(Medicare Claims Processing Manual)

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:   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)