Last Chance to Avoid the eRx 2014 Payment Penalty



Eligible professionals (EPs) who did not successfully report and qualify for the 2012 eRx incentive program, reporting period of January 1, 2012 – December 31, 2012, will have another opportunity to avoid the 2014 payment adjustment (penalty) of 2% on their Medicare Part B payments. (Providers who are exempt from eRx reporting are listed at the end of the article)

EPs may avoid the 2014 penalty adjustment by submitting e-prescribe encounters via code G8553 for service dates between January 1, 2013– June 30, 2013.

This submission option does not need to be sent with a denominator code. (one of the 56 eligible CPT code visits)  As long as the EP sends prescriptions on a qualified e-prescribe system, the G8553 code may be submitted on any Medicare Part B claim that includes a billable Part B service.   This is beneficial to those providers who do not usually prescribe during one of the 56 eligible CPT code visits.

The G8553 code must be reported via claims-based submission and must be processed into Medicare’s National Claims History by July 26, 2013.



Individual EPs

If an EP did not successfully report 25 eRx encounters in calendar year 2012, he/she may still submit;

  • the electronic prescribing measure’s numerator (G8553) code on any Medicare Part B claim that includes a billable Part B service at least 10 times for service dates January 1, 2013June 20, 2013reported via claims-based reporting only.


Group Practices Reporting thru GPRO (Group Practice Reporting Option)

If  GPROs do not report the appropriate number of encounters in calendar year 2012, they may still report the G8553 code for the reporting period of January 1, 2013June 20, 2013 as follows:

  • GPs with 25-99 EPs – Must report the electronic prescribing measure’s numerator code at least 625 times, via claims only
  • GPs with 100+ EPs – Must report the electronic prescribing measure’s numerator code at least 2,500 times, via claims only


Hardship Exemptions for the 2014 Payment Penalty

If you did not successfully submit e-prescribe encounters to CMS in 2012 or can not submit 10 encounters between January 1, 2013 and June 30, 2013, because of one of the available hardships, you must submit your hardship exemption to CMS via the Communication Support Page by June 30, 2013.

Significant hardship exemptions for payment adjustment year 2014 are for providers who:

  • G8642 – practice in a rural area with limited high speed internet access; or
  • G8643 – practice in an area with limited available pharmacies for electronic prescribing.
  • Have the inability to electronically prescribe due to local, state, or federal law or regulation
  • Who prescribe fewer than 100 prescriptions during a 6-month payment adjustment reporting period.

Requests must be submitted each year to avoid the penalty in the subsequent year. Office staff may submit e-prescribing hardship exemption requests on behalf of their EPs for the purpose of avoiding the 2014 e-prescribing payment adjustment.

Additional information on avoiding the 2014 payment adjustment may be found on the CMS website here


EPs Exempt from the 2014 Payment Adjustment

The 2014 eRx payment adjustment would NOT apply to the following providers:

  • An EP who is not a physician, NP or PA as of June 30, 2013
  • An EP who does not have at least 100 cases (claims for patient services) containing an encounter that falls within the denominator (CPT code) of the eRx measure for service dates of J anuary 1, 2013–June 30, 2013
  • An EP’s Medicare charges to which the eRx measure applies (applicable denominator codes) are less than 10% of an EP’s total Medicare charges.
  • The EP does not have prescribing privileges and reported G8644 on a billable Medicare Part B service at least once on a claim betweenJanuary 1, 2013–June 30, 2013