(Medicare Claims Processing Manual)

3. The x -ray film(s) must have been taken at a time reasonably proximate to the initiation of the course of treatment and must demonstrate a subluxation at the level of the spine specified by the treating chiropractor on the claim.  (See Pub. 100-02, Benef its Policy Manual, Chapter 15, Section 240.1.2.)   4. An x -ray obtained by the chiropractor for his own diagnostic purposes before commencing treatment should suffice for claims documentation purposes. However, when subluxation was for treatment purposes diagnosed by some other means and x -rays are taken t o satisfy Medicare's documentation requirement, carriers should ask chiropractors to hone in on the site of the subluxation in producing x- rays.  Such a practice would not only minimize the exposure of the patient but also should result in a film more clea rly portraying the subluxation.  5. An x -ray will be considered of acceptable technical quality if any individual trained in the reading of x- rays could recognize a subluxation if present.   6. When claims have been denied because the x -ray(s) initially offered failed to document the existence of a subluxation requiring treatment, no review of these decisions should be undertaken on the basis of x -ray(s) subsequently taken.  Permitting such re views could be an inducement to excessive exposure of patients to radiation in cases where the decision to treat was made despite x -rays that did not show a subluxation.  230 - Primary Care Incentive Payment Program (PCIP)  (Rev. 2152, Issued: 02- 11-11, Effective: 07 -01-11, Implementation: 07- 05-11)  Section 5501(a) of the Affordable Care Act revises section 1833 of the Social Security Act (the Act) by adding a new paragraph, (x), Incentive Payments for Primary Care Services.  Section 1833(x) of the Act states that in the case of primary care services furnished on or after January 1, 2011, and before January 1, 2016, there shall be a 10 percent incentive payment for such services under Part B when furnished by a primary care practitioner.   Information regarding Primary Care Incentive Payment Program (PCIP) payments made to critical access hospitals (CAHs) paid under the optional method can be found in Pub. 100-04, Chapter 4, 250.12 of this manual.  230.1 - Definition of Primary Care Practitioners and Primary Care Services  (Rev. 2152, Issued: 02- 11-11, Effective: 07 -01-11, Implementation: 07- 05-11)  Primary care practitioner is defined as:   1. A physician who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine for whom primary care services accounted for at least 60 percent of the allowed charges under the PFS (excluding hospital i npatient care and emergency department visits) for the practitioner in a prior period as determined appropriate by the Secretary; or   2. A nurse practitioner, clinical nurse specialist, or physician assistant for whom primary care services accounted for at least 60 percent of the allowed charges under the PFS (excluding hospital inpatient care and emergency department visits) for the practitioner in a prior period as determined appropriate by the Secretary.   Primary care services are defined as HCPCS Codes:   1. 99201 through 99215 for new and established patient office or outpatient evaluation and management (E/M) visits;   2. 99304 through 99340 for initial, subsequent, discharge, and other nursing facility E/M services; new and established patient domiciliary, rest home or custodial care E/M services; and domiciliary, rest home or home care plan oversight services; and  3. 99341 through 99350 for new and established patient home E/M visits.   Practitioner Identification   Primary care practitioners will be identified using the National Provider Identifier (NPI) number of the rendering practitioner on claims.  If the claim is submitted by a practitioners group practice, the rendering practitioners NPI must be included on t he line-item for the primary care service and reflect an eligible HCPCS as identified.  In order to be eligible for the PCIP, physician assistants, clinical nurse specialists, and nurse practitioners must be billing for their services under their own NPI a nd not furnishing services incident to physicians services.  Regardless of the specialty area in which they may be practicing, the specific nonphysician practitioners are eligible for the PCIP based on their profession and historical percentage of allowed charges as primary care services that equals or exceeds the 60 percent threshold.   The claims data  used for the primary care percentage calculations depend on the potential primary care practitioners date of enrollment in Medicare.  We will use Medicare claims data 2 years prior to the PCIP payment year to determine PCIP eligibility fo r those potential primary care practitioners who were enrolled in Medicare in that year.  For example, for CY 2011, we will use Medicare claims data from CY 2009 for practitioners who were already enrolled in Medicare in CY 2009. We will use claims data fr om the year immediately preceding the PCIP payment year in order to determine PCIP eligibility for potential primary care practitioners who newly enroll in Medicare in the year immediately preceding the PCIP payment year.  For example, for CY 2011, we will use the available Medicare claims data from CY 2010 only for potential primary care practitioners who newly enrolled in Medicare in CY 2010.  Eligible practitioners for PCIP payments in a given calendar year who were enrolled in Medicare 2 years earlier will be listed by eligible NPI in the Primary Care Incentive Payment Program Eligibility File, available after January 31 of the PCIP payment ye ar on their A/B MAC (B)s website.  Eligible practitioners for PCIP payments in a given calendar year who were newly enrolled in Medicare in the year immediate preceding the PCIP payment year will be identified in the PCIP Payment  for New Providers Enroll ed in Medicare File, available after October 1 of the PCIP payment year.  Practitioners should contact their A/B MAC (B) with any questions regarding their eligibility for the PCIP.   230.2 - Coordination with Other Payments (Rev. 2152, Issued: 02- 11-11, Effective: 07 -01-11, Implementation: 07- 05-11)  Section 5501(a)(3) of the Affordable Care Act 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 Act.  Therefore, an eligible primary care physic ian furnishing a primary care 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 12, 90.4) under the HPSA physician bonus progr am and a PCIP incentive payment under the new program beginning in CY 2011.  230.3 - Claims Processing and Payment  (Rev. 2152, Issued: 02- 11-11, Effective: 07 -01-11, Implementation: 07- 05-11)  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) for those services furnished during the incentive payment year. PCIP payments for new ly enrolled practitioners will be delayed due to the lag in their eligibility determination.  Newly enrolled primary care practitioners will receive a single cumulative PCIP payment, retroactive for primary care services furnished from the beginning of the  PCIP payment year, following the fourth quarter of the PCIP payment year after the primary care practitioner is deemed eligible.  Quarterly payments will be made for subsequent incentive payments.   For information on PCIP payments to CAHs paid under the optional method, see the Medicare Claims Processing Manual, Pub. 100- 04, Chapter 4, 250.12.   On an annual basis A/B MACs (B) shall receive a Primary Care Incentive Payment Program Eligibility File and PCIP Payment for New Providers Enrolled in Medicare File that they shall post to their websites.  The files will list the NPIs of all practitioners who are eligible to receive PCIP payments for the PCIP payment year.   B. Method of Payment    Calculate and pay qualifying primary care practitioners an additional 10 percent incentive payment.    Calculate the payment based on the amount actually paid for the services, not the Medicare approved amount.    Combine the PCIP incentive payments, when appropriate, with other incentive payments, including the HPSA physician bonus payment, and the HPSA Surgical Incentive Payment Program (HSIP) payment;    Provide a special remittance form that is forwarded with the incentive payment so that physicians and practitioners can identify which type of incentive payment (HPSA physician and/or PCIP) was paid for which services.    Practitioners should contact their A/B MAC (B) with any questions regarding PCIP payments.   C. Changes for Contractor Systems   The Medicare Carrier System, (MCS), Common Working File (CWF) and the 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; and  Space = Not Applicable.   The MCS shall send the HIGLAS 810 invoice for incentive payment invoices, including the new PCIP payment.  The A/B MAC (B) shall also combine the providers HPSA physician bonus, physician scarcity (PSA) bonus (if it should become available at a later date), HSIP payment and/or PCIP payment invoice per provider.  The A/B MAC (B) shall receive the HIGLAS 835 payment file from HIGLAS showing a single incentive payment per provider.  Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R12423CP  12/20/2023  Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92  01/02/2024  13222  R12370CP  11/21/2023  Implement Edits to Prevent Payment of Complexity Add- On Code G2211 When Associated Office/Outpatient Evaluation and Management Visit (Codes 99202-99205, 99211- 99215) is Reported With Modifier 25 NO LONGER SENSITIVE  01/02/2024  13272   07/28/2023  Implement Edits to Prevent Payment of Complexity Add- On Code G2211 When Associated Office/Outpatient Evaluation and Management Visit (Codes 99202-99205, 99211- 99215) is Reported with Modifier 25 SENSITIVE CONTROVERSIAL  Rescinded and replaced by Transmittal  12370 01/02/2024  13272  R11842CP  02/09/2023  Internet -Only Manual (IOM) Updates to Pub. 100- 04, Chapter 12 for the New Hospital Inpatient or Observation Care Code Family, Nursing Facility Visits Code Family, Billing the Substantive Portion of a Split (or Shared) Visit, Changes for Prolonged Services, and Updates to the IOM with Policies Finalized for Office/Outpatient E/M Visits in the CY2020 and CY2021 Final Rules  05/09/2023  13064  R11828CP  02/02/2023  Correction of Split (or Shared) Critical Care Billing Requirement in Section 30.6.12.5. of Chapter 12 of the Medicare Claims Processing Manual  03/03/2023  13065  R11732CP  12/08/2022  Billing Instructions for Home or Residence Services  01/03/2023  13004  R11288CP  03/04/2022  Internet -Only Manual Updates (IOM) for Critical Care, Split/Shared Evaluation and 02/15/2022  12543  Rev #  Issue Date  Subject  Impl Date  CR#  Management Services, Teaching Physicians, and Physician Assistants