(Medicare Claims Processing Manual)

The Medicare Prescription Drugs, Improvement, and Modernization Act (MMA) of 2003, changed the requirement that each practitioner rendering a service at a CAH that has elected the optional method, reassign their billing rights to that CAH.  This provision allows each practitioner to choose whether to reassign billing rights to the CAH or file claims for professional services through their A/B MAC (B).  The reassignment will remain in effect for that entire cost reporting period.  The individual practitioner must certify, using the Form CMS -855R, if he/she wishes to reassign their billing rights.  The CAH must then forward a copy of Form CMS -855R to the A/B MAC (A), and the A/B MACs (B) must have the practitioner sign an attestation  that clearly states that the practitioner will not bill the A/B MAC (A) or A/B MAC (B) for any services rendered at the CAH once the reassignment has been given to the CAH.  This attestation will remain at the CAH.   For CAHs that elected the optional method before November 1, 2003, the provision is effective beginning on or after July 1, 2001.  For CAHs electing the optional method on or after November 1, 2003, the provision is effective for cost reporting periods beginning on or after July 1, 2004.  Under this election, a CAH will receive payment from their A/B MAC (A) for professional services furnished in that CAHs outpatient department. Professional services are those furnished by all licensed professionals who ot herwise would be entitled to bill the A/B MAC (B) under Part B.  Payment to the CAH for each outpatient visit (reassigned billing) will be the sum of the following:    For facility services, not including physician or other practitioner services, payment will be based on 101 percent of the reasonable costs of the services.  List the facility service(s) rendered to outpatients using the appropriate revenue code.  The A/B MAC will pay 101 percent of the reasonable costs for the outpatient services less applicable Part B deductible and coinsurance amounts, plus:    Show the professional services separately, along with the appropriate HCPCS code (physician or other practitioner) in one of the following revenue codes - 096X, 097X, or 098X.   The A/B MAC (A) uses the Medicare Physician Fee Schedule (MPFS) amounts to pay for all the physician/nonphysician practitioner services rendered in a CAH that elected the optional method.  Payment is based on the lesser of the actual charge or the facility -specific MPFS amount less deductible and coinsurance times 1.15; and    AK -  Service rendered in a CAH by a non -participating physician   For a non -participating physician service, a CAH must place modifier AK on the claim.  Payment is based on the lesser of the actual charge or a reduced fee schedule amount of 95 percent. Payment is calculated as follows:    [(facility -specific MPFS amount times the non -participating physician reduction (0.95) minus (deductible and coinsurance] times 1.15.   GF -  Services rendered by a nurse practitioner (NP), clinical nurse specialist (CNS), or physician assistant (PA)   GF - Services rendered in a CAH by a nurse practitioner (NP), clinical nurse specialist (CNS), certified registered nurse (CRN) or physician assistant (PA).  (The GF modifier is not to be used for CRNA services.  If a claim is received and it has the GF  modifier for certified registered nurse anesthetist (CRNA) services, the claim is returned to the provider.)  Also, while this national GF modifier includes CRNs, there is no benefit under Medicare law that authorizes payment to CRNs for their services .  Accordingly, if a claim is received and it has the GF modifier for CRN services, no Medicare payment should be made.   Services billed with the GF modifier are paid based on the lesser of the actual charge or a reduced fee schedule amount of 85 percent.  Payment is calculated as follows:    [(facility -specific MPFS amount times the nonphysician practitioner services reduction (0.85) minus (deductible and coinsurance)] times 1.15.   SB - Services rendered in a CAH by a certified nurse- midwife  For dates of service prior to January 1, 2011, certified nurse -midwife services billed with the SB modifier are paid based on the lesser of the actual charge or a reduced fee schedule amount of 65 percent.  Payment is calculated as follows:   For dates of service on or after January 1, 2011, Medicare covers the services of a certified nurse- midwife.  The SB modifier is used to bill for the services and payment is based on the lesser of the actual charge or 100 percent of the MPFS.  MPFS Payme nt is calculated as follows :   [(facility -specific MPFS amount) minus (deductible and coinsurance)] times 1.15.  AH -  Services rendered in a CAH by a clinical psychologist  Payment for the services of a clinical psychologist is based on the lesser of the actual charge or 100 percent of the MPFS.   Payment is calculated as follows:    [(facility -specific MPFS amount) minus (deductible and coinsurance)] times 1.15.   AE -  Services rendered in a CAH by a nutrition professional/registered dietitian.  Services billed with the AE modifier are paid based on the lesser of the actual charge or a reduced fee schedule amount of 85 percent. Payment is calculated as follows:    [(facility -specific MPFS amount times the registered dietitian reduction (0.85) minus (deductible and coinsurance)] times 1.15. Outpatient services, including ASC type services, rendered in an all -inclusive rate provider should be billed using the 85X type of bill (TOB).  Non- patient laboratory specimens are billed on TOB 14X.  MPFS rates contained in the HHH abstract file are used for payment of all physician/professional services rendered in a CAH that has elected the optional method.  If a HCPCS code has a facility rate and a non -facility rate, the facility rate is paid.  See Chapter 23 of Pub. 100- 04, section 50.1 for the record layout for the HHH abstract file.   Physician Fee Schedule Payment Policy Indicator File  The information on the Physician Fee Schedule Payment Policy Indicator file is used to identify endoscopic base codes, payment policy indicators, global surgery indicators, diagnostic imaging family indicators, or the preoperative, intraoperative and postoperative percentages that are needed to determine if payment adjustment rules apply to a specific CPT code and the associated pricing modifier(s). See Chapter 12 of Pub. 100-04 for more information on payment policy indicators and payment adjustment rules.  See Chapter 23 of Pub. 100- 04, section 50.6 for the record layout of the Payment Policy Indicator file.   Health Professional Shortage Area (HPSA) Incentive Payments for Physicians   Section 1833 (m) of the Social Security 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 statute recognizes geographic -based, primary medical care and mental health HPSAs, are areas for receiving a 10 percent bonus payment.  The Health Resources and Services Administration (HRSA), within the Department of Health & Human Services, is responsible for designating shortage areas.   Physicians, including psychiatrists, who provide covered professional services in a primary medical care HPSA, are entitled to an incentive payment.  In addition, psychiatrists furnishing services in mental health HPSAs are eligible to receive bonus paymen ts.  The bonus is payable for psychiatric services furnished in either a primary care HPSA, or a mental health HPSA.  Dental HPSAs remain ineligible for the bonus payment.  Physicians providing services in either rural or urban HPSAs are eligible for a 10 percent incentive payment.  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 provision is within an area designed as a HPSA.  On the other 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.   If the CAH electing the Optional Method (Method II) is located within a primary medical care HPSA, and/or mental health HPSA, the physicians providing (outpatient) professional services in the CAH are eligible for HPSA physician incentive payments. Therefo re, payments to such a CAH for professional services of physicians in the outpatient department will be 115 percent times  the amount payable under fee schedule times  110 percent.  An approved Optional Method CAH that is located in a HPSA County should noti fy you of its HPSA designation in writing .  Once you receive the information, place an indicator on the provider file showing the effective date of the CAHs HPSA status. The CMS will furnish quarterly lists of mental health HPSAs to A/B MACs (A).   The HPSA incentive payment is 10 percent of the amount actually paid, not the approved amount.  Do not include the incentive payment in each claim.  Create a utility file so that you can run your paid claims file for a quarterly log.  From this log you wil l send a quarterly report to the CAHs for each physician payment, one month following the end of each quarter.  The sum of the 10% of line Reimbursement column should equal the payment sent along with the report to the CAH.  If any of the claims included on the report are adjusted, be sure the adjustment also goes to the report.  If an adjustment request is received after the end of the quarter, any related adjustment by the A/B MACs (A) will be included on next quarters report.  The CAHs must be sure to keep adequate records to permit distribution of the HPSA bonus payment when received.  If an area is designated as both a mental health HPSA and a primary medical care HPSA, only  one 10 percent bonus payment shall be made for a single service.   250.2.1 - Billing and Payment in a Physician Scarcity Area (PSA)  (Rev. 3019, Issued: 08- 07-14, Effective: 01 -01-12, ICD -10: Upon Implementation of ICD-  10, Implementation: 09- 08-14, ICD -10: Upon Implementation of ICD - 10)  Section 413a of the MMA 2003 requires that a new 5 percent bonus payment be established for physicians in designated physician scarcity areas.  The payment should be made on a quarterly basis and placed on the quarterly report that is now being produced for the HPSA bonus payments.  Section 1861(r)(1), of the Act, defines physicians as doctors of medicine or osteopathy.  Therefore, dentists, chiropractors, podiatrists, and optometrists are not eligible for the physician scarcity bonus as either primary care or specialty physicians.  O nly the primary care designations of general practice, family practice, internal medicine, and obstetrics/gynecology, will be paid the bonus for the ZIP codes designated as primary care scarcity areas.  All physician provider specialties are eligible for t he specialty physician scarcity bonus except the following:  oral surgery (dentist only); chiropractic; optometry; and podiatry.  The bonus is payable 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.  One of the following modifier(s) must accompany the HCPCS code to indicate type of physician:   AG -  Primary Physician  AF - Specialty Physician   Modifiers AG and AF are not required for dates of service on or after January 1, 2005. Modifier AR, physician providing services in a physician scarcity area, may be required for claims with dates of service on or after January 1, 2005 to receive the PSA bonus. Refer to 250.2.2 of this chapter for more information on when modifier AR is required.