100-22 Medicare Quality Reporting Incentive programs Manual: Chapter 2 - The Electronic Prescribing (E-Rx) Incentive Program

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Medicare Quality Reporting Incentive
Programs Manual
Chapter 2 – The Electronic Prescribing (eRx) Incentive
Program
Table of Contents
(Rev. 31, 08-29-14)
Transmittals for Chapter 2
10 - Background
20 - Eligibility
20.1 - Individual Eligible Professionals
20.1.1 - Professionals Eligible to Participate But Not Able to Participate
20.1.2 - Professionals Not Eligible to Participate
20.1.3 - Professionals Eligible to Participate But For Whom the Payment
Adjustment Does Not Apply
20.2 - Participation by Group Practices Using the eRx Group Practice Reporting
Option (GPRO)
30 - Reporting Period
30.1 - Reporting Period for the Incentive Payments
30.2 - Reporting Period for the Payment Adjustments
40 - Payment for Reporting
50 - Form and Manner of Reporting for the Purpose of Receiving Incentive Payments and
Payment Adjustment
50.1 - Claims-Based Reporting Mechanism
50.1.1 - Coding and Reporting Principles for Claims-Based Reporting
50.2 - Registry-based Reporting Mechanism
50.3 - Electronic Health Record-based (EHR-based) Reporting Mechanism
60 - Criteria for Determination of Successful Electronic Prescriber
60.1 - Eligible Professionals
60.1.1 - Criteria for Determination of Successful Electronic Prescriber for
the Incentive Payments – Individual Eligible Professionals
60.1.2 - Criteria for Determination of Successful Electronic Prescriber for
the Payment Adjustments – Individual Eligible Professionals
60.2 - Group Practices

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60.2.1 - Criteria for Determination of Successful Electronic Prescriber for
the Incentive Payments – Group Practices
60.2.2 - Criteria for Determination of Successful Electronic Prescriber for
the Payment Adjustments – Group Practices
70 - Significant Hardship Exemptions for the Payment Adjustments
70.1 - Significant Hardship Exemptions for the Payment Adjustments – Individual
Eligible Professionals and Group Practices
80 - Confidential Feedback Reports
90 - Direct Mailings
100 - Public Posting of Program Performance

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10 - Background
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
Chapter 2 of this manual focuses on the requirements for the Electronic Prescribing (eRx)
Incentive Program, a quality reporting program which promotes the adoption and use of
eRx systems through a combination of incentives and payment adjustments. 	ERx is the
transmission of prescription or prescription-related information through electronic media.
ERx takes place between a prescriber, dispenser, pharmacy benefit manager, or health
plan. It can take place directly or through an intermediary (such as a network).
Section 132 of the Medicare Improvements for Patients and Providers Act of 2008
(MIPPA) required the Secretary to establish a new reporting program for individual
eligible professionals who are successful electronic prescribers as defined by MIPPA,
beginning on January 1, 2009. While the eRx Incentive Program has similarities in
structure and processes to the Physician Quality Reporting System (formerly the
Physician Quality Reporting Initiative or PQRI) described in Chapter 1 of this
Publication, this program is a stand alone program with distinct reporting requirements
and associated incentive payment and payment adjustment.
The eRx Incentive Program encourages significant expansion of the use of eRx by
authorizing a combination of financial incentives and payment differentials. Any
incentive payment earned through the eRx Incentive Program is separate from and in
addition to any incentive payment that eligible professionals may earn through the
Physician Quality Reporting System program. Except for eligible professionals who
wish to participate in the eRx Incentive Program under the group practice reporting
option (GPRO) beginning 2010 (see §20.2), eligible professionals do not have to
participate in Physician Quality Reporting System to participate in the eRx Incentive
Program or vice-versa.
See Chapter 1, “Physician Quality Reporting System,” for information on the Physician
Quality Reporting System.
20 – Eligibility
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
20.1 – Individual Eligible Professionals
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
For purposes of the eRx Incentive Program, the definition of “eligible professional” is
identical to that for the Physician Quality Reporting System. An eligible professional is
any one of the following:
• 	Physician
o 	Doctor of Medicine
o 	Doctor of Osteopathy
o 	Doctor of Podiatric Medicine

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o 	Doctor of Optometry
o 	Doctor of Dental Surgery
o 	Doctor of Dental Medicine
o 	Doctor of Chiropractic
• 	Practitioner
o 	Physician assistant
o 	Nurse Practitioner
o 	Clinical nurse specialist
o 	Certified registered nurse anesthetist (and Anesthesiologist Assistant)
o 	Certified nurse midwife
o 	Clinical social worker
o 	Clinical psychologist
o 	Registered dietitian
o 	Nutrition professional
o 	Audiologists (as of January 1, 2009)
• 	Therapist
o 	Physical therapist
o 	Occupational therapist
o 	Qualified speech-language therapist (began billing Medicare directly as of
July 1, 2009)
All Medicare-enrolled professionals in these categories are eligible to participate in the
eRx Incentive Program regardless of whether the professional has signed a Medicare
participation agreement to accept assignment on all claims. However, eligibility is
further restricted by scope of practice to those professionals who have prescribing
authority under their respective state practice laws.
20.1.1 – Professionals Eligible to Participate But Not Able to Participate
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
Some professionals who are included in the definition of “eligible professional” above
are eligible to participate but are not able to participate for one or more reasons. These
include: eligible professionals in certain settings in which Medicare Physician Fee
Schedule billing is processed by Medicare fiscal intermediaries (FIs)/AB Medicare
Administrative Contractors (MACs). The FI/MAC claims processing systems for the
following settings currently cannot accommodate billing at the individual eligible
professional level:
• 	Critical access hospitals (CAHs), 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 or Part A MAC for the covered professional services
furnished by the eligible professional.

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• 	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.
20.1.2 – Professionals Not Eligible to Participate
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
Providers and professionals not defined as eligible professionals are not eligible to
participate in the eRx Incentive Program do not qualify for an incentive, and are not
subject to a payment adjustment. Services payable under or based on fee schedules or
methodologies other than the PFS are not included in the eRx Incentive Program (for
example, services provided in federally qualified health centers, independent diagnostic
testing facilities, portable x-ray suppliers, independent laboratories, hospitals [including
critical access], rural health clinics, ambulance providers, and ambulatory surgery center
facilities). In addition, suppliers of durable medical equipment (DME) are not eligible for
the eRx Incentive Program since DME is not based on or paid under the PFS.
20.1.3 – Professionals Eligible to Participate But For Whom the
Payment Adjustment Does Not Apply
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
The payment adjustment does not apply to an eligible professional if any of the following
apply:
• 	Based on primary taxonomy code in the National Plan and Provider Enumeration
System (NPPES),the eligible professional is not a physician (MD, DO, or
podiatrist), nurse practitioner, or physician assistant as of –
o 	June 30, 2011 for the 2012 payment adjustment,
o 	June 30, 2012 for the 2013 payment adjustment, or
o 	June 30, 2013 for the 2014 payment adjustment.
• 	The eligible professional does not have prescribing privileges and reports G-code
G8644 (defined as not having prescribing privileges) at least one time on a
Medicare Part B claim prior to –
o 	June 30, 2011 for the 2012 payment adjustment,
o 	June 30, 2012 for the 2013 payment adjustment, and/or
o 	June 30, 2013 for the 2014 payment adjustment.
• 	The eligible professional does not have at least 100 cases containing an encounter
code in the eRx measure’s denominator for dates of service between –
o 	January 1, 2011 and June 30, 2011 for the 2012 payment adjustment,

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o 	January 1, 2012 and June 30, 2012 for the 2013 payment adjustment,
and/or
o 	January 1, 2013 and June 30, 2013 for the 2014 payment adjustment.
20.2 – Participation by Group Practices Using the eRx Group Practice
Reporting Option (GPRO)
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
Prior to 2010, the eRx Incentive Program was limited to participating as an individual
eligible professional and the determination of whether an eligible professional is a
successful electronic prescriber was made at the individual professional level, based on
the National Provider Identifier (NPI). No incentive payments were available to a group
practice based on a determination that the group practice, as a whole, was a successful
electronic prescriber. To the extent that individual eligible professionals (based on
individuals’ NPIs) are associated with more than one practice, or Taxpayer Identification
Number (TIN), the determination of whether an eligible professional is a successful
electronic prescriber was made for each unique TIN/NPI combination. Therefore, the
incentive payment amount was calculated for each unique TIN/NPI combination and
payment was made to the holder of the applicable TIN (see §40 below).
As required by the MIPPA, beginning in 2010, group practices, by participating in the
eRx group practice reporting option (GPRO), are eligible to qualify for an eRx incentive
payment based on the determination that the group practice, as a whole, is a successful
electronic prescriber. The criteria for determining whether a group practice is a
successful electronic prescriber and the process for reporting by group practices under the
eRx GPRO are discussed in §60.2 below.
In 2010, for purposes of being able to participate in the eRx Incentive Program under the
eRx GPRO, a “group practice” was defined as a TIN with at least 200 or more individual
eligible professionals (as identified by NPIs) who have reassigned their billing rights to
the TIN.
However, in 2011, with the addition of “GPRO II” described in Chapter 1, § 20.3, the
definition of group practice was expanded to include a TIN with at least 2 or more
individual eligible professionals (as identified by NPIs) who have reassigned their billing
rights to the TIN.
In 2012, the definition of group practice for the eRx Incentive Program was further
modified to mirror the 2012 definition of group practice for the 2012 Physician Quality
Reporting System as described in Chapter 1, § 20.3 of this manual. Therefore, a group
practice was defined as a TIN with at least 25 or more individual eligible professionals
(as identified by NPIs) who have reassigned their billing rights to the TIN. In 2012, the
definition of group practice also includes those groups participating in certain Medicare-
approved demonstrations projects or various other CMS programs, under which
Physician Quality Reporting System requirements and incentives have been incorporated,
such as groups participating in the Medicare Shared Savings Program.

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In order to participate in the eRx Incentive Program through the GPRO, including those
groups that are deemed participating in the Physician Quality Reporting System, group
practices must have self-nominated and been selected to participate in the Physician
Quality Reporting System GPRO (see Chapter 1, §20 for information on the requirements
for participation in the Physician Quality Reporting System GPRO). CMS assesses
whether the participation requirements are met by each self-nominated group practice and
notifies group practices of a decision.
As required by section 1848(m)(3)(C)(iii) of the Social Security Act (the Act), an
individual eligible professional who is a member of a group practice selected to
participate in the eRx GPRO for a particular program year is not eligible to separately
earn an eRx incentive payment as an individual eligible professional under that same TIN
(that is, for the same TIN/NPI combination) for that year. Once a group practice (TIN) is
selected to participate in the GPRO for a particular program year, this is the only method
of eRx Incentive Program participation available to the group and all individual NPIs
who bill Medicare under the group’s TIN for that program year.
In addition, the group practice will be assessed for applicability of the payment
adjustment, beginning in 2012, discussed in § 60.2.2 below under the GPRO criteria as
well. Although the determination of whether a GPRO is a successful electronic
prescriber will be analyzed at the TIN level, if group practices elect to participate in the
eRx GPRO for a particular program year and the group practice fails to meeting the
reporting thresholds for reporting its eRx activities (i.e., fails to become a successful
electronic prescriber), each eligible professional who belongs to the group practice will
be subject to the payment adjustment, regardless of whether or not the eligible
professional, as an individual, successfully reports . For example, for purposes of the
2012 payment adjustment, if a group practice consisting of 2 individual eligible
professionals elects to participate in the eRx GPRO under the 2011 eRx GPRO II option,
based on the size of this group practice (which is 2), this group practice must report the
eRx measure via claims on 75 unique events for patients in the denominator of the
measure for services occurring between January 1, 2011 and June 30, 2011. If an eligible
professional within the group practice reports the eRx measure on 25 unique events
during the January 1, 2011 and June 30, 2011 reporting period and the other eligible
professional does so for only 5 unique events , provided a limitation or significant
hardship exemption does not apply to the group practice, the group practice as a whole
(i.e., both individual eligible’s) will be subject to a 1.0% payment adjustment on all their
Medicare Part B PFS allowed charges for covered professional services furnished in
2012. Although the first eligible professional would have successfully reported as an
individual, the entire group practice (i.e., both eligible professionals) will be subject to
the 2012 payment adjustment for failing to reach the reporting threshold of 75 unique
events that was required for groups with 2 eligible professionals.
30 – Reporting Period
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)

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30.1 – Reporting Period for the Incentive Payments
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
The reporting period for the eRx Incentive Program incentive payments is the entire
calendar year. Specifically, the reporting periods for the following incentive payments
are as follows:
Incentive Payment 	12-month Reporting Period
2009 	January 1, 2009 – December 31, 2009
2010 	January 1, 2010 – December 31, 2010
2011 	January 1, 2011 – December 31, 2011
2012 	January 1, 2012 – December 31, 2012
2013 	January 1, 2013 – December 31, 2013
30.2 – Reporting Period for the Payment Adjustments
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
Except for the 2012 payment adjustment, there are two reporting periods for purposes of
the eRx Incentive Program payment adjustments: (1) the 12-month calendar year 2 years
prior to the applicable payment adjustment and (2) a 6-month reporting period occurring
during the first 6 months of the calendar year prior to the applicable payment adjustment.
For the 2012 payment adjustment, there was only one reporting period: the 6-month
reporting occurring during the first 6 months of 2011. Specifically, the reporting periods
for the following payment adjustments are as follows:
Payment
Adjustment
12-month Reporting Period 	6-month Reporting Period
2012 	N/A 	January 1, 2011 – June 30,
2011
2013 	January 1, 2011-December 31, 2011 	January 1, 2012 – June 30,
2012
2014 	January 1, 2012 – December 31,
2012
January 1, 2013 – June 30,
2013
40 – Payment for Reporting
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
A participating individual eligible professional or group practice (see §20) who is
determined to be a “successful electronic prescriber” (see §60) may earn an incentive
payment or receive a payment adjustment with respect to covered professional services
furnished by the eligible professional (or group practice) during a specified reporting
period (see §30). Section 1848(k)(3)(A) of the Act defines “covered professional
services” as services for which payment is made under, or is based on, the Medicare Part
B PFS and which are furnished by an eligible professional (or group practice).

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An eligible professional who is determined to be a successful electronic prescriber may
qualify to earn an incentive payment or receive a payment adjustment equal to a
percentage of the total estimated Medicare Part B allowed charges for covered
professional services furnished by the eligible professional during the respective
reporting period. The incentive payments for successful electronic prescribers for each
authorized year are as follows:
• 	2.0 percent for 2009;
• 	2.0 percent for 2010;
• 	1.0 percent for 2011;
• 	1.0 percent for 2012; and
• 	0.5 percent for 2013.
In addition to the eRx incentive payment, under § 1848(a)(5)(A) of the Act, a PFS
payment adjustment applies beginning in 2012 to those who are not successful electronic
prescribers for 2012. The payment adjustments for eligible professionals who are not
successful electronic prescribers for each authorized year are as follows:
• 	1.0 percent for 2012;
• 	1.5 percent for 2013; and
• 	2.0 percent for 2014.
The eRx incentive payment amount is calculated based on an eligible professional’s (or
group practice’s) total estimated allowed charges for all covered professional services:
(1) furnished during the applicable reporting period, (2) received into the National Claims
History (NCH) file by no later than 2 months after the end of the reporting period, and (3)
paid under or based upon the Medicare PFS. Because claims processing times may vary
by time of the year and Medicare Carrier/AB MAC, eligible professionals should submit
claims from the end of the reporting period promptly, so that if, for example, the
reporting period ends on December 31st of a particular year, claims from the end of the
reporting period will reach the NCH file by February 28th of the following year. The eRx
incentive payments are paid as a lump sum. Eligible professionals and group practices
who receive an eRx incentive will see the following statement on their paper remittance
advice: “This is an E-Rx incentive payment.” On electronic remittance statements, the
code “LE” and a year indicator (e.g., “RX10 for a 2010 incentive payment) appears on
the remittance advice to indicate the amount provided is for an eRx incentive earned. A
glossary of these codes is provided for eligible professionals or group practices.
The eRx payment adjustment amount is calculated based on the Secretary’s total
estimated allowed part B charges for all covered professional services: (1) furnished by
the eligible professional (or group practice) during the applicable payment adjustment
year and (2) paid under or based upon the Medicare PFS. Eligible professionals and
group practices that are subject to a payment adjustment will see the following codes on
their remittance advice: CARC #237 (“Legislated/Regulatory Penalty”) and RARC
#N545 (“Payment reduced based on status as an unsuccessful eprescriber per the ERx
Incentive Program”). If a payment adjustment was applied in error and an eligible

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professional or group practice is reimbursed due to this error, CARC #237 and RARC
#N546 (“Payment represents a previous reduction based on the ERx Incentive Program”)
will appear on the remittance advice. A glossary of these codes is provided for the
eligible professionals or group practices.
Payment for this program is calculated at the individual eligible professional level using
individual NPI data and beginning in 2010, for group practices participating in the eRx
GPRO, at the group practice level using TIN data. CMS uses the TIN as the billing unit
so that any eRx incentive payment earned (regardless of whether the incentive payment
was earned by an individual eligible professional or a group practice) is paid to the TIN
holder of record. Individual incentive payments for groups that bill under one TIN are
aggregated and paid to the holder of the TIN. Some individuals (NPIs) may be associated
with more than one practice or TIN, and thus CMS groups claims by TIN for purposes of
the incentive. In other words, the incentive payment is made for each unique TIN/NPI
combination so that an eligible professional who qualifies for the eRx incentive payment
under more than one TIN would receive a separate eRx incentive payment associated with
each TIN.
Under the statute, however, there is a limitation with regard to the application of the
incentive and payment adjustment. The incentive and payment adjustment does not
apply to eligible professionals (and group practices participating in the eRx GPRO), for
the reporting period, if the Medicare allowed charges for all covered professional services
for the codes to which the eRx quality measure applies are less than 10% of the total
allowed charges under Medicare Part B for all such covered professional services
furnished by the eligible professional (or group practice).
The eRx incentive payment and payment adjustment amount is calculated using allowed
charges for all covered professional services, not just those charges associated with eRx
events. The term “allowed charges” refers to total charges, including the beneficiary
deductible and co-payment, not just the 80% paid by Medicare or the portion covered by
Medicare where Medicare is a secondary payer. Note that the amounts billed above the
Medicare PFS amounts for assigned and non-assigned claims do not apply to the
incentive and/or payment adjustment. The statute defines eRx covered professional
services as those paid under or based upon the Medicare PFS only, which includes
technical components of diagnostic services and anesthesia services, as anesthesia
services are considered fee schedule services though based on a unique methodology.
Other Part B services and items that may be billed by eligible professionals but are not
paid under or based upon the Medicare PFS are not included in the calculation of the eRx
incentive and/or payment adjustment amount.
Please note that, according to section 1848(m)(2)(D) of the Act, an eligible professional
cannot receive an incentive payments under both the Medicare eRx Incentive Program
and Medicare EHR Incentive Program.

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For information on operational payment instructions related to the eRx Incentive
Program, please see Chapter 3(§30) of this manual titled “Contractor Incentive Program
Payment Operational Instructions.”
50 – Form and Manner of Reporting for the Purpose of Receiving
Incentive Payments and Payment Adjustments
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
Prior to the 2010 eRx Incentive Program, participation in the eRx Incentive Program was
limited to the submission of quality data codes (QDCs) for the eRx measure through
Medicare’s claim processing system. Beginning with the 2010 eRx Incentive Program,
eligible professionals may choose to report the eRx measure to CMS using one of the
following reporting mechanisms:
• 	Claims-based reporting;
• 	Registry-based reporting; or
• 	EHR-based reporting.
50.1 – Claims-based Reporting Mechanism
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
Individual eligible professionals and group practices who choose to participate in the eRx
Incentive Program via the claims-based reporting mechanism do not have to enroll or
register to begin claims-based reporting of the eRx measure to CMS.
Participating eligible professionals or group practices who bill for the services or
procedures included in the denominator of the eRx measure report the corresponding
appropriate numerator G-code on their claim. Claims-based reporting may be via: (1) the
paper-based CMS 1500 Claim form or (2) the equivalent electronic transaction claim, the
837-P. The specifications for the eRx measure are available on the E-Prescribing
Measure section page of the CMS eRx Incentive Program website at
http://www.cms.gov/ERXincentive and may be updated on an annual basis.
The applicable G-code quality data must be reported on the same claim as the billable
service or procedure to which the QDC applies. The eRx measure does not require a
specific diagnosis to help determine the denominator; therefore, any diagnosis reported
on the claim is sufficient. The analysis algorithms that are used to determine whether an
eligible professional is a “successful electronic prescriber” match the QDCs to the service
and/or procedure codes on the claim. Thus, QDCs that are not submitted on the same
claim as the applicable service and/or procedure codes do not count toward an eligible
professional meeting the requirements of being a “successful electronic prescriber.”
Claims-based reporting is the only reporting mechanism available for purposes of
reporting on the eRx measure for the 2012 payment adjustment and for the 6-month
reporting periods for the 2013 and 2014 payment adjustments.

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50.1.1 - Coding and Reporting Principles for Claims-based Reporting
Coding and Reporting Principles for Claims-Based Reporting
(Rev. 31, Issued: 08-29-14, Effective: ASC 12X: January 1, 2012; ICD – 10: Upon
Implementation of ICD – 10, Implementation: ICD – 10: Upon Implementation of ICD
– 10; ASC X12: 09 -30-14)
The following principles apply for claims-based reporting of the eRx measure:
For the eRx measure used for the reporting period that occurred during calendar year
2009, report one of the three eRx codes listed below as the claim numerator, when
applicable:
o 	G8443 - “All prescriptions created during the encounter were generated using a
qualified eRx system.”
o 	G8445 - “No prescriptions were generated during the encounter.”
o 	G8446 - “Provider does have access to a qualified eRx system and some or all of
the prescriptions generated during the encounter were printed or phoned in as
required by the 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.”
One of these codes must be reported on at least 50% of patients who meet the
denominator criteria of the measure.
For the eRx measure used for the reporting period that occurred during calendar year
2010 the eRx measure’s numerator includes only 1 G-code (CMS eliminated the 3
numerator G-codes used for the 2009 reporting period). To report the eRx measure for
the 2010 reporting period, report the following eRx numerator G-code, when applicable:
o 	G8553 – At least one prescription created during the encounter was generated and
transmitted electronically using a qualified eRx system.
For the eRx measure for reporting periods that occurred during calendar year 2011, the
eRx measure’s numerator is the same G-code used in the 2010 reporting period. To report
the eRx measure for 2011 reporting periods, report the following eRx numerator G-code,
when applicable:
• 	G8553 – “At least one prescription created during the encounter was generated
and transmitted electronically using a qualified eRx system.”
For the eRx measure used for reporting periods that occur during the 2012 or 2013
calendar year, the eRx measure’s numerator code is the same G-code used in 2010 and
2011 reporting periods. To report the eRx measure for the 2012 or 2013 reporting
periods, report the following eRx numerator G-code, when applicable:

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• 	G8553 – “At least one prescription created during the encounter was generated
and transmitted electronically using a qualified eRx system (faxes do not count).”
The eRx G-code, which supplies the numerator, must be reported for the applicable
amount of unique visits (for services in the denominator) to successfully report for
incentive payment purposes:
• 	on the claim(s) with the denominator billing code(s) that represent the eligible
encounter for the 2012 eRx incentive payment; OR on the claim(s) with any billing
code(s) that represent the encounter to avoid the 2013 eRx payment adjustment,
• 	for the same beneficiary,
• 	for the same date of service (DOS), and
• 	by the same eligible professional (individual NPI) who performed the covered
service as the payment codes, CPT Category I or
The eRx G-code must be submitted with a line-item charge of zero dollars ($0.00) at the time the
associated covered service is performed:
• 	The submitted charge field cannot be blank.
• 	The line item charge should be $0.00.
• 	If an eligible professional’s billing software does not allow a $0.00 line-item
charge, a nominal amount, such as $0.01, can be substituted - the beneficiary is
not liable for this nominal amount.
• 	Entire claims with a zero charge will be rejected. (Total charge for the claim
cannot be $0.00.)
• 	Whether a $0.00 charge or a nominal amount is submitted to the Medicare
Administrative Contractor (MAC) (B), the eRx G-code line is denied and tracked.
ERx line items will be denied for payment, but are passed through the claims processing
system to the NCH database and used for eRx claims analysis. Eligible professionals will
receive a Remittance Advice (RA) which includes a standard remark code (N365). N365
reads: “This procedure code is not payable. It is for reporting/information purposes only.”
The N365 remark code does NOT indicate whether the eRx G-code is accurate for that
claim or for the measure the eligible professional is attempting to report. N365 only
indicates that the eRx G-code passed into NCH.

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When a group bills, the group NPI is submitted at the claim level, the individual
rendering/performing physician’s NPI must be placed on each line item, including all
allowed charges and quality-data line items.
Solo practitioners should follow their normal billing practice of placing their individual
NPI in the billing provider field, (on the ASC X12 837 professional claim format or item
33 on the Form CMS-1500).
Claims may NOT be resubmitted for the sole purpose of adding or correcting an eRx
code.
Submission Through A/B MACs (B)
ERx G-codes shall be submitted to A/B MACs (B) either through: Electronic submission
using the current version of the ASC X12 837 professional claim, or via paper-based
submission, using the Form CMS-1500 claim.
Electronic-based Submission:
Physician Quality Reporting QDCs are submitted on the claim just like any other code;
however, QDCs will have a $0.00 (or nominal) charge. Electronic submission, which is
accomplished using the ASC X12 837 professional claim format, should follow the
current HIPAA standard version of the ASC X12 837 technical report 3.
Paper-based Submission:
Paper-based submissions are accomplished using the Form CMS-1500 claim (version 02-
12). Relevant diagnosis codes are entered in Field 21. Service codes (including CPT,
HCPCS, CPT Category II and/or G-codes) with any associated modifiers are entered in
Field 24D with a single reference letter in the diagnosis pointer Field 24E that
corresponds with the diagnosis letter in Field 21.
For group billing, the NPI of the rendering/performing provider is entered in Field 24J
and the TIN of the employer is entered in Field 25.
Timeliness of Quality Data Submission
Claims processed by the must reach the National Claims History (NCH) file by no later
than 2 months after the end of the reporting period to be included in the analysis. For the
2011 eRx Incentive Program, for example, claims processed by the A/B MAC (B) must
reach the NCH file by no later than February 28, 2011 to be included in the analysis.
Claims for services furnished toward the end of the reporting period should be filed
promptly. Claims that are resubmitted only to add QDCs will not be included in the
analysis.
50.2 – Registry-based Reporting Mechanism
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)

15
Beginning with the 2010 eRx Incentive Program, individual eligible professionals and
group practices Individual eligible professionals and group practices may choose to
participate in the eRx Incentive Program via the registry-based reporting mechanism for
all reporting periods except those 6-month reporting periods associated with a payment
adjustment. 	Eligible professionals and group practices that choose to participate in the
eRx Incentive Program via the registry-based reporting mechanism do not have to enroll
or register to begin registry-based reporting of the eRx measure to CMS. However, to
report eRx measure data via the registry-based reporting mechanism, an eligible
professional or group practice must select a qualified clinical data registry and must enter
into and maintain an appropriate legal arrangement with a qualified clinical data registry.
Such arrangements should provide for the registry’s receipt of patient-specific data from
the eligible professional and the registry’s disclosure of eRx measure results and
numerator and denominator data on behalf of the eligible professional or group practice
to CMS. An eligible professional or group practice choosing the registry-based reporting
mechanism must submit information on the eRx measure to their selected registry in the
form and manner and by the deadline specified by the registry. Thus the registry would
act as a Health Insurance Portability and Accountability Act of 1996 (Pub. L.104-191)
(HIPAA) Business Associate and agent of the eligible professional. Such agents are
referred to as “data submission vendors.” The “data submission vendors” would have the
requisite legal authority to provide information on eRx measure results and numerator
and denominator data on the eRx measure on behalf of the eligible professional for the
eRx.
Only a registry that is qualified to submit Physician Quality Reporting System quality
measures information to CMS on behalf of eligible professionals for the applicable
program year is eligible to become a qualified registry for the purpose of submitting eRx
measure information to CMS on behalf of eligible professionals or group practices. CMS
qualifies registries for the Physician Quality Reporting System for each program year
through a self-nomination process (see Chapter 1, §50.2). The list of qualified registries
for a specific program year are made available on the CMS eRx Incentive Program
website at http://www.cms.gov/ERXincentive. For a specific program year, this list
usually is made available in the summer of that same year. For example, we anticipate
the list of qualified registries for the 2010 eRx Incentive Program was anticipated to be
made available in the summer of 2010.
Please note that, for all 6-month reporting periods associated with a payment adjustment,
only the claims-based reporting mechanism may be used for purposes of the eRx payment
adjustment. For example, for purposes of the 6-month reporting period for the 2013
payment adjustment (i.e., January 1, 2012-June 30, 2012, only the claims-based reporting
mechanism may be used for purposes of the 2013 eRx payment adjustment even though
the registry-based reporting mechanism was finalized for use by eligible professionals for
the 12-month reporting period for the 2013 payment adjustment (i.e., January 1, 2011 –
December 31, 2011) and for purposes of the reporting period for the 2012 incentive (i.e.,
January 1, 2012-December 31, 2012). As such, to the extent an eligible professional
intends to use a registry to submit eRx measure data for purposes of qualifying for the

16
2012 eRx payment incentive, the eligible professional would still need to submit eRx
measure data on claims for services furnished between January 1, 2012 and June 30,
2012, in order to avoid the 2013 eRx payment adjustment.
50.3 – Electronic Health Record-based (EHR-based) Reporting
Mechanism
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
Beginning with the 2010 eRx Incentive Program, Individual eligible professionals and group
practices may choose to participate in the eRx Incentive Program via the EHR-based reporting
mechanism for all reporting periods except those 6-month reporting periods associated
with a payment adjustment. Beginning in 2012, as described in further detail in Chapter
1, section 50.3, eligible professionals and group practices may participate in the eRx
Incentive Program via two EHR-based reporting mechanisms: (1) a qualified direct EHR
or (2) a qualified EHR data submission vendor.
Eligible professionals and group practices that choose to participate in the eRx Incentive
Program via the EHR-based reporting mechanism do not have to enroll or register to
begin EHR-based reporting of the eRx measure to CMS.
Likewise, eligible professionals and group practices that choose to participate in the eRx
Incentive Program via EHR data submission vendors do not have to enroll or register to
begin EHR-based reporting of the eRx measure to CMS.
However, to report eRx measure data via the EHR-based reporting mechanism, an
eligible professional or group practice must select a qualified EHR product. An eligible
professional or group practice choosing the EHR-based reporting mechanism must:
• 	Have an active Individuals Authorized Access to CMS Systems (IACS) user
account that will be used to submit the eRx measure data extracted from the EHR
to CMS;
• 	Submit a test file containing real or dummy clinical quality data extracted from
the EHR to a CMS clinical data warehouse; and
• 	Submit a file containing the eligible professional’s or group practice’s eRx
measure data extracted from the EHR for the entire reporting period via IACS by
no later than 2 months after the end of the reporting period. (For the 2010
incentive, the submission period will be 02/01/11 – 03/31/11).
Only an EHR product that is qualified for use by eligible professionals to submit
Physician Quality Reporting System quality measures information to CMS is eligible to
become a qualified EHR product for the purpose of an eligible professional or group
practice using the product to submit eRx measure information to CMS. CMS qualifies
EHR vendors and their specific product(s) for use by eligible professionals to submit
Physician Quality Reporting System quality measures data to CMS (see Chapter 1,

17
§50.3). The list of qualified EHR direct and data submission vendors and their qualified
products for a specific program year are made available on the CMS eRx Incentive
Program website at http://www.cms.gov/ERXincentive.
Please note that, for all 6-month reporting periods associated with a payment adjustment,
only the claims-based reporting mechanism may be used for purposes of the eRx payment
adjustment. For example, for purposes of the 6-month reporting period for the 2013
payment adjustment (i.e., January 1, 2012-June 30, 2012, only the claims-based reporting
mechanism may be used for purposes of the 2013 eRx payment adjustment even though
the EHR-based reporting mechanism was finalized for use by eligible professionals for
the 12-month reporting period for the 2013 payment adjustment (i.e., January 1, 2011 –
December 31, 2011) and for purposes of the reporting period for the 2012 incentive (i.e.,
January 1, 2012-December 31, 2012). As such, to the extent an eligible professional
intended to use an EHR or EHR data submission vendor to submit eRx measure data for
purposes of qualifying for the 2012 eRx payment incentive, the eligible professional
would still need to submit eRx measure data on claims for services furnished between
January 1, 2012 and June 30, 2012, in order to avoid the 2013 eRx payment adjustment
unless the eligible professional was a successful prescriber for the 12-month 2011
reporting period or a hardship exemption or other exclusion applies.
60 – Criteria for Determination of Successful Electronic Prescriber
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
In order to qualify to earn an eRx incentive payment and/or avoid a payment adjustment
for a particular program year, unless an exception applies, eligible professionals and
group practices must be considered a “successful electronic prescriber.” The criteria that
will be used to determine whether an eligible professional or group practice is a
successful electronic prescriber differ depending on whether participation is at the
individual eligible professional level or at the group practice level and may differ from
one program year to another.
60.1 – Eligible Professionals
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
The criteria for the determination of a successful electronic prescriber for individual
eligible professionals with respect to receiving incentive payments and/or avoiding
payment adjustments are described in §§ 60.1.1 and 60.1.2 of this manual. See below.
60.1.1 – Criteria for Determination of Successful Electronic Prescriber
for the Incentive Payments – Individual Eligible Professionals
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
For the 2009 incentive, an individual eligible professional was considered a “successful
electronic prescriber” if he/she reported the eRx measure (as specified for 2009) on at
least 50% of the cases in which the measure is reportable by the eligible professional
during the 2009 reporting period.

18
For the 2010 through 2013 incentives, an individual eligible professional was/is
considered a “successful electronic prescriber” if he/she reports the eRx measure (as
specified for the year) for at least 25 unique denominator-eligible events during
respective incentive reporting periods.
60.1.2 – Criteria for Determination of Successful Electronic Prescriber
for the Payment Adjustments – Individual Eligible Professionals
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
For the 2012 payment adjustment, an individual eligible professional is considered a
“successful electronic prescriber” if the eligible professional reports the eRx measure’s
numerator via claims for at least 10 unique eRx events for patients in the denominator of
the measure between January 1, 2011 and June 30, 2011.
For the 2013 payment adjustment, an individual eligible professional is considered a
“successful electronic prescriber” if the eligible professional meets the criteria for being a
successful electronic prescriber for the 2011 incentive. Additionally, an individual
eligible professional may also be considered a “successful electronic prescriber” if the
eligible professional reports the eRx measure‘s numerator via claims for at least 10
unique eRx events (regardless of whether the event is one associated with the eRx
measure’s denominator) between January 1, 2012 and June 30, 2012.
For the 2014 payment adjustment, an individual eligible professional is considered a
“successful electronic prescriber” if the eligible professional meets the criteria for being a
successful electronic prescriber for the 2012 incentive. Additionally, an individual
eligible professional may also be considered a “successful electronic prescriber” if the
eligible professional reports the eRx measure‘s numerator via claims for at least 10
unique eRx events (regardless of whether the event is one associated with the eRx
measure’s denominator) between January 1, 2013 and June 30, 2013.
60.2 –Group Practices
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
The criteria for the determination of a successful electronic prescriber for group practices
with respect to receiving incentive payments and/or avoiding payment adjustments are
described in §§ 60.2.1 and 60.2.2 of this manual. See below.
60.2.1 – Criteria for Determination of Successful Electronic Prescriber
for the Purpose of Receiving Incentive Payments – Group Practices
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
For the 2010 incentive, a group practice selected to participate in the eRx GPRO is
considered a “successful electronic prescriber” if the practice reports the eRx measure (as
specified for 2010) for at least 2,500 unique denominator-eligible events during the 2010
reporting period.

19
For the 2011 incentive, a group practice selected to participate in the eRx GPRO is
considered a “successful electronic prescriber” if the practice reports the eRx measure (as
specified for 2011) for at least 75-2,500 unique denominator-eligible events, depending
on the group practice’s size, during the 2011 incentive reporting period. The following is
a table showing the required number of instances a group practice must report the eRx
measure in order to be deemed a successful electronic prescriber according to group size:
Group size (Number of
Eligible Professionals)
Required Number of Unique Visits Where an Electronic
Prescription was Generated to be a Successful Electronic
Prescriber
2-10 	75
11-25 	225
26-50 	475
51-100 	925
101-199 	1875
200+ 	2500
For the 2012 and 2013 incentives, a group practice selected to participate in the eRx
GPRO is considered a “successful electronic prescriber” if the practice reports the eRx
measure (as specified for the year) for the following number of instances, depending on
the group practice’s size, during the respective 2012 and 2013 incentive reporting
periods:
• 	625 unique denominator-eligible events for group practices comprised of 25-99
eligible professionals or
• 	2,500 unique denominator-eligible events for group practices comprised of 100+
eligible professionals.
60.2.2 – Criteria for Determination of Successful Electronic Prescriber
for the Payment Adjustments – Group Practices
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
For the 2012 payment adjustment, a group practice is considered a “successful electronic
prescriber” if, depending on the group’s size, the group practice reports the eRx measure
via claims on 75-2,500 unique eRx events for patients in the denominator of the measure
for services occurring between January 1, 2011 and June 30, 2011. The following table
shows the required number of instances a group practice must report the eRx measure
according to group size:

20
Group size (Number of
Eligible Professionals)
Required Number of Unique Visits Where an Electronic
Prescription was Generated to be a Successful Electronic
Prescriber
2-10 	75
11-25 	225
26-50 	475
51-100 	925
101-199 	1875
200+ 	2500
For the 2013 payment adjustment, a group practice is considered a “successful electronic
prescriber” if the group meets the criteria for the 2011 incentive. A group practice may
also be considered a “successful electronic prescriber” if, depending on the group’s size,
the group practice reports the eRx measure’s numerator via claims on 625 (for group
practices comprised of 25-99 eligible professionals) or 2,500 (for group practices
comprised of 100+ eligible professionals) unique eRx events, regardless of whether the
event is associated with the eRx measure’s denominator, between January 1, 2012 and
June 30, 2012.
For the 2014 payment adjustment, a group practice is considered a “successful electronic
prescriber” if the group meets the criteria for the 2012 incentive. A group practice may
also be considered a “successful electronic prescriber” if, depending on the group’s size,
the group practice reports the eRx measure’s numerator via claims on 625 (for group
practices comprised of 25-99 eligible professionals) or 2,500 (for group practices
comprised of 100+ eligible professionals) unique eRx events, regardless of whether the
event is indicated in the eRx measure’s denominator, between January 1, 2013 and June
30, 2013.
70 – Significant Hardship Exemptions for the Purposes of the Payment
Adjustments
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
70.1 – Significant Hardship Exemptions for the Purposes of the
Payment Adjustments – Individual Eligible Professionals and Group
Practices
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
For the 2012 payment adjustment, an eligible professional or group practice may request
a significant hardship exemption via the Quality Reporting Communication Support Page
if any of the following situations apply:
• 	The eligible professional practices in a rural area without sufficient high speed
internet access (also reportable via reporting G-code G8642 on claims)

21
• 	The eligible professional practices in an area without sufficient available
pharmacies for eRx (also reportable via reporting G-code G8643on claims)
• 	Eligible professionals who register to participate in the Medicare or Medicaid
EHR Incentive Programs and adopt Certified EHR Technology
• 	Inability to electronically prescribe due to local, state, or federal law or regulation
• 	Limited prescribing activity
• 	Insufficient opportunities to report the eRx measure due to limitations of the
measure’s denominator
For the 2012 payment adjustment, the initial deadline for submitting a request for the first
two significant hardship exemption categories via submission of the appropriate G-code
on at least one claim was the end of the 2012-6-month payment adjustment reporting
period (that is, June 30, 2011). For group practices that self-nominated to participate in
the 2011 GPRO, group practices were required to request a significant hardship
exemption for these first two significant hardship exemption categories at the time that
they self-nominated to participate in either GPRO I or II for 2011. However, with the
addition of the last four significant hardship exemption categories to the 2012 payment
adjustment in September 2011, the deadline for individual eligible professionals to
submit a request for a significant hardship exemption under all significant hardship
exemption categories via the Quality Reporting Communication Support Page was
extended to November 1, 2011. Similarly, group practices that participated in the eRx
GPRO for 2011 were given until November 1, 2011 to submit a letter requesting a
significant hardship exemption under all significant hardship exemption categories.
For the 2013 and 2014 payment adjustments, an eligible professional or group practice
may request a significant hardship exemption via the Quality Reporting Communication
Support Page if any of the following situations apply:
• 	The eligible professional or group practice practices in a rural area without
sufficient high speed internet access (also reportable via reporting G-code G8642
on claims)
• 	The eligible professional or group practice practices in an area without sufficient
available pharmacies for eRx (also reportable via reporting G-code G8643on
claims)
• 	The eligible professional or group practice is unable to electronically prescribe
due to local, state, or Federal law or regulation
• 	The eligible professional who prescribes fewer than 100 prescriptions during a 6-
month, payment adjustment reporting period

22
The deadline for eligible professionals and group practices to report the first two
hardships via the respective G-code on a claim is June 30, 2012 for the 2013 payment
adjustment and June 30, 2013 for the 2014 payment adjustment. For eligible
professionals, the deadline for submitting a request for a significant hardship exemption
to the 2013 and 2014 payment adjustment via the Quality Reporting Communication
Support Page is June 30, 2012 and June 30, 2013 respectively.
Group practices wishing to request a significant hardship exemption to the 2013 and 2014
payment adjustment must indicate its request for a significant hardship exemption due to
one of the above significant hardship exemption categories in its self-nomination letter to
participate in the eRx GPRO for the 2012 and/or 2013 respective program year.
Therefore, the deadline for group practices to submit a significant hardship exemption
letter via its self-nomination letter is the date in which the self-nomination letter is due
for the respective program year.
80 – Confidential Feedback Reports
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
CMS provides confidential feedback reports to participating eligible professionals for a
particular program year on or about the time that the lump sum incentive payments are
made for the program year. For example, eligible professionals who participate in the
2009 eRx Incentive Program can expect to receive confidential feedback reports with
respect to the 2009 program year after the 2009 incentive payments are made in 2010.
Access to confidential feedback reports may require eligible professionals to complete an
identity-verification process. Receipt of a report is not a requirement for 	participation in
the eRx Incentive Program or to receive an incentive payment.
To receive a feedback report the eligible professional must have had at least one valid
eRx measure submission. A valid submission is defined as receipt by CMS of the correct
numerator, denominator, age and gender (where applicable) as listed in the eRx measure
specifications. The eRx measure specifications are subject to change for each program
year. The eRx measure specifications for the current or an upcoming program year, as
well as those for prior program years are posted or archived on the CMS eRx Incentive
Program website at http://www.cms.gov/ERXincentive.
90 – Direct Mailings
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
At the request of CMS, contractors shall print and distribute hardcopy mailings to all or a
subset of their active providers related to the eRx Incentive Program. Mailings shall be
sent to the best address to reach the provider, not the billing agency used by the provider.
As such, contractors should consider using the correspondence address in PECOS if it is
available.
100 – Public Posting of Program Performance

23
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
In addition, section 1848(m)(5)(G) of the Act requires CMS to post on the CMS website,
in an easily understandable format, a list of the names of the eligible professionals (or
group practices) who are successful electronic prescribers. Therefore, beginning with the
2009 eRx Incentive Program the names of eligible professionals group practices who are
determined to be successful electronic prescribers for the eRx Incentive Program are
required to be posted on http://www.medicare.gov. The names of eligible professionals
and group practices who are successful electronic prescribers for a particular year will be
publicly posted after the lump sum incentive payments for that program year are made in
the following year. CMS will also indicate whether an eligible professional is a
successful electronic prescriber on the Physician Compare website, available at
http://www.medicare.gov/Default.aspx.
Note: The eRx measure specifications are subject to change for each program year. The
eRx measure specifications for the current or an upcoming program year, as well as those
for prior program years are posted or archived on the appropriate eRx Incentive Program
page of the CMS eRx Incentive Program website at http://www.cms.gov/eRxincentive.

24
Transmittals Issued for this Chapter
Rev # 	Issue Date Subject 	Impl Date 	CR#
R31QRI 	08/29/2014 Language-Only Changes for Updating ICD-
10 and ASC X12 Language in Pub 100-22,
Chapters 1 and 2
09/30/2014 8787
R10QRI 	07/27/2012 Physician Quality Reporting System and
Electronic Prescribing (eRx) Incentive
Program
10/29/2012 7879
R1QRI 	06/11/2010 Physician Quality Reporting Initiative (PQRI)
and E-Prescribing (eRx) Medicare Quality
Reporting Incentive Programs Manual
09/13/2010 6935