(Medicare Claims Processing Manual)

Given the absence of national policy on this provision, A/B MACs (A) have the authority to establish procedures to define the appropriate supporting documentation needed to establish medical necessity.  The A/B MACs (A) shall also determine if a clinician or non-clinician medical reviewer shall review co -surgeon services.  250.11 - Coding Bilateral Procedures Performed in a Method II CAH  (Rev. 1777; Issued:  07- 24-09; Effective Date:  01 -01-08; Implementation Date:  01-04-10)  Under authority of 42 CFR 414.40, CMS establishes uniform national definitions of services, codes to represent services, and payment modifiers to the codes. This includes the use of payment modifiers for bilateral procedures.  Bilateral procedures rendered by a physician that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedure is authorized as a bilateral procedure and is billed on type of bill 85X with revenue code (RC) 96X, 97X or 98X and the 50 modifier (bilateral procedure).   Modifier 50 applies to a bilateral procedure performed on both sides of the body during the same operative session. When a procedure is identified by the terminology as bilateral or unilateral, the 50 modifier is not reported.   If a procedure is authorized for the 150 percent payment adjustment for bilateral procedures (payment policy indicator 1), the procedure shall be reported on a single line item with the 50 modifier and one service unit.  Modifiers LT (left side) and RT (ri ght side) shall not be reported when the 50 modifier applies. See 20.6 in this chapter for more information on the use of the 50, LT and RT modifiers. See the Physician Fee Schedule Payment Policy Record Layout in 250.2 for a description of the bilateral  procedure payment policy indicators.  If a procedure can be billed as bilateral, but is not authorized for the 150 percent bilateral adjustment (payment policy indicator 3), the procedure shall be reported on a single line item with the 50 modifier and one service unit.   250.11.1 - Use of Payment Policy Indicators for Determining Bilateral Procedures Eligible for 150 Percent Payment Adjustment  (Rev. 1777; Issued:  07- 24-09; Effective Date:  01 -01-08; Implementation Date:  01-04-10)  Medicare uses the payment policy indicators on the Medicare Physician Fee Schedule Database (MPFSDB) to determine if a bilateral procedure is authorized for a specific HCPCS/CPT code. The MPFSDB is located at http://www.cms.gov/Medicare/Medicare -Fee-for-Service -Payment/PhysicianFeeSched/index.html .  The A/B MACs (A) have access to the payment policy indicators via the Physician Fee Schedule Payment Policy Indicator File in the FISS.   See the Physician Fee Schedule Payment Policy Record Layout in 250.2 for a description of the bilateral procedure payment policy indicators.   250.11.2 - Payment of Bilateral Procedures Rendered in a Method II CAH  (Rev. 1777; Issued:  07- 24-09; Effective Date:  01 -01-08; Implementation Date:  01-04-10)  Under Section 1834(g)(2)(B) of the Act, outpatient professional services performed in a Method II CAH are paid 115 percent of such amounts as would otherwise be paid under the Act if the services were not included in the outpatient CAH services.   Payment for bilateral procedures with a payment policy indicator of 1 and the 50 modifier is based on the lesser of the actual charges or the 150 percent payment adjustment for bilateral procedures and is calculated as follows:    (facility specific MPFS amount times payment adjustment for bilateral procedures (150%) minus (deductible and coinsurance)) times 115%   Payment for bilateral procedures with the 50 modifier and a payment policy indicator of 3 is based on the lesser of the actual charges or 100% of the MPFS for each  side of the body (200%) and is calculated as follows:   (facility specific MPFS amount times 200% minus (deductible and coinsurance)) times 115%   250.12 - Primary Care Incentive Payment Program (PCIP) Payments to Critical Access Hospitals (CAHs) Paid Under the Optional Method  (Rev. 2169, Issued: 03- 03-11, Effective: 04 -01-11, Implementation: 04- 04-11)  Section 5501(a) of the Affordable Care Act revises section 1833 of the Social Security 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 prim ary care practitioner.   250.12.1 - Definition of Primary Care Practitioners and Primary Care Services  (Rev. 2169, Issued: 03- 03-11, Effective: 04 -01-11, Implementation: 04- 04-11)  Primary care practitioners are 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 CPT 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.   250.12.2 - Identifying Primary Care Services Eligible for the PCIP  (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)  CAHs paid under the optional method billing on TOB 85X for professional primary care services (revenue code 96X, 97X or 98X) furnished by primary care physicians and nonphysician practitioners who have reassigned their billing rights to the CAH are eligible for PCIP payments.   The National Provider Identifier (NPIs) of  primary care practitioners eligible for PCIP payment in a given calendar year (CY) are posted on Medicare contractor Web sites in the Primary Care Incentive Payment Program Eligibility File by January 31 of  the applicable incentive payment CY.   Eligible practitioners for PCIP payment in a given calendar year who were newly enrolled in Medicare in the year immediately preceding the PCIP payment year will be identified later in the payment year and posted on their  Medicare contractors Web site at that point in time.  CAHs paid under the optional method should contact their contractor with any questions regarding the eligibility of physician and nonphysician practitioners for PCIP payments.  Primary care practitioners furnishing primary care services will be identified on CAH claims by the NPI of the rendering practitioner as follows:    Line level Rendering Provider field when populated or,    Claim level Rendering Provider field where a line level Rendering Provider field is blank or,   Claim level Attending Provider field if the claim level Rendering Provider field is blank.  In order for a primary care service to be eligible for PCIP payment, the CAH paid under the optional method must be billing for the professional services of physicians under their NPIs or of physician assistants, clinical nurse specialists, or nurse practi tioners  under their own NPIs because they are not furnishing services incident to physicians services.   Multiple primary care services rendered by different physicians may be present on a single claim.  Providers shall ensure they identify each physician on the claim form per the ASC X12 837 Institutional Claim Implementation Guide.  250.12.3 - Coordination with Other Payments (Rev. 2169, Issued: 03- 03-11, Effective: 04 -01-11, Implementation: 04- 04-11)  Section 5501(a)(3) of the ACA 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 Social Security Act, the established Health Professional Shortage Area (HPSA) Medicare physician bonus program.  Therefore, a CAH paid under the optional method and billing for the professional services of an eligible primary care physician or nonphysician practitioner furnishing a primary car e 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 4, Section 250.2) under the HPSA physician bonus program and a PCIP incenti ve payment under the new program beginning in CY 2011.  250.12.4 - Claims Processing and Payment for Critical Access Hospitals Paid Under the Optional Method  (Rev. 2169, Issued: 03- 03-11, Effective: 04 -01-11, Implementation: 04- 04-11)  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) times 1.15 percent for those services furnished during the incentive payment year.  P CIP payments for newly enrolled practitioners may be delayed due to the lag in claims data processing.  PCIP payments for services by a newly enrolled primary care practitioner will be paid in the quarter following eligibility determination, and then quart erly for all subsequent incentive payments. Retroactive payments will be provided from the beginning of the PCIP year once these primary care practitioners are deemed eligible.  On an annual basis Medicare contractors shall receive a Primary Care Incentive Payment Program Eligibility File that they shall post to their websites.  The file will list the NPIs of all physicians and nonphysician practitioners who are eligible to receive PCIP payments for the upcoming CY.  The NPIs of eligible newly enrolled primary care practitioners will be posted to the contractors websites later in the payment year.   On an annual basis Medicare contractors shall receive a Physician/Practitioner Specialty File. This file it to be used by contractors to answer provider inquiries regarding eligibility for the PCIP.   The PCIP payments will be calculated by Medicare contractors and made quarterly to CAHs  paid under the optional method on behalf of the  eligible primary care physician or nonphysician practitioner for the  primary care services furnished by the practitioner in that quarter.  The PCIP payments will be based on 10 percent of 115 percent of the PFS amount that the CAH was paid for the professional service.   B. Method of Payment  Calculate and pay a CAH paid under the optional method based on primary care services furnished by qualifying primary care physicians and nonphysician practitioners an additional 10 percent incentive payment;    Calculate the payment based on 115 percent of the PFS amounts that were paid to the CAH for the services; not the Medicare approved amounts;    Combine the PCIP incentive payments, when appropriate, with other incentive payments, including the physician HPSA bonus payment and the HPSA Surgical Incentive Payment Program (HSIP) payment;    Provide a special remittance for CAHs form that is forwarded with the incentive payment so that CAHs paid under the optional method can identify which type of incentive payment was paid for which services.    CAHs paid under the optional method should contact their contractor with any questions regarding PCIP payments.  C.  Changes for Contractor Systems   The Fiscal Intermediary Standard System (FISS), Common Working File (CWF) and 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  Space = Not Applicable