(Medicare Claims Processing Manual)

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   ACTION: Effective for claims received prior to October 1, 2005, A/B MACs (B) return the service as unprocessable and notify the physician that the professional component must be re -billed if it is performed within a qualifying bonus area.  If the technical component is the only component of the service that was performed in the bonus area, there wouldnt be a qualif ying service.  Effective for claims received on or after October 1, 2005, A/B MACs (B) shall accept claims with services with a PC/TC indicator of 1 that are eligible for the HPSA or PSA bonus. They shall pay the bonus only on the professional component of the service.  1 Professional Component (modifier 26). A/B MACs (B) pay the bonus.  1 Technical Component (modifier TC). A/B MACs (B) do not pay the bonus. 2 Professional Component only. A/B MACs (B) pay the bonus. 3 Technical Component only. A/B MACs (B) do not pay the bonus.  4 Global test only. Only the professional component of this service qualifies for the bonus payment.  ACTION: Effective for claims received prior to July 1, 2006, A/B MACs  (B) return the service as unprocessable.  They instruct the provider to re - bill the service as separate professional and technical component procedure codes.  Effective for claims received on or after July 1, 2006, except for 93015, A/B MACs (B) shall accept claims with services with a PC/TC indicator of 4 that are eligible for the HPSA or PSA bonus. They shall pay the bonus only on the associated professional c omponent of the service. Since 93015 has two associated professional components, A/B MACs (B) will not be able to make a determination as to which would be the correct component to use to calculate the bonuses.  Therefore, A/B MACs (B) shall continue to treat 93015 as  unprocessable. 5 Incident to codes. A/B MACs (B) do not pay the bonus. 6 Laboratory physician interpretation codes. A/B MACs (B) pay the bonus.  7 Physical therapy service. A/B MACs (B) do not pay the bonus. 8 Physician interpretation codes. A/B MACs (B) pay the bonus. PC/TC Indicator  Bonus Payment Policy 9 Concept of PC/TC does not apply. A/B MACs (B) do not pay the bonus.    NOTE:   Codes that have a status of X on the Medicare Physician Fee Schedule Database (MFSDB) have been assigned PC/TC indicator 9 and are not considered physician services for MFSDB payment purposes. Therefore, neither the HPSA bonus payment nor the physician scarcity area bonus payment will be paid for these codes.   B. Anesthesia Codes (CPT Codes 00100 Through 01999) That Do Not Appear on the MFSDB  Anesthesia codes (CPT codes 00100 through 01999) do not appear on the MFSDB. However, when a medically necessary anesthesia service is furnished within a HPSA or physician scarcity area by a physician, a HPSA bonus and/or physician scarcity bonus is payabl e.  To claim a bonus payment for anesthesia, physicians bill codes 00100 through 01999 with modifiers QY, QK, AD, AA, or GC to signify that the anesthesia service was performed by a physician along with the QB or QU modifier, or the AQ modifier for claims with  dates of service on or after January 1, 2006, when required per 90.4.3 or the AR modifier as required per 90.5.3.   C. Mental Health Services  Physicians professional services rendered by any of the psychiatry provider specialties, are eligible for a HPSA bonus when rendered in a mental health HPSA. The service must have a PC/TC designation per the chart above. Should a zip code fall within both a primary care and mental health HPSA, only one bonus must be paid on the service.   90.4.6 - Reserved for Future Use   90.4.7 - Post-payment Review (Rev. 4431, Issued: 11- 01-19, Effective: 02 -04-20, Implementation: 02 -04-20)  On a post -payment basis, services submitted with the QB or QU modifier, or the AQ modifier for claims with dates of service on or after January 1, 2006, will be subject to validation.  Effective for claims with the dates of service on or after January 1, 2005, the date of the HPSA designation or withdrawal on the HRSA Web site or the date of designation or withdrawal in notification letters from HRSA are used as the effective date for pa ying the  HPSA bonus.  Effective for claims with dates of service on or after January 1, 2006, A/B MAC Part B A/B MACs (B) shall only include services paid with the AQ modifier for post -payment HPSA review. Services with bonuses that were automatically paid based on the ZIP code for the HPSA post -payment review process shall not be included. Additional post - payment will be conducted at the A/B MAC (B)s discretion. Effective for claims with dates of service on or after January 1, 2009, for Medicare bonus payment purposes, A/B MACs (B) shall o nly consider services eligible for bonuses if the area was designated as a HPSA as of December 31 of the prior year.   The post -payment review will be conducted each quarter as follows:   B. Array each list of physicians by the total amount of incentive payments  received.   C. Select the 25 percent of physicians on each list who received the highest  payments.  D. Review a sample of 5 claims by each physician on each list (ensure the sample is representative of different types of settings, if  applicable).   E. The findings must be transmitted via CROWD (Form 1565E) to central office no later than the 75th day following the close of the CROWD reporting quarter.   Physicians who appear on a list, were previously reviewed, and subsequently found to be in compliance shall be excluded from the current reporting. The 5 claim sample shall be reviewed to ensure the place of service was actually in a HPSA bonus area. In addition, effective for claims with dates of service on or after July 1, 2004, services selected as part of the 25% sample will be verified that they were provided in a mental health HPSA by any of the psychiatry provider specialties.   Once a physician has incorrectly claimed incentive payments, the A/B MACs (B) shall continue to monitor the physicians claims until they are found to be in compliance.   The designations on the HRSA Web site and HRSA letters can be used to verify that services were provided in a HPSA. Physicians are permitted to submit copies of HRSA designation letters as appropriate documentation to their.  If it is determined that a HPSA bonus was paid in error, the A/B MAC (B) will pursue the amount of any overpayment by directly contacting the physician and his/her billing staff. For Medicare HPSA bonus payment purposes, designations are valid for the entire calendar year regardless of whether the HPSA designation is withdrawn by the HRSA during that year.   90.4.8 - Reporting  (Rev. 1, 10- 01-03) B3-3350.8, B3- 13320, B3- 13320.1, B3- 13322.3 Reporting instructions are included in Chapter 6 of the Medicare Financial Management Manual.  90.4.9 - HPSA Incentive Payments for Physician Services Rendered in a Critical Access Hospital (CAH)  (Rev. 608, Issued:  07- 22-05; Effective:  01 -01-06; Implementation: 01 -03-06) If a CAH electing the Optional Method (Method II) is located within a mental health HPSA, the psychiatrists providing (outpatient) professional services in the CAH are eligible for the Mental Health and Primary Care HPSA bonus payments.  When billing for this service, the CAH must bill using Revenue code 961 plus the applicable HCPCS.  This Mental Health HPSA bonus will be paid to the CAH on a quarterly basis by the FI.  If an area is designated as both a mental health HPSA and a primary medical HPSA, only one 10% bonus will be paid for the service.  Refer to 250.2 in the Claims Processing Manual, Chapter 4 for additional information. 90.4.10 - 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(b)(1) 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.   90.4.11 - Health Professional Shortage Areas (HPSA) Surgical Incentive Payment Program (HSIP) for Surgical Services Rendered in HPSAs  (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) of the Affordable Care Act revises Section 1833(m) of the Act and authorizes a 10 percent incentive payment for 10 - and 90 -  day global  surgical procedures furnished by 02  general surgeons in Health Professional Shortage Areas (HPSAs).   90.4.11.1 - Overview of the HSIP  (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 applies to major surgical procedures, that are defined as 10 -  and 90 - day global procedures under the Physician Fee Schedule (PFS) and furnished on or after January 1, 2011, and before January 1, 2016, by an 02- general surgeon in an  area designated under Section 332(a)(1)(A) of the Public Health Service Act as a HPSA.  To be consistent with the Medicare HPSA physician bonus program (Pub. 100- 04, Chapter 12, 90.4), HSIP payments are calculated by A/B MACs (B) on a quarterly basis, on behalf of the qualifying general surgeon, for the qualifying surgical procedures.  The surgeons professional services are paid under the PFS based on a claim for professional services.    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.