(Medicare Claims Processing Manual)

90.4.11.2 - HPSA Identification  (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)   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 gene ral surgeons.  A/B MACs (B) 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 p rior 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.  90.4.11.3 - Coordination with Other Payments (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)   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 s urgeon may receive both a HPSA physician bonus payment under the established program, and an HSIP payment under the new program beginning in CY 2011.  90.4.11.4 - 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 physicians 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/Medicare/Medicare -Fee-for-Service -Payment/PhysicianFeeSched/PFS -Relative -Value- Files.html, with a global period designation of 10 -  or 90 -  days.   90.4.11.5 - Claims Processing and Payment  (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)   A. General Overview   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.  A/B MACs (B) 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.   A/B MACs (B) 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 A/B MAC (B) with any questions regarding HSIP payments.   C. Changes for A/B MAC (B)  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 MCS shall send the HIGLAS 810 invoice for incentive payment invoices, including the new HSIP payment.  The A/B MAC (B) shall also combine the practitioners 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 A/B MAC (B) shall receive the HIGLAS 835 payment file from HIGLAS showing a single incentive payment per practitioner.   90.5 - Billing and Payment in a Physician Scarcity Area (PSA)  (Rev. 1434; Issued:  02- 05-08; Effective:  01 -01-08; Implementation:  01 -07-08)  Section 413a of the MMA requires that a 5 percent bonus payment be established for physicians in designated physician scarcity areas for dates of service January 1, 2005, through December 31, 2007.  T he Medicare, Medicaid, and State Childrens Health Insurance Program (SCHIP) Extension Act of 2007 amended 1833(u)(1) of the Social Security Act and has extended payment of that bonus through June 30, 2008.  Physician scarcity designations will be based on the lowest primary care and specialty care ratios of Medicare beneficiaries to active physicians in every county.  In addition, based on rural census tracts of metropolitan statistical areas identified through the latest modification of the Goldsmith Modification (i.e., Rural -Urban Commuting Area Codes), addi tional physician scarcity areas will be identified based on the lowest primary care and specialty care ratios of Medicare beneficiaries to active physicians in each identified rural census area.   90.5.1 - Provider Education  (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))  Upon publication of the final rule of the 2005 Medicare Physician Fee Schedule, CMS will post on its Web site zip codes that are eligible for automatic payment of the physician scarcity bonus payment.  90.5.2 - Identifying Physician Scarcity Area Locations  (Rev. 1434; Issued:  02- 05-08; Effective:  01 -01-08; Implementation:  01 -07-08)  The CMS shall provide to the standard systems and A/B MACs (B)  file of zip codes for the automated payment of the primary care and specialty physician scarcity bonus.  The file will be effective for claims with dates of service on or after January 1, 2005, through December 31, 2007.  A/B MACs (B)  and shared systems will be notified by e -mail of the name of the file and when it will be available for downloading.  The Medicare, Medicaid, and State Childrens Health Insurance Program (SCHIP) Extension Act of 2007 amended 1833(u)(1) of the Social Security Act and has extended payment of the Physician Scarcity Area bonus through June 30, 2008, using the same file used for prior years.   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: