(Medicare Claims Processing Manual)

CAHs paid under the optional method billing on TOB 85X for professional primary care services (revenue code 96X, 97X or 98X) furnished by primary care physicians and nonphysician practitioners who have reassigned their billing rights to the CAH are eligible for PCIP payments.   The National Provider Identifier (NPIs) of  primary care practitioners eligible for PCIP payment in a given calendar year (CY) are posted on Medicare contractor Web sites in the Primary Care Incentive Payment Program Eligibility File by January 31 of  the applicable incentive payment CY.   Eligible practitioners for PCIP payment in a given calendar year who were newly enrolled in Medicare in the year immediately preceding the PCIP payment year will be identified later in the payment year and posted on their  Medicare contractors Web site at that point in time.  CAHs paid under the optional method should contact their contractor with any questions regarding the eligibility of physician and nonphysician practitioners for PCIP payments.  Primary care practitioners furnishing primary care services will be identified on CAH claims by the NPI of the rendering practitioner as follows:    Line level Rendering Provider field when populated or,    Claim level Rendering Provider field where a line level Rendering Provider field is blank or,   Claim level Attending Provider field if the claim level Rendering Provider field is blank.  In order for a primary care service to be eligible for PCIP payment, the CAH paid under the optional method must be billing for the professional services of physicians under their NPIs or of physician assistants, clinical nurse specialists, or nurse practi tioners  under their own NPIs because they are not furnishing services incident to physicians services.   Multiple primary care services rendered by different physicians may be present on a single claim.  Providers shall ensure they identify each physician on the claim form per the ASC X12 837 Institutional Claim Implementation Guide.  250.12.3 - Coordination with Other Payments (Rev. 2169, Issued: 03- 03-11, Effective: 04 -01-11, Implementation: 04- 04-11)  Section 5501(a)(3) of the ACA authorizes payment under the PCIP as an additional payment amount for specified primary care services without regard to any additional payment for the service under Section 1833(m) of the Social Security Act, the established Health Professional Shortage Area (HPSA) Medicare physician bonus program.  Therefore, a CAH paid under the optional method and billing for the professional services of an eligible primary care physician or nonphysician practitioner furnishing a primary car e service in a health professional shortage area (HPSA) may receive both a HPSA physician bonus payment (as described in the Medicare Claims Processing Manual, Pub. 100- 04, Chapter 4, Section 250.2) under the HPSA physician bonus program and a PCIP incenti ve payment under the new program beginning in CY 2011.  250.12.4 - Claims Processing and Payment for Critical Access Hospitals Paid Under the Optional Method  (Rev. 2169, Issued: 03- 03-11, Effective: 04 -01-11, Implementation: 04- 04-11)  A. General Overview   Incentive payments will be made on a quarterly basis and shall be equal to 10 percent of the amount paid for such services under the Medicare Physician Fee Schedule (PFS) times 1.15 percent for those services furnished during the incentive payment year.  P CIP payments for newly enrolled practitioners may be delayed due to the lag in claims data processing.  PCIP payments for services by a newly enrolled primary care practitioner will be paid in the quarter following eligibility determination, and then quart erly for all subsequent incentive payments. Retroactive payments will be provided from the beginning of the PCIP year once these primary care practitioners are deemed eligible.  On an annual basis Medicare contractors shall receive a Primary Care Incentive Payment Program Eligibility File that they shall post to their websites.  The file will list the NPIs of all physicians and nonphysician practitioners who are eligible to receive PCIP payments for the upcoming CY.  The NPIs of eligible newly enrolled primary care practitioners will be posted to the contractors websites later in the payment year.   On an annual basis Medicare contractors shall receive a Physician/Practitioner Specialty File. This file it to be used by contractors to answer provider inquiries regarding eligibility for the PCIP.   The PCIP payments will be calculated by Medicare contractors and made quarterly to CAHs  paid under the optional method on behalf of the  eligible primary care physician or nonphysician practitioner for the  primary care services furnished by the practitioner in that quarter.  The PCIP payments will be based on 10 percent of 115 percent of the PFS amount that the CAH was paid for the professional service.   B. Method of Payment  Calculate and pay a CAH paid under the optional method based on primary care services furnished by qualifying primary care physicians and nonphysician practitioners an additional 10 percent incentive payment;    Calculate the payment based on 115 percent of the PFS amounts that were paid to the CAH for the services; not the Medicare approved amounts;    Combine the PCIP incentive payments, when appropriate, with other incentive payments, including the physician HPSA bonus payment and the HPSA Surgical Incentive Payment Program (HSIP) payment;    Provide a special remittance for CAHs form that is forwarded with the incentive payment so that CAHs paid under the optional method can identify which type of incentive payment was paid for which services.    CAHs paid under the optional method should contact their contractor with any questions regarding PCIP payments.  C.  Changes for Contractor Systems   The Fiscal Intermediary Standard System (FISS), Common Working File (CWF) and National Claims History (NCH) shall be modified to accept a new PCIP indicator on the claim line. Once the type of incentive payment has been identified by the shared systems, the shared system shall 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  Space = Not Applicable   The FISS shall send the HIGLAS 810 invoice for incentive payment invoices, including the new PCIP payment.  The contractor shall also combine the CAHs HPSA bonus, physician scarcity (PSA) bonus (if it should become available at a later date), HSIP payment  and/or PCIP payment invoice per CAH.  The contractor shall receive the HIGLAS 835 payment file from HIGLAS showing a single incentive payment per CAH.   250.13  - Health Professional Shortage Areas (HPSA) Surgical Incentive Payment Program (HSIP) for Surgical Services Rendered in Critical Access Hospitals (CAHs) Paid under the Optional Method  (Rev. 2078, Issued: 10- 28-10, Effective: 04 -01-11, Implementation: 04- 04-11)  There are two methods of payment for outpatient services furnished by Critical Access Hospitals (CAHs).  The amount of payment for outpatient services furnished by a CAH under the traditional method is equal to 101 percent of the reasonable cost of the fac ility service and payment to the physician/practitioner under the Physician Fee Schedule(PFS) for the professional service or a CAH may elect to receive amounts that are equal to 101 percent of the reasonable cost of the facility service plus, with respect  to the professional service, 115 percent of the amount otherwise paid for the professional service under the PFS.  This election is sometimes referred to as "method II" or "the optional method."  Section 5501(b) (2) of the ACA is a conforming amendment, which refers to payments to the CAH for professional services under the optional method.  As such, section 5501(b)(2) requires that, under the optional method, the 115 percent adjusted payment to the CAH for professional services does apply to the incentive payment for major surgical services furnished by general surgeons in HPSAs.   For major surgical services furnished by general surgeons on or after January 1, 2011 and before January 1, 2016, the additional incentive amount specified is to be included in the determination of payment for professional services made to CAHs  paid under  the optional method, but will be provided as a separate incentive payment to the CAH, on behalf of the qualified general surgeon, when they furnish a 10 -  or 90 - day global surgical procedure in an identified HPSA.  Therefore, the 10 percent incentive pa yment will be made based on 115 percent of the amount that would be paid for the surgeons professional services under the PFS.   250.13.1 Overview of the HSIP (Rev. 2078, Issued: 10- 28-10, Effective: 04 -01-11, Implementation: 04- 04-11)  The incentive payment applies to major surgical procedures, defined as 10 - and 90 -  day global procedures under the PFS and furnished on or after January 1, 2011 and before January 1, 2016, furnished 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 program (Publication 100- 04, Chapter 12, Section 90.4), HSIP payments will be calculated by Medicare contractors on a quarterly basis, on behalf of the qualifying 02- general surgeon for the qualifying surgi cal procedures.   250.13.2 - HPSA Identification  (Rev. 2078, Issued: 10- 28-10, Effective: 04 -01-11, Implementation: 04- 04-11)  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 HPSA physician bonus is published.  This list is also utilized for automatic payments of the incentive for eligible services furnished by general surgeons.  Modifier AQ is used to identif y circumstances when general surgeons furnish services 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 surgica l procedure on claims submitted for payment for professional services furnished in a HPSA that is not recognized as such for the purpose of automatic payment.  250.13.3 - Coordination with Other Payments (Rev. 2078, Issued: 10- 28-10, Effective: 04 -01-11, Implementation: 04- 04-11)  Section 5501(b)(4) of the ACA 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.  250.13.4 - General Surgeon and Surgical Procedure Identification for Professional Services Paid under the Physician Fee Schedule (PFS)  (Rev. 2078, Issued: 10- 28-10, Effective: 04 -01-11, Implementation: 04- 04-11)  Qualifying general surgeons will be identified on a claim for a 10 -  or 90 -  day global surgical procedure based on the NPI listed in the operating provider field on the claim and the associated primary enrolled specialty of the operating physician of 02 -  general surgery.   Major surgical procedures are those procedures for which a 10 -  or 90 -  day global period is used for payment under the PFS.  The specific procedure codes eligible for the HSIP are identified in column U (global period) of the Physician Fee Schedule Relati ve Value Update (RVU) file located at:  http://www.cms.gov/Medicare/Medicare -Fee-for-Service -Payment/PhysicianFeeSched/PFS -Relative -Value- Files.html, with a global period designation of 10 -  or 90 day.  250.13.5 - Claims Processing and Payment  (Rev. 2078, Issued: 10- 28-10, Effective: 04 -01-11, Implementation: 04- 04-11)  A. General Overview   The HPSA physician bonus program guidelines are contained in Publication 100- 04, Chapter 12, and Section 90.4.  Refer to that manual for payment and claims processing guidance for the HPSA physician bonus program that was established in 2005.  The following guidelines pertain only to qualifying 02-  general surgeons  who have reassigned their billing rights to CAHs paid under the optional method, and who are eligible to receive the additional 10 percent HSIP payment for major surgical procedures furnished  in HPSAs from January 1, 2011 through December 31, 2015.