HPSA bonus payment policy reminders
Physicians who furnish services to Medicare beneficiaries in areas designated as primary care geographic HPSAs by the Health Resources and Services Administration (HRSA) as of December 31, 2011, are eligible for a 10 percent bonus payment for services furnished from January 1, 2012, to December 31, 2012. If an area does not have a geographic primary care HPSA designation, but does have a geographic mental health HPSA designation, then only psychiatrists furnishing services to Medicare beneficiaries in the designated area are eligible for the ten percent bonus.
The physician must determine whether a service is furnished in a geographic primary care (or mental health) HPSA. Eligibility is determined annually based on the status of the designation, as of December 31 of the prior year. That is, a physician who was eligible for the 10 percent bonus in 2011 may not be eligible for the bonus in 2012. A physician or provider that was not eligible for the 10 percent bonus in 2011 may be eligible for the bonus in 2012.
The Centers for Medicare & Medicaid Services (CMS) publishes an annual list of ZIP codes that automatically receive the HPSA bonus. Only areas where the entire ZIP code falls within the designated area at the time the list is developed are listed. Services provided in eligible areas that are not listed for automatic bonus payment must use the AQ modifier to receive the bonus.
HPSA designations are made by the Health Resources and Services Administration’s (HRSA) Division of Shortage Designation (DSD). An automated file of areas eligible for the HPSA bonus payment will be updated on an annual basis and will be effective for services rendered with dates of service on or after January 1 of each calendar year.
Physicians may only use the AQ modifier for services furnished in an area that was designated as of December 31 of the prior year. This information can be downloaded from the HRSA Web site.
Carriers will be informed of the availability of the file and the file name via an email notice. Carriers will automatically pay bonuses for services rendered in ZIP Code areas that fully fall within a designated primary care or mental health full county HPSA; are considered to fully fall in the county based on a determination of dominance made by the United States Postal Service (USPS); or are fully within a partial county HPSA area.
Should a ZIP Code fall within both a primary care and mental health HPSA, only one bonus will be paid on the service. Bonuses for mental health HPSAs will only be paid when performed by the provider specialty of 26 – psychiatry.
For services rendered in ZIP Code areas that do not fall within a designated full county HPSA; are not considered to fall within the county based on a determination of dominance made by the USPS; or are partially within a partial county HPSA, physicians must submit a AQ modifier to receive payment.
To determine whether a modifier is needed, physicians must review the information provided on the CMS Web or the HRSA Web site for HPSA designations to determine if the location where they render services is, indeed, within a HPSA bonus area. Physicians
may also base the determinations on letters of designations received from HRSA. They must be prepared to provide these letters as documentation upon the request of the carrier and should verify the eligibility of their area for a bonus with their carrier before submitting services with a HPSA modifier.
For services rendered in ZIP Code areas that cannot automatically receive the bonus, it will be necessary to know the census tract of the area to determine if a bonus should be paid and a modifier submitted. Census tract data can be retrieved by visiting the U.S. Census Bureau Web site at www.Census.gov or the Federal Financial Institutions Examination Council (FFIEC) Web site at www.ffiec.gov/geocode/default.htm.
Instructions on how to use these Web sites can be found on the CMS Web site at http://new.cms.hhs.gov/HPSAPSAPhysicianBonuses. Neither CMS nor the Medicare carriers can provide information on the functionality of these Web sites.
Claims Coding Requirements
For services with dates of service prior to January 1, 2005, physicians must indicate that their services were provided in an incentive-eligible rural or urban HPSA by using one of the following modifiers:
QB – physician providing a service in a rural HPSA; or QU – physician providing a service in an urban HPSA.
Effective for claims with dates of service on or after January 1, 2006, the QB and QU modifiers will no longer be accepted. Claims with prior dates of service must still be submitted with those modifiers. The AQ modifier, Physician providing a service in a Health Professional Shortage Area (HPSA), will replace the QB and QU modifiers and will be effective for claims with dates of service on or after January 1, 2006.
For services with dates of service on or after January 1, 2005, the bonus will automatically be paid without the submission of a modifier for the following:
•When services are provided in a zip code area that fully falls within a full county HPSA;
•When services are provided in a zip code area that partially falls within a full county HPSA and has been determined to be dominant for the county by the USPS; and
•When services are provided within a zip code that fully falls within a partial county HPSA.
The submission of the QB or QU modifier, or the AQ modifier for claims with dates of service on or after January 1, 2006, will be required for the following:
•When services are provided in zip code areas that do not fully fall within a designated full county HPSA bonus area;
•When services are provided in a zip code area that partially falls within a full county HPSA but is not considered to be in that county based on the dominance decision made by the USPS;
•When services are provided in a zip code area that partially falls within a partial county HPSA; and.
•When services are provided in a zip code area that was not included in the automated file based on the date of the data run used to create the file.
In order to be considered for the bonus payment, the name, address, and zip code of where the service was rendered must be included on all electronic and paper claims submissions.
The incentive payment is 10 percent of the amount actually paid, not the approved amount. Contractors pay the incentive payment for services identified on either assigned or unassigned claims.
They do not include the incentive payment with each claim payment. Contractors should:
*Establish a quarterly schedule for issuing incentive payments. These payments are taxable and must be reported to the IRS; and
*Prepare a special incentive remittance to accompany each payment. Include a line-item for each assigned claim represented in the incentive check and a “summary” item showing the number of unassigned claims represented. Claims should be identified as HPSA physician, Scarcity, HSIP and/or PCIP in the summary. The sum of the line-items and the “summary” item should equal the amount of the check.
Services Eligible for HPSA and Physician Scarcity Bonus Payments
A.Information in the Professional Component/Technical Component (PC/TC) Indicator Field of the Medicare Physician Fee Schedule Database
Carriers use the information in the Professional Component/Technical Component (PC/TC) indicator field of the Medicare Physician Fee Schedule Database to identify professional services eligible for HPSA and physician scarcity bonus payments. The following are the rules to apply in determining whether to pay the bonus on services furnished within a geographic HPSA or, physician scarcity bonus area. Should carriers receive notification from physicians that they have chosen to forego the bonus payments, the carriers shall make no bonus payments to that physician for any service.
PC/TC Indicator Bonus Payment Policy
0 Pay bonus
1 Globally billed. Only the professional component of this service qualifies for the bonus payment. The bonus cannot be paid on the technical component of globally billed services.
ACTION: Effective for claims received prior to October 1, 2005, carriers return the service as unprocessable and notify the physician that the professional component must be re-billed if it is performed within a qualifying bonus area. If the technical component is the only component of the service that was performed in the bonus area, there wouldn’t be a qualifying service.
Effective for claims received on or after October 1, 2005, carriers shall accept claims with services with a PC/TC indicator of 1 that are eligible for the HPSA or PSA bonus. They shall pay the bonus only on the professional component of the service.
1 Professional Component (modifier 26). Carriers pay the bonus.
1 Technical Component (modifier TC). Carriers do not pay the bonus.
2 Professional Component only. Carriers pay the bonus.
3 Technical Component only. Carriers do not pay the bonus.
4 Global test only. Only the professional component of this service qualifies for the bonus payment.
ACTION: Effective for claims received prior to July 1, 2006, carriers return the service as unprocessable. They instruct the provider to re-bill the service as separate professional and technical component procedure codes.
Effective for claims received on or after July 1, 2006, except for 93015, carriers shall accept claims with services with a PC/TC indicator of 4 that are eligible for the HPSA or PSA bonus. They shall pay the bonus only on the associated professional component of the service. Since 93015 has two associated professional components, carriers will not be able to make a determination as to which would be the correct component to use to calculate the bonuses. Therefore, carriers shall continue to treat 93015 as unprocessable.
5 Incident to codes. Carriers do not pay the bonus.
6 Laboratory physician interpretation codes. Carriers pay the bonus.
7 Physical therapy service. Carriers do not pay the bonus.
8 Physician interpretation codes. Carriers pay the bonus.
9 Concept of PC/TC does not apply. Carriers do not pay the bonus.
NOTE: Codes that have a status of “X” on the Medicare Physician Fee Schedule Database (MFSDB) have been assigned PC/TC indicator 9 and are not considered physician services for MFSDB payment purposes. Therefore, neither the HPSA bonus payment nor the physician scarcity area bonus payment will be paid for these codes.
B.Anesthesia Codes (CPT Codes 00100 Through 01999) That Do Not Appear on the MFSDB
Anesthesia codes (CPT codes 00100 through 01999) do not appear on the MFSDB. However, when a medically necessary anesthesia service is furnished within a HPSA or physician scarcity area by a physician, a HPSA bonus and/or physician scarcity bonus is payable.
To claim a bonus payment for anesthesia, physicians bill codes 00100 through 01999 with modifiers QY, QK, AD, AA, or GC to signify that the anesthesia service was performed by a physician along with the QB or QU modifier, or the AQ modifier for claims with dates of service on or after January 1, 2006, when required per §90.4.3 or the AR modifier as required per §90.5.3.
C.Mental Health Services
Physicians’ professional services rendered by the provider specialty of 26 – psychiatry, are eligible for a HPSA bonus when rendered in a mental health HPSA. The service must have a PC/TC designation per the chart above. Should a zip code fall within both a primary care and mental health HPSA, only one bonus must be paid on the service.
Overview of the HSIP
(Rev. 2040, Issued: 08-27-10, Effective: 01-01-11 and 04-04-11, Implementation: 01- 03-11 for the claim identification of the incentive and 04-04-11 for full implementation)
The incentive payment applies to major surgical procedures, that are defined as 10 – and 90 – day global procedures under the Physician Fee Schedule (PFS) and furnished on or after January 1, 2011, and before January 1, 2016, by an 02-general surgeon in an area designated under Section 332(a)(1)(A) of the Public Health Service Act as a HPSA.
To be consistent with the Medicare HPSA physician bonus program (Pub. 100-04, Chapter 12, §90.4), HSIP payments are calculated by Medicare contractors on a quarterly basis, on behalf of the qualifying general surgeon, for the qualifying surgical procedures. The surgeons’ professional services are paid under the PFS based on a claim for professional services.
126.96.36.199- HPSA Identification
For HSIP payments to be applicable, the 10 – or 90 – day global surgical procedure must be furnished in an area designated by the Secretary as of December 31 of the prior year as a HPSA.
Each year, a list of ZIP codes eligible for automatic payment of the HSIP incentive payment (and the Medicare HPSA physician bonus program) is published. This list is utilized for automatic payments of the incentive for eligible services furnished by general surgeons. Contractors will use the existing HPSA modifier -AQ ,along with the physician specialty (02), to identify circumstances when general surgeons furnish major surgical procedures in areas that are designated as HPSAs as of December 31 of the prior year, but that are not on the list of ZIP codes eligible for automatic payment. Modifier – AQ should be appended to the major surgical procedure on claims submitted for payment under these circumstances.
Coordination with Other Payments
Section 5501(b)(4) of the Affordable Care Act provides payment under the HSIP as an additional payment amount for specified surgical services without regard to any additional payment for the service under section 1833(m) of the Act. Therefore, a
general surgeon may receive both a HPSA physician bonus payment under the established program, and an HSIP payment under the new program beginning in CY 2011.
188.8.131.52- General Surgeon and Surgical Procedure Identification for Professional Services Paid Under the Physician Fee Schedule (PFS) (Rev. 2040, Issued: 08-27-10, Effective: 01-01-11 and 04-04-11, Implementation: 01- 03-11 for the claim identification of the incentive and 04-04-11 for full implementation)
Qualifying general surgeons are identified on a claim for a 10 – or 90 – day global surgical procedure based on the primary specialty of the rendering physician, identified by his or her National Provider Identifier (NPI), of 02 – general surgery. If the claim is submitted by a physician group practice, the rendering physician’s NPI must be included on the line-item for the qualifying surgical procedure in order for a determination to be made regarding whether or not the procedure is eligible for payment under the HSIP.
Eligible surgical procedures are those procedures for which a 10 – or 90 – day global period is used for payment under the PFS. The specific HCPCS procedure codes eligible for the HSIP are identified in column U (global period) of the Physician Fee Schedule Relative Value Update (RVU) file located at: http://www.cms.gov/PhysicianFeeSched/PFSRVF/list.asp*listpage=4, with a global period designation of 10 – or 90 – days.
Claims Processing and Payment
The HPSA physician bonus program guidelines are contained in Pub. 100-04, Chapter 12, §90.4. Refer to that section for payment and claims processing guidance for the HPSA physician bonus program that was established in 2005. The following guidelines pertain only to the additional 10 percent incentive payment for 10 – or 90 – day global surgical procedures furnished by 02 – general surgeons in HPSAs from January 1, 2011 through December 31, 2015.
Contractors shall identify eligible surgical procedures with a 10 – or 90 – day global period rendered in an eligible primary care HPSA zip code area based on the HPSA physician bonus ZIP code file for the appropriate date of service. The HPSAs eligible for automatic payment may be found on the CMS Web site at: http://www.cms.gov/HPSAPSAPhysicianBonuses/01_overview.asp.
Contractors must also inform eligible practitioners about the use of modifier -AQ on claims for 10 – or 90 – day global surgical procedures that were furnished in HPSAs
approved by December 31 of the preceding calendar year, but that are not recognized for automatic payment. The modifier must be appended to the surgical procedure for the service to be eligible for the 10 percent additional HSIP payment.
B.Method of Payment
*Calculate and pay general surgeons an additional 10 percent incentive payment;
*Calculate the payment based on the amount actually paid for the service, not the Medicare approved amount;
*Combine the HSIP incentive payments, when appropriate, with other incentive payments, including the HPSA physician bonus payment;
*Accept and pay the incentive payment for 10 – and 90 – day global period surgical procedures furnished by general surgeons (02) and submitted with the modifier – AQ;
*Provide a special remittance form that is forwarded with the incentive payment so that physicians and nonphysician practitioners can identify which type of incentive payment (HPSA, HSIP, and/or PCIP) was paid for which services;
*Use the PLB03 adjustment reason code LE;
*Add the following message to the incentive checks: This check is for the HPSA, HSIP and/or PCIP. See special remittance for details; and
*Inform practitioners to contact their contractor with any questions regarding HSIP payments.
C.Changes for Contractor Systems
The Medicare Carrier System, (MCS), Common Working File (CWF,) and National Claims History (NCH) shall be modified to accept a new incentive HPSA/PSA/HSIP/PCIP payment indicator on the claim line.
Once the type of incentive has been identified by the shared systems, the shared system shall transmit the HPSA/PSA/HSIP/PCIP indicator to CWF and modify their systems to set the indicator on the claim line as follows:
1 = HPSA;
2 = PSA;
3 = HPSA and PSA;
4 = HSIP;
5 = HPSA and HSIP;
6 = PCIP;
7 = HPSA and PCIP; and Space = Not Applicable.
The contractor shared system shall send the HIGLAS 810 invoice for incentive payment invoices, including the new HSIP payment. The contractor shall also combine the practitioner’s HPSA physician bonus, Physician Scarcity (PSA) bonus (if it should become available at a later date), HSIP payment, and/or PCIP payment invoice per practitioner. The contractor shall receive the HIGLAS 835 payment file from HIGLAS showing a single incentive payment per practitioner.
Only physicians who furnish services in areas designated as a geographic primary care HPSA, as of December 31, 2011, and whose ZIP code is not on the list should use the modifier. Only psychiatrists who furnish services in areas that are not designated as primary care HPSAs, as of December 31, 2011, but are designated as a geographic mental health HPSA, should use the modifier if the ZIP code is not on the list for automatic payment.