(Medicare Claims Processing Manual)

90.5.3 - Claims Coding Requirements (Rev. 280, Issued 08- 13-04, Effective/Implementation: October 1, 2004 for the analysis and design phases for the MCS Maintainer and A/B MACs (B)  January 1, 2005 for the coding, testing, and implementation phases for the MCS Maintainer and A/B MACs (B)  January 1, 2005 for all phases for the VIPS Maintainers and A/B MACs (B)) Medicare will automatically pay the physician scarcity bonus on a quarterly basis  for services provided in ZIP  code areas that fully fall within a county designated as a PSA, partially fall within a county designated as a PSA area and are considered to be dominant for that county based on a determination by the United States Postal Service (USPS), or fall within a  rural census tract of a metropolitan statistical area identified through the latest modification of the Goldsmith Modification that is determined  to be a PSA.  In some cases, a service may be provided in a county that is considered to be a PSA, but the ZIP  code is not considered to be dominant for that area.  The bonus payment cannot automatically be made.  In order to receive the bonus for those areas, physicians must include the following modifier on the claim:   AR - Physician providing service in a Physician Scarcity Area.  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.  90.5.4 - Payment  (Rev. 280, Issued 08- 13-04, Effective/Implementation: October 1, 2004 for the analysis and design phases for the MCS Maintainer and A/B MACs (B)  January 1, 2005 for the coding, testing, and implementation phases for the MCS Maintainer and A/B MACs (B)  January 1, 2005 for all phases for the VIPS Maintainers and A/B MACs (B))  Section 413a of the MMA adds subsection (u)(6) to Section 1833 of the Social Security Act.  For the payment of the physician scarcity bonus, this section defines physicians as doctors of medicine or osteopathy described per Section 1861(r)(1).  Therefore, dentists, chiropractors, podiatrists, and optometrists are not eligible for the physician scarcity bonus as either primary care or specialty physicians  Only the provider specialty designations of General Practice - 01, Family Practice - 08, Internal Medicine -  11, and Obstetrics/Gynecology -  16, will be paid the bonus for the zip codes designated as primary care PSAs.  All other physician provider specialties  will be eligible for the specialty physician scarcity bonus for the zip codes designated as specialty PSAs.  The bonus is to be paid based on date of service.  Accommodations must be made in payment systems to maintain an active file for a current period as well as an active file for a previous period so that the bonus can be paid based on date of service.  Also, the A/B MACs (B)  and standard systems maintainers shall program systems to be able to maintain files for the periods prior to the two active periods as an archive for reference purposes.  90.5.5 - Services Eligible for the Physician Scarcity Bonus  (Rev. 280, Issued 08- 13-04, Effective/Implementation: October 1, 2004 for the analysis and design phases for the MCS Maintainer and A/B MACs (B)  January 1, 2005 for the coding, testing, and implementation phases for the MCS Maintainer and A/B MACs (B)  January 1, 2005 for all phases for the VIPS Maintainers and A/B MACs (B)) Eligible physician services for the physician scarcity bonus are identified in the same manner that they are currently identified for the HPSA bonus payment per Pub. 100- 4, Chapter 12, 90.4.5A and B.  A quarterly 5 percent bonus payment is made to the physician based on the amount actually paid, not the Medicare approved amount of the service.  90.5.5.1 - Remittance Messages (Rev. 280, Issued 08- 13-04, Effective/Implementation: October 1, 2004 for the analysis and design phases for the MCS Maintainer and A/B MACs (B)  January 1, 2005 for the coding, testing, and implementation phases for the MCS Maintainer and A/B MACs (B)  January 1, 2005 for all phases for the VIPS Maintainers and A/B MACs (B)) See 90.4.6 for applicable remittance messages when submitted services are not eligible for a HPSA and/or physician scarcity bonus payment. 90.5.6 - Post-payment Review (Rev. 280, Issued 08- 13-04, Effective/Implementation: October 1, 2004 for the analysis and design phases for the MCS Maintainer and A/B MACs (B)  January 1, 2005 for the coding, testing, and implementation phases for the MCS Maintainer and A/B MACs (B)  January 1, 2005 for all phases for the VIPS Maintainers and A/B MACs (B)) On a post -pay basis, services submitted with the AR modifier will be subject to validation. 90.5.7 - Administrative and Judicial Review  (Rev. 280, Issued 08- 13-04, Effective/Implementation: October 1, 2004 for the analysis and design phases for the MCS Maintainer and A/B MACs (B)  January 1, 2005 for the coding, testing, and implementation phases for the MCS Maintainer and A/B MACs (B)  January 1, 2005 for all phases for the VIPS Maintainers and A/B MACs (B))  Per Section 413(a) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, there shall be no administrative or judicial review respecting:   The identification of a county or area;   The assignment of a specialty of any physician;   The assignment of a physician to a county; or   The assignment of a postal ZIP code to a county or other area.   90.6 - The Indian Health Service (IHS) Provider Payment to Non -IHS Physicians for Teleradiology Interpretations  (Rev. 1643, Issued: 12- 05-08, Effective: 01 -01-07, Implementation: 03- 09-09)  The IHS providers may choose to purchase or otherwise contract with non- IHS physicians or practitioners for teleradiology interpretations services.  These services may be paid using either contractual reassignment or purchased test methodologies.  See Chap ter 19, Section 120 of this Manual for further information.  90.7 - Bundling of Payments for Services Provided in Wholly Owned and Wholly Operated Entities (including Physician Practices and Clinics): 3- Day Payment Window  (Rev. 2373, Issued: 12- 21-11, Effective: 01 -01-12, Implementation: 01- 03-12)  In accordance with section 102(a)(1) of the PACMBPRA, for outpatient services furnished on or after June 25, 2010, the technical portion of all nondiagnostic services, other than ambulance and maintenance renal dialysis services, provided by the hospital (or an entity wholly owned or wholly operated by the hospital) on the date of a beneficiarys inpatient admission are deemed related to the admission and thus, must be included on the bill for the inpatient stay. Also, the technical portion of outpatient nondiagnostic services, other than ambulance and maintenance renal dialysis services, provided by the hospital (or an entity wholly owned or wholly operated by the hospital) on the first, second,  and  the third  calendar days (1 calendar day for a nonsubsec tion (d) hospital) immediately preceding the date of admission are deemed related to the admission and, therefore, must be billed with the inpatient stay, unless the nondiagnostic services are unrelated to the inpatient hospital claim (that is, the preadmission nondiagnostic services are clinically distinct or independent from the reason for the beneficiarys inpatient admission).  In such cases, the unrelated outpatient hospital nondiagnostic services are covered by Medicare Part B, and the hospital or wholly owned or wholly operated physician practice shall include the technical portion of the services in their billing. PACMBPRA did not change the requirement that the technical portion of all diagnostic services provided by the hospital (or entity wholly owned or wholly operated by the hospital) occurring on the date of an inpatient admission, or during the 3 calendar days (or 1 calendar day) immediately preceding the date of an inpatient admission must be billed with the inpatient admission.   Implementation of the 3- day Payment Window Policy in Wholly Owned or Operated Entities   Wholly owned or wholly operated entities are subject to the 3- day (or 1- day) payment window policy when they furnish preadmission diagnostic services to a patient, who is later admitted as an inpatient on the same day or within the preceding 3 calendar days (preceding1 calendar day), or when they furnish preadmission nondiagnostic services to a patient, who is later admitted as an inpatient on the same day or within the preceding 3 calendar days (preceding 1 calendar day) for related medical care. Only unre lated nondiagnostic preadmission services are not subject to the payment window policy, where unrelated preadmission nondiagnostic services are clinically distinct or independent from the reason for the beneficiary's inpatient admission and are furnished on the 1st, 2nd, or 3rd calendar day immediately preceding the date of the inpatient admission. (Note: nondiagnostic services furnished by a wholly owned or wholly operated physician practice on the date of a beneficiarys inpatient admission to the hospita l are always deemed to be related to the admission and their technical portion must be included on the bill for the inpatient admission.) When an entity that is wholly owned or wholly operated by a hospital furnishes a service subject to the 3- day window policy, Medicare will pay the professional component of services with payment rates that include a professional and technical split and at the facility rate for services that do not have a professional and technical split. Once the entity has received confi rmation of a beneficiarys inpatient admission from the admitting hospital, they shall, for services furnished during the three -day window,  append a CMS payment modifier to all claim lines for diagnostic services and for those nondiagnostic services that have been identified as related to the inpatient stay.   Physician nondiagnostic services that are unrelated to the hospital admission are not subject to the payment window and shall be billed without the payment modifier.   Definition of Wholly Owned or Wholly Operated Entities   Wholly owned or wholly operated entities are defined in 42 CFR 412.2; "An entity is wholly owned by the hospital if the hospital is the sole owner of the entity. And, an entity is wholly operated by a hospital if the hospital has exclusive responsibilit y for conducting and overseeing the entitys routine operations, regardless of whether the hospital also has policymaking authority over the entity."   90.7.1 - Payment Methodology: 3 -Day Payment Window in Wholly Owned or Wholly Operated Entities (including Physician Practices and Clinics)  (Rev. 2373, Issued: 12- 21-11, Effective: 01 -01-12, Implementation: 01- 03-12)  CMS has established HCPCS payment modifier PD (Diagnostic or related nondiagnostic item or service provided in a wholly owned or operated physician office to a patient who is admitted as an inpatient within 3 days), and requires that the modifier be appended to the physician preadmission diagnostic and admission- related nondiagnostic services, reported with HCPCS/CPT codes, which are subject to the 3- day payment window polic y. The wholly owned or wholly operated physicians office will need to manage their billing processes to ensure that they bill for their physician services appropriately when a related inpatient admission has occurred.  The hospital is responsible for noti fying the practice of an inpatient admissions for a patient who received services in a wholly owned or wholly operated physician office within the 3- day (or, when appropriate,1- day) payment window prior to the inpatient stay.  The modifier is effective for  claims with dates of service on or after January  1, 2012. Wholly owned or wholly operated per their readiness to do so. Entities have the discretion to apply these policies for claims with dates of service on and after January 1, 2012, but shall comply wi th these polices no later than July 1. 2012.  When the modifier is present on claims for service CMS shall pay   only the Professional Component (PC) for CPT/HCPCS codes with a Technical Component (TC)/PC split that are provided in the 3- day (or, in the case of non -IPPS hospitals, 1- day) payment window, and    The facility rate for codes without a TC/PC split.   Global Surgical Services and the 3 -day Payment Window Policy