Provider Action Needed:

Change Request (CR) 8942 alerts you that the annual
HPSA bonus payment file for 2015 will be made available by the Centers for
Medicare & Medicaid Services (CMS) to your MAC and will be used for HPSA
bonus payments on applicable claims with dates of service on or after January
1, 2015, through December 31, 2015. You should review Physican Bonuses below ,
whether you need to add modifer AQ to your claim in order to receive the bonus
payment, or to see if the ZIP code in which you rendered services will
automatically receive the HPSA bonus payment. Make sure that our billing staffs
are aware of thes changes.


The Health Resources and Services
Administration (HRSA) published an updated Federal Register Notice on June 27,
2013, that contains important information about new and withdrawn HPSA
designations. For purposes of the Medicare Physician Bonus and the Medicare
Surgical Bonus programs, changes in designation status are effective for dates
of services on and after January 1 of the year following the designation date.
Therefore, areas whose designation is shown as “Withdrawn” on the June 27, 2013
Federal Register list, remain eligible for the HPSA bonuses through December
31, 2013.

MMA Section 413(b) required CMS to
revise some of the policies that address HPSA bonus payments. Section 1833(m)
of the Social Security Act provides bonus payments for physicians who furnish
medical care services in geographic areas that are designated by the HRSA as
primary medical care HPSAs under section 332 (a)(1)(A) of the Public Health
Service (PHS) Act. In addition, for claims with dates of service on or after
July 1, 2004, psychiatrists (provider specialty 26) furnishing services in
mental health HPSAs are also eligible to receive bonus payments. If a zip code
falls within both a primary care and mental health HPSA, only one bonus will be
paid on the service.


Effective January 1, 2005, a
modifier no longer has to be included on claims to receive the HPSA bonus payment,
which will be paid automatically, if services are provided in ZIP code areas
that either:
  • Fall entirely in a county designated as a full-county
    HPSA; or
  • Fall entirely within the county, through a USPS
    determination of dominance; or
  • Fall entirely within a partial county HPSA.
However, if services are provided in
ZIP code areas that do not fall entirely within a full county HPSA or partial
county HPSA, the AQ modifier must be entered on the claim to receive the bonus.
The following are the specific instances
in which a modifier must be entered:
  • When services are provided in ZIP code areas that do
    not fall entirely within a designated full county HPSA bonus area;
  • When services are provided in a ZIP code area that
    falls partially within a full county HPSA but is not considered to be in
    that county based on the USPS dominance decision;
  • When services are provided in a ZIP code area that
    falls partially within a non-full county HPSA;
  • When services are provided in a ZIP code area that was
    not included in the automated file of HPSA areas based on the date of the
    data run used to create the file.
To determine if a service will
automatically qualify to receive the bonus payment, review the information
provided on the CMS Web site.  The HRSA website should be reviewed for the
most recent designations.  Physicians may also use the HRSA website
designations when making the decision on whether or not to include the HPSA
modifier on their claims.
Some points to remember include the
  • Medicare contractors will base the bonus on the amount
    actually paid (not the Medicare approved payment amount for each service)
    and the ten-percent bonus will be paid on a quarterly basis.
  • The HPSA bonus pertains only to physician’s
    professional services. Should a service be billed that has both a
    professional and technical component, only the professional component will
    receive the bonus payment.
  • The key to eligibility is not that the beneficiary
    lives in a HPSA nor that the physician’s office or primary location is in
    a HPSA, but rather that the services are actually rendered in a HPSA.
  • To be considered for the bonus payment, the name,
    address, and ZIP code of the location where the service was rendered must
    be included on all electronic and paper claim submissions.
  • Physicians should verify the eligibility of their area
    for a bonus before submitting services with a HPSA modifier for areas they
    think may still require the submission of a modifier to receive the bonus
  • Services submitted with the AQ modifier will be subject
    to validation by Medicare.

Care Act of 2010 Changes (New for January 2011 for the HSIP Bonus)

The Affordable Care Act of 2010,
Section 5501 (b)(4) expands bonus payments for general surgeons in HPSAs. 
Effective January 1, 2011 through December 31, 2015, physicians serving in
designated HPSAs will receive an additional 10% bonus for major surgical
procedures with a 10 or 90 day global period.  This additional payment,
referred to as the HPSA Surgical Incentive Payment (HSIP) will be combined with
the original HPSA payment and will be paid on a quarterly basis.  Modifier
AQ should be appended for these major surgical procedures similar to claims for
the Medicare original HPSA bonus when services are provided in ZIP code areas that
do not fall entirely within a full or partial county HPSA.
Some points to remember:
  •  The current HPSA physician bonus program
    requirements will remain intact.
  • Medicare contractors will identify and pay the
    additional bonus on eligible services rendered in eligible ZIP code areas
    based on the HPSA ZIP code file as of December 31st of the
    prior year.
  • Medicare contractors will calculate the bonus amount
    based on the amount actually paid for the service, not the Medicare
    approved amount

Services submitted with modifier AQ will be
subject to validation by Medicare.