CMS Pub. 100-22, ch. 2, § 50.1.1

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:

13

• 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.

14

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.