(Medicare Claims Processing Manual)

Eligibility for receiving the 10 percent bonus payment is based on whether the specific location at which the service is furnished is within an area that is designated (under section 332(a)(1)(A) of the Public Health Services Act) as a HPSA. The Health Res ources and Services Administration (HRSA), within the Department of Health & Human Services, is responsible for designating shortage areas.   HRSA designates three types of HPSAs:  geographic, population, and facility- based.  Geographic -based HPSAs are areas with shortages of primary care physicians, dentists or psychiatrists.  Population -based HPSAs are designations based on underserved populat ions within an area.  Facility -based HPSAs are designations based on a public or non- profit private facility that is providing services to an underserved area or population and has an insufficient capacity to meet their needs.   Section 1833(m) of the Social Security Act (the Act) provides incentive payments for physicians who furnish services in areas designated as HPSAs under section 332 (a)(1)(A) of the Public Health Service (PHS) Act.  This section of the PHS Act pertains to g eographic -based HPSAs.  Consequently, Medicare incentive payments are available only in geographic HPSAs.   Although section 1833(m) of the Act provides the authority to recognize the three types of geographic -based HPSAs (primary medical care, dental and mental health), only physicians, including psychiatrists, furnishing services in a primary medical care HPSA  are eligible to receive bonus payments.  In addition, effective for claims with dates of service on or after July 1, 2004, psychiatrists furnishing services in mental health HPSAs are eligible to receive bonus payments. CMS does not recognize dental HPSAs  for the bonus payment program.   It is not enough for the physician merely to have his/her office or primary service location in a HPSA, nor must the beneficiary reside in a HPSA, although frequently this will be the case.  The key to eligibility is where the service is actually provided (place of service).  For example, a physician providing a service in his/her office, the patients home, or in a hospital qualifies for the incentive payment as long as the specific location of the service is within an area designated as a HPSA.  On the ot her hand, a physician may have an office in a HPSA but go outside the office (and the designated HPSA area) to provide the service.  In this case, the physician would not be eligible for the incentive payment.  A/B MAC (B) responsibilities include:   Informing the physician community of these provisions;   Providing a link to the CMS Web site to access the HPSA automated ZIP code files;   Providing a direct link to HRSAs HPSA database   Modifying the claims processing system to recognize and appropriately handle eligible claims;  Paying physicians the incentive payments; and   Performing post -payment reviews of samples of paid claims submitted using the AQ modifier.   90.4.1 - Provider Education  (Rev. 1639, Issued: 11- 21-08, Effective: 01 -01-09, Implementation: 01- 05-09)  ZIP Code files for the automated payment of the HPSA bonus payment will be developed and updated annually. Effective for claims with dates of service on or after January 1, 2009, only services provided in areas that are designated as of December 31 of the prior year are eligible for the HPSA bonus payment.  Physicians providing services in areas that were designated as of December 31 of the prior year but not on the automated file may use the AQ modifier.  Only services provided in areas that were designated as of December 31 of the prior year but not on the automated file may use the modifier.  Services provided in areas that are designated throughout the year will not be eligible for the HPSA bonus payment until the following year, provided they are still designated on December 31. Services provided in areas that are de -designated throughout the year will continue to be eligible for the HPSA bonus through the end of the calendar year.   CMS will post on its Web site ZIP Codes that are eligible to automatically receive the bonus payment as well as information on how to determine when the modifier is needed to receive the bonus payment. Through regularly scheduled bulletins and list serves, A/B MACs (B) must notify all physicians to verify their ZIP Code eligibility via the CMS Web site or the HRSA Website for the area where they provide physician services.   90.4.1.1 - A/B MAC (B) Web Pages  (Rev. 1273; Issued:  06- 29-07; Effective/Implementation Dates:  10 -01-07)  A/B MAC (B)  Web pages shall direct the physician community to a direct link to the CMS Web site to access the automated HPSA bonus payment files, and a direct link to the HRSA/HPSA designations database.   90.4.2 - HPSA Designations  (Rev. 4431, Issued: 11- 01-19, Effective: 02 -04-20, Implementation: 02- 04-20)  HPSA designations are made by the Health Resources and Services Administrations (HRSA) Division of Shortage Designation (DSD). An automated file of areas eligible for the HPSA bonus payment will be updated on an annual basis and will be effective for services rendered with dates of service on or after January 1 of each calendar year. Physicians may only use the AQ modifier for services furnished in an area that was designated as of December 31 of the prior year. This information can be downloaded from the HRSA Web site.  A/B MACs (B) will be informed of the availability of the file and the file name via an email notice. A/B MACs (B) will automatically pay bonuses for services rendered in ZIP Code areas that fully fall within a designated primary care or mental health full county HPSA; are considered to fully fall in the county based on a determination of dominance made by the United States Postal Service (USPS); or are fully within a partial county HPSA area. Should a ZIP Code fall within both a primary care and mental heal th HPSA, only one bonus will be paid on the service. Bonuses for mental health HPSAs will be paid when performed by any of the psychiatry provider specialties.   For services rendered in ZIP Code areas that do not fall within a designated full county HPSA; are not considered to fall within the county based on a determination of dominance made by the USPS; or are partially within a partial county HPSA, physicians must submit a AQ modifier to receive payment.  To determine whether a modifier is needed, physicians must review the information provided on the CMS Web or the HRSA Web site for HPSA designations to determine if the location where they render services is, indeed, within a HPSA bonus area. Physicians ma y also base the determinations on letters of designations received from HRSA. They must be prepared to provide these letters as documentation upon the request of the A/B MAC (B) and should verify the eligibility of their area for a bonus with their A/B MAC  (B) before submitting services with a HPSA modifier.  For services rendered in ZIP Code areas that cannot automatically receive the bonus, it will be necessary to know the census tract of the area to determine if a bonus should be paid and a modifier submitted. Census tract data can be retrieved by visiting t he U.S. Census Bureau Web site at www.Census.gov or the Federal Financial Institutions Examination Council (FFIEC) Web site at www.ffiec.gov/geocode/default.htm .  Instructions on how to use these Web sites can be found on the CMS Web site at http://new.cms.hhs.gov/HPSAPSAPhysicianBonuses. Neither CMS nor the Medicare A/B MACs (B) can provide information on the functionality of these Web sites.   90.4.3 - Claims Coding Requirements (Rev. 608, Issued:  07- 22-05; Effective:  01 -01-06; Implementation: 01 -03-06) For services with dates of service prior to January 1, 2005, physicians must indicate that their services were provided in an incentive -eligible rural or urban HPSA by using one of the following modifiers:  QB - physician providing a service in a rural HPSA; or  QU -  physician providing a service in an urban HPSA.  Effective for claims with dates of service on or after January 1, 2006, the QB and QU modifiers will no longer be accepted.  Claims with prior dates of service must still be submitted with those modifiers.  The AQ modifier, Physician providing a service in a Health Professiona l Shortage Area (HPSA), will replace the QB and QU modifiers and will be effective for claims with dates of service on or after January 1, 2006.  For services with dates of service on or after January 1, 2005, the bonus will automatically be paid without the submission of a modifier for the following:   When services are provided in a zip code area that fully falls within a full county HPSA;   When services are provided in a zip code area that partially falls within a full county HPSA and has been determined to be dominant for the county by the USPS; and  When services are provided within a zip code that fully falls within a partial county HPSA.  The submission of the QB or QU modifier, or the AQ modifier for claims with dates of service on or after January 1, 2006, will be required for the following:   When services are provided in zip code areas that do not fully fall within a designated full county HPSA bonus area;   When services are provided in a zip code area that partially falls within a full county HPSA but is not considered to be in that county based on the dominance decision made by the USPS;   When services are provided in a zip code area that partially falls within a partial county HPSA; and.  When services are provided in a zip code area that was not included in the automated file based on the date of the data run used to create the file.  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.   90.4.4 - 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)   The incentive payment is 10 percent of the amount actually paid, not  the approved amount.  A/B MACs (B) pay the incentive payment for services identified on either assigned or unassigned claims.  They do not include the incentive payment with each claim payment.  A/B MACs (B) should:    Establish a quarterly schedule for issuing incentive payments.  These payments are taxable and must be reported to the IRS; and   Prepare a special incentive remittance to accompany each payment.  Include a line- item for each assigned claim represented in the incentive check and a summary item showing the number of unassigned claims represented.  Claims should be identified as HPSA  physician, Scarcity, HSIP and/or PCIP in the summary.  The sum of the line -items and the summary item should equal the amount of the check.   90.4.5 - Services Eligible for HPSA and Physician Scarcity Bonus Payments (Rev. 4431, Issued: 11- 01-19, Effective: 02 -04-20, Implementation: 02- 04-20)  A. Information in the Professional Component/Technical Component (PC/TC) Indicator Field of the Medicare Physician Fee Schedule Database  A/B MACs (B) use the information in the Professional Component/Technical Component (PC/TC) indicator field of the Medicare Physician Fee Schedule Database to identify professional services eligible for HPSA and physician scarcity bonus payments. The follow ing are the rules to apply in determining whether to pay the bonus on services furnished within a geographic HPSA or, physician scarcity bonus area. Should A/B MACs (B) receive notification from physicians that they have chosen to forego the bonus payments , the A/B MACs (B) shall make no bonus payments to that physician for any service.  PC/TC Indicator  Bonus Payment Policy  0 Pay bonus  1 Globally billed. Only the professional component of this service qualifies for the bonus payment. The bonus cannot be paid on the technical component of globally billed services.     PC/TC Indicator  Bonus Payment Policy