Electronic Prescribing (eRx) Incentive Program: Future Payment Adjustments

Under Section 1848(a)(5)(A) of the Social Security Act, for years 2012 through 2014, a Medicare Physician Fee Schedule (MPFS) payment adjustment applies to eligible professionals who are not successful electronic prescribers at an increasing rate through 2014. Specifically, if the eligible professional is not a successful electronic prescriber for the respective reporting period for the appropriate program year, the MPFS amount for covered professional services during the year shall be a percentage less than the MPFS amount that would otherwise apply.

The applicable electronic prescribing percent for payment adjustments under the eRx Incentive Program are as follows:

1.0% adjustment in 2012 (eligible professional will receive 99% of their Medicare Part B PFS amount that would otherwise apply to such services);

1.5% adjustment in 2013 (eligible professional will receive 98.5% of their Medicare Part B PFS amount for covered professional services); and

2.0% adjustment in 2014 (eligible professional will receive 98% of their Medicare Part B PFS amount for covered professional services).

eRx Participation Feedback

Refer to the Remittance Advice (RA) to determine whether or not eRx quality-data codes submitted to the Medicare Carrier or A/B Medicare Administrative Contractor (MAC) are processed into the National Claims History database (NCH). CMS uses the NCH data for eRx program analysis. Take the following steps to ensure the eRx Quality-Data Codes (QDCs) are processed into the NCH:

The eRx line items will be denied for payment, but are passed through the claims processing system to the NCH used for eRx claims analysis.

The RA will include 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 reported measure. N365 only indicates that the eRx G-code passed into the NCH.

If the entire claim is rejected, please review claim for errors before re-submitting, since eRx G-codes will NOT be processed or tracked if the claim is rejected.

Claims may NOT be resubmitted for the sole purpose of adding or correcting QDCs.

Reference: http://www.cms.gov/MLNMattersArticles/Downloads/SE1206.pdf