(Medicare Claims Processing Manual)

 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.   Contractors shall only identify eligible services with a 10 -  or 90 -  day global period rendered in eligible zip code areas based on the HPSA physician bonus program ZIP code file for the appropriate date of service.   Providers may report modifier AQ when submitting claims for major surgical procedures that were furnished in approved HPSAs, where those HPSAs are not recognized for automatic payment.  The modifier must be appended to the major surgical procedure HCPCS co de in order for the CAH paid under the optional method to be paid the 10 percent additional incentive payment for the surgical procedure on behalf of the general surgeon.   B. Method of Payment:    Calculate and pay CAHs paid under the optional method on behalf of  02-  general surgeons furnishing  10 -  and 90 -  day global surgical procedures in a recognized HPSA an additional 10 percent incentive payment based on 115 percent of the amount that would be paid for the surgeons professional services under the PFS;    Calculate the payment based on the amount actually paid for the service, not the Medicare approved amount;    Combine the additional payment with the HPSA physician bonus payment;    Accept and pay services submitted with modifier AQ and;    Revise the special incentive remittance for CAHs that is forwarded with the incentive check so that physicians can identify which type of incentive payment (HPSA physician, HSIP, or PCIP) was paid for which service.   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 HSIP and 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 contractor shared system shall send the HIGLAS 810 invoice for incentive payment invoices, including the new HSIP payment.  The contractor shall also combine the practitioners HPSA physician bonus, Physician Scarcity (PSA) bonus (if it should become available at a later date), and HSIP payment invoice per practitioner.  The contractor shall receive the HIGLAS 835 payment file from HIGLAS showing a single incentive payment per practitioner.   250.14 - Payment of Licensed Clinical Social Workers (LCSWs),  Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs) in a Method II CAH  (Rev. 12477; Issued:01- 25-24; Effective: 01 -01-24; Implementation:02- 26-24)    The services of a LCSW, MFT or MHC that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedure is billed on type of bill 85X with revenue code (RC) 96X, 97X, and/or 98X.  In addition, the LCSW services requires an AJ modifier and the MFT or MHC must be enrolled as a MFT or MHC specialty. Under Section 1834(g)(2)(B) of the Act, outpatient professional services performed in a Method II CAH are paid 115 percent of such amounts as would otherwise be paid under the Act if the services were not included in the outpatient CAH services.   The Medicare payment for services performed by a LCSW, MFT or MHC shall be 80 percent of the lesser of the actual charges for the services or 75 percent of the amount determined for the payment of a psychologist.  Payment is calculated as follows:   ((Facility specific MPFS amount times the LCSW, MFT or MHC reduction (75%)) minus (deductible and coinsurance)) times 115%.   250.15 - Coding and Payment of Multiple Surgeries Performed in a Method II CAH  (Rev. 2333, Issued: 10- 28-11, Effective: 04 -01-12, Implementation: 04- 02-12)  Multiple surgeries rendered by a physician that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedures are eligible and billed on type of bill 85x with revenue code (RC) 096x, 097x and/or 098x.   Multiple surgeries are separate procedures performed by a single physician or physicians in the same group practice on the same patient at the same operative session or on the same day for which separate payment may be allowed. Co -surgeons, surgical teams, or assistants- at-surgery may participate in performing multiple surgeries on the same patient on the same day.