(Medicare Claims Processing Manual)

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 the 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 Professional 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  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 qualifying 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.