribing system. In addition, at least 10% of eligible professionals' Medicare Part B covered services must be made up of codes that appear in the denominator of the e-prescribing measure. For cardiologists, this means that 10% of Medicare allowed charges must come from office visits or consultations. For some physicians who perform the majority of their work in the facility or inpatient setting, this threshold may not be reached.

Q7: How do I know if I have a qualified e-prescribing system?

A: In order to report this measure, a qualified electronic prescribing (e-Rx) system must have been adopted. A qualified e-prescribing system is one that is capable of ALL of the following:

• Generate a complete active medication list incorporating electronic data received from applicable pharmacies and benefit managers (PBMs) if available
• Select medications, print prescriptions, electronically transmit prescriptions, and conduct all alerts (defined below)
• Provide 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 for 2009)
• 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 e-prescribing standards adopted by the Secretary for Part D by virtue of the 2003 Medicare Modernization Act (MMA).
  

DEFINITIONS:
E-prescribing – 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 e-prescribing network. E-prescribing includes, but is not limited to, two-way transmissions between the point of care and the dispenser.
Alerts – Written or acoustic signals to warn prescriber of possible undesirable or unsafe situations, including potentially inappropriate dose or route of administration of a drug, drug-drug interactions, allergy concerns, or warnings and cautions

Q8: How do I register to participate in the program?

A: There is no sign-up or pre-registration to participate in the E-Prescribing Incentive Program. Beginning January 1, 2009, eligible professionals can participate by reporting on their adoption and use of an e-prescribing system by submitting claims information on one e-prescribing measure on their Medicare Part B claims.

Q9: What is the process for reporting in 2009?

A: Much like the PQRI, physicians must report an additional code on their claim forms in order to participate in the program. For each office visit or outpatient consultation performed on a Medicare patient, the physician must report one of the following:

G8443: All prescriptions created during the encounter were generated using a qualified e-prescribing system

G8445: No prescriptions were generated during the encounter.

G8446: Some or all prescriptions generated during the encounter were printed or phoned in as required by state or federal law or regulations, patient request, or pharmacy system being unable to receive electronic transmission; OR because they were for narcotics or other controlled substances.

Q10: Can I get a bonus payment if I do not have an e-prescribing system.

A: No. All of the codes above require that you have electronic prescribing technology, even the code that indicates that you did not use the electronic prescribing on this patient.

Q11: What are the reporting requirements?

A: For the 2009 e-prescribing reporting year, to be a successful e-prescriber and to receive an incentive payment, an eligible professional must report one e-prescribing measure in at least 50% of the cases in which the measure is reportable by the eligible professional during 2009.

Q12: When will I get my bonus payment?

A: Physicians will receive a bonus payment some time in the year following the reporting period. For 2009, bonus payments would likely be made in mid 2010.

Q13: Can a physician assistant receive a bonus payment for participation?

A: All providers who treat Medicare patients and have prescriptive authority are eligible to participate in the e-prescribing bonus incentive program.

Q14: What should I do right now?

A.

1. Bookmark the CMS E-Prescribing Link: http://www.cms.hhs.gov/PQRI/03_EPrescribingIncentiveProgram.asp#TopOfPage. Check it often.
2. Bookmark the ACC Health Information Technology Initiative for E-Prescribing link: http://www.acc.org/practicemgt/HealthCareTechnology/e_prescribing.htm
3. Understand the measure.
4. Educate staff.

Q15: Who can I contact for help at the ACC?

A. Brian Whitman, Associate Director, Regulatory Affairs
800-253-4636, ext 66396 or bwhitman@acc.org