(Medicare Claims Processing Manual)

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.   Each year, a list of ZIP codes eligible for automatic payment of the HSIP incentive payment (and the Medicare HPSA physician bonus program) is published.  This list is utilized for automatic payments of the incentive for eligible services furnished by gene ral surgeons.  A/B MACs (B) will use the existing HPSA modifier - AQ ,along with the physician specialty (02), to identify circumstances when general surgeons furnish major surgical procedures in areas that are designated as HPSAs as of December 31 of the p rior year, but that are not on the list of ZIP codes eligible for automatic payment.  Modifier -AQ should be appended to the major surgical procedure on claims submitted for payment under these circumstances.  90.4.11.3 - Coordination with Other Payments (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)(4) of the Affordable Care Act provides payment under the HSIP as an additional payment amount for specified surgical services without regard to any additional payment for the service under section 1833(m) of the Act.  Therefore, a general s urgeon may receive both a HPSA physician bonus payment under the established program, and an HSIP payment under the new program beginning in CY 2011.  90.4.11.4 - General Surgeon and Surgical Procedure Identification for Professional Services Paid Under the Physician Fee Schedule (PFS)  (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)   Qualifying general surgeons are identified on a claim for a 10 - or 90 - day global surgical procedure based on the primary specialty of the rendering physician, identified by his or her National Provider Identifier (NPI), of 02 - general surgery.  If the claim is submitted by a physician group practice, the rendering physicians NPI must be included on the line-item for the qualifying surgical procedure in order for a determination to be made regarding whether or not the procedure is eligible for payment under the HSIP.  Eligible surgical procedures are those procedures for which a 10 - or 90 - day global period is used for payment under the PFS.  The specific HCPCS procedure codes eligible for the HSIP are identified in column U (global period) of the Physician Fee Schedule Relative Value Update (RVU) file located at:  http://www.cms.gov/Medicare/Medicare -Fee-for-Service -Payment/PhysicianFeeSched/PFS -Relative -Value- Files.html, with a global period designation of 10 - or 90 - days.   90.4.11.5 - Claims Processing and 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)   A. General Overview   The HPSA physician bonus program guidelines are contained in Pub. 100-04, Chapter 12, 90.4.  Refer to that section for payment and claims processing guidance for the HPSA physician bonus program that was established in 2005.  The following guidelines pertain only to the additional 10 percent incentive payment for 10 - or 90 - day global surgical procedures furnished by 02 - general surgeons in HPSAs from January 1, 2011 through December 31, 2015.  A/B MACs (B) shall identify eligible surgical procedures with a 10 - or 90 - day global period rendered in an eligible primary care HPSA zip code area based on the HPSA physician bonus ZIP code file for the appropriate date of service.  The HPSAs eligible for automatic payment may be found on the CMS Web site at: http://www.cms.gov/HPSAPSAPhysicianBonuses/01_overview.asp.  A/B MACs (B) must also inform eligible practitioners about the use of modifier - AQ on claims for 10 - or 90 - day global surgical procedures that were furnished in HPSAs approved by December 31 of the preceding calendar year, but that are not recognized for automatic payment.  The modifier must be appended to the surgical procedure for the service to be eligible for the 10 percent additional HSIP payment.  B. Method of Payment    Calculate and pay general surgeons an additional 10 percent incentive payment;    Calculate the payment based on the amount actually paid for the service, not the Medicare approved amount;    Combine the HSIP incentive payments, when appropriate, with other incentive payments, including the HPSA physician bonus payment;