2011 E-Prescribing Incentive Requirements

The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) created an eprescribing reporting incentive that pays successful electronic prescribers a percent of Medicare billing. For 2009 and 2010, that was 2 percent; for 2011, it is 1 percent; and a penalty begins in 2012 for physicians not utilizing electronic prescribing. It is important to note that physicians must begin reporting in 2011 to avoid the 2012 penalty!


  1. E-Prescribing Overview
  2. Qualified E-Prescribing Systems
  3. 2011 Incentive Instructions
  4. Avoiding Penalties
  5. Program Exclusions and Hardship Codes
  6. EHR Medicare Incentive Program Participation
  7. Payment Timeline

E-Prescribing Overview






Incentive         1% 1% .5% None
Penalty           None     1% 1.5% 2%

E-prescribing is the electronic transmission of prescription or prescription-related information among a prescriber, dispenser, pharmacy benefit manager, or health plan either directly or through an intermediary, including an e-prescribing network. It includes, but is not limited to, two-way transmissions between the point of care and the dispenser. It is important to note that computergenerated faxing does not qualify as e-prescribing.  Potential benefits of e-prescribing include:

  • Increased patient safety resulting from harmful-interaction checks and alerts,
  • Fewer medication errors through computerized transmission of legible prescriptions directly to the pharmacy,
  • Fewer phone calls between physician and pharmacy for clarification, and
  • Improved formulary compliance, which may result in higher patient compliance.
  • Qualified E-Prescribing Systems

    To qualify for the incentive, a physician must use a qualified e-prescribing system. This can be a stand-alone system, or one integrated with an electronic medical record system or through a qualified registry. A qualified e-prescribing system must be able to:

    • Generate a complete active medication list incorporating electronic data from applicable pharmacies and benefit managers;
    • Select medications;
    • Print prescriptions;
    • Electronically transmit prescriptions;
    • Conduct safety alerts (written or audible signals that warn prescribers of possible undesirable or unsafe situations, including potentially inappropriate doses or routes of administration of a drug, drug-drug interactions, allergies, or warnings and cautions);
    • Provide information on lower-cost, therapeutically appropriate alternatives;
    • Provide information on formulary medications; and
    • Electronically receive authorization requirements from the patient’s drug plan.


    SureScripts provides the network that connects physician to pharmacy and also certifies e-prescribing solutions. The SureScripts website (www.surescripts.com/) provides a list of e-prescribing systems and a matrix of each system’s functionalities.  Physicians considering installing e-prescribing software can view the SureScripts’ certified products page to assist with selection.  As a benchmark, practices should expect to pay approximately $50 monthly per physician for this type of software.  

    2011 Incentive Instructions

    To be eligible for the 1-percent incentive in 2011, physicians’ estimated allowed Medicare Part B charges for the e-prescribing measure codes (listed below in Step 1) must be at least 10 percent of their total Medicare Part B allowed charges. The physician reporting period is for the entire calendar year. Physicians do not need to sign up to participate; submission of the e-prescribing G-code, G8553 indicates participation. To be eligible, physicians must report that an e-prescription was generated for a minimum of 25 unique Medicare patient visits.

    Step 1
    Bill under one of the following denominator codes (CPT or HCPCS): 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90862, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0101, G0108, G0109.
    Electronically generated prescriptions not associated with one of these denominator codes do not count toward the minimum 25 e-prescriptions needed for eligibility.

    Step 2
    Choose one of three reporting methods:

    1. Claims-Based Reporting
      If an electronic prescription is generated, on the claim form, report G-code G8553 for the
      numerator for at least 25 unique visits for Medicare Part B patients during the reporting period. G8553 indicates that at least one prescription created during the encounter was generated and transmitted electronically using a qualified e-prescribing system.
    2. Registry-based reporting using a “CMS-selected” registry to submit 2011 data to CMS.
    3. EHR-based reporting using a “CMS-selected” electronic health record product, submitting 2011 data to CMS.

    Avoiding Penalties

    To avoid the 1-percent penalty in 2012, by June 30, 2011, physicians must successfully e-prescribe and report via claims using G-code G8553 on at least 10 Medicare encounters.

    What type of encounter will count as an event?
    A physician must generate at least one electronic prescription using a qualified system during a patient visit from a set of defined services. Multiple prescriptions to the same patient will only constitute one event.

    Program Exclusions

    A physician or other provider can avoid the 2012 and 2013 e-prescribing penalties if they: 

    • Do not have at least 100 cases containing an encounter code in the measure’s denominator, Electronically generated refills without a patient visit do not count and faxes do not qualify as eRx;
    • Do not have prescribing privileges and reports G-code G8644 (defined as  not having prescribing privileges) at least one time on an eligible claim prior to June 30, 2011;
    • Are not a physician (MD, DO, or podiatrist), Nurse Practitioner, or Physician Assistant as of June 30, 2011, based on primary taxonomy code in the National Plan and Provider Enumeration System (NPPES); or
    • Claim a hardship as described below.

    Hardship Codes

    The Centers for Medicare & Medicaid Services (CMS) introduced new codes referred to as “hardship codes” for physicians not able to e-prescribe based on insufficient Internet access or insufficient pharmacies accepting e-prescribing. If that is the case, the G-code should be reported at least one time before June 30, 2011, to prevent the e-prescribing penalties in 2012. G8642: The 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. G8643: The 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.

    EHR Medicare Incentive Program Participation

    Physicians participating in the Medicare EHR incentive program are not eligible for participation in the e-prescribing incentive program during the same calendar year. Physicians can participate in the Medicaid EHR incentive program and Medicare e-prescribing incentive program in the same year. A physician participating in the Medicare EHR incentive program still needs to report on 10 eprescriptions to avoid the e-prescribing penalty.

    Payment Timeline

    Participants will receive their incentive payments in the fall of 2012 for the 2011 reporting year. Feedback reports will be available around the same time. No interim reports will be available during the reporting year.

    For more information, contact Texas Medical Association’s Department of Health Information Technology at (800) 880-5720 or e-mail HIT@texmed.org