(Medicare Claims Processing Manual)

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.   There may be situations when a CAH is not located in a bonus area but its outpatient department is in a designated bonus area, or vice versa.  If a CAH has an off -site outpatient department/clinic the off -site departments complete address, including the Z IP code, must be placed on the claim as the service facility.  The FISS must look at the service facility ZIP code to determine if a bonus payment is due.  For electronic claims, the service facility address should be in the 2310E loop of the ASC X12 837 institutional claim format.  On the hard copy Form CMS -1450  the address should be placed in Remarks; however, the ZIP code placement will be determined by the A/B MAC (A).   250.2.2 - Zip Code Files  (Rev. 2169, Issued: 03- 03-11, Effective: 04 -01-11, Implementation: 04- 04-11)  The CMS provided a file of ZIP Codes for the primary care and specialist care Physician Scarcity Area (PSA) bonus payment.  The file is effective for claims with dates of service January 1, 2005 through June 30, 2008. Prior to January 1, 2005, CMS posted on its Web site ZIP Codes that are eligible for the bonus payment.  Through regularly scheduled bulletins and list serves, A/B MACs (A) must notify the CAH to verify their ZIP Code eligibility via the CMS Web site.   ZIP Code files for the automated payment of the Health Professional Shortage Area (HPSA) bonus payment will be developed and updated annually.  Effective for claims with dates of service on or after January 1, 2009, only services provided in areas that are  designated as of December 31 of the prior year are eligible for the HPSA bonus payment.  Physicians providing services in areas that were designated as of December 31 of the prior year but not on the automated file may use the AQ modifier.  Only services provided in areas that were designated as of December 31 of the prior year but not on the automated file may use the modifier.  Services provided in areas that are designated throughout the year will not be eligible for the HPSA bonus payment until the fol lowing year, provided they are still designated on December 31.  Services provided in areas that are de -designated throughout the year will continue to be eligible for the HPSA bonus through the end of the calendar year.   The contractors and standard systems will be provided with a file at the appropriate time prior to the beginning of the calendar year for which it is effective.  This file will contain ZIP Codes that fully and partially fall within a HPSA bonus area for both mental health and primary care services.  A recurring update notification will be issued for each annual update.  Contractors will be informed of the availability of the file and the file name via an email notice.   Contractors will automatically pay bonuses for services rendered in ZIP Code areas that: 1) fully fall within a designated primary care or mental health full county HPSA; 2) are considered to fully fall in the county based on a determination of dominance m ade by the United States Postal Service (USPS); or 3) are fully within a non- full county HPSA area.  Should a ZIP Code fall within both a primary care and mental health HPSA, only one bonus will be paid on the service.  Bonuses for mental health HPSAs will  only be paid when performed by psychiatrists.  For services rendered in ZIP Code areas: 1) that do not fall within a designated full county HPSA; 2) are not considered to fall within the county based on a determination of dominance made by the USPS; or 3) are partially within a non- full county HPSA, the CAH must still submit a AQ modifier to receive payment for claims.  To determine whether a modifier is needed, the CAH must review the information provided on the CMS Web site for HPSA designations to determine if their location is, indeed, within a HPSA b onus area.   For service 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.   Special Incentive Remittance for CAHS   A Special Incentive Remittance for CAHs is generated on a quarterly basis that identifies beneficiary and claims information for which a HPSA, PSA, Primary Care Incentive Payment Program (PCIP) or HPSA Surgical Incentive Payment Program (HSIP) payment is being made. Since there is a possibility that more than one type of incentive payment may be paid for a single service, each type of incentive payment being made is identified on the remittance 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   See sections 250.12 through 250.12.4 for more information on PCIP payments to CAHs paid under the optional method.  Use the information in the Professional Component/Technical Component (PC/TC) indicator field of the CORF extract of the Medicare Physician Fee Schedule Supplementary File to identify professional services eligible for HPSA and physician scarcity bonus payments.  The following are the rules to apply in determining whether to pay the bonus on services furnished within a geographic HPSA billed with a QB or QU modifier for dates of service prior to January 01, 2006 or the AQ modifier for services on or after J anuary 01, 2006, and/or whether to pay the bonus on services furnished within a Physician Scarcity Area with the AR modifier effective for dates of service January 01, 2005, through June 30, 2008.  (Field 20 on the full MPFS file layout)   PC/TC Indicator  Bonus Payment Policy  0 Physician services. The concept of PC/TC does not apply since physician services cannot be split into professional and technical components.   ACTION: Pay the 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.   ACTION: Return the service as unprocessable and notify the CAH 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.  1 Professional Component (modifier 26).   ACTION: Pay the bonus.  1 Technical Component (modifier TC).   ACTION: Do not pay the bonus.  2 Professional Component only.   ACTION: Pay the bonus.  3 Technical Component only.   ACTION: Do not pay the bonus.  4 Global test only. Only the professional component of this service qualifies for the bonus payment.  ACTION: Return the service as unprocessable. Instruct the provider to re-bill the service as separate professional and technical component procedure codes.  5 Incident to codes.   ACTION: Do not pay the bonus.  6 Laboratory physician interpretation codes.   ACTION: Pay the bonus  7 Physical therapy service.   ACTION: Do not pay the bonus.  8 Physician interpretation codes.   ACTION: Pay the bonus.  PC/TC Indicator  Bonus Payment Policy  9 Concept of PC/TC does not apply.   ACTION: Do not pay the bonus.   NOTE:  Codes that have a status of X on the CORF extract 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 nor the physician bonus payment (5 percent) will be paid for these codes.   250.3 - Payment for Anesthesia in a Critical Access Hospital (CAH)  (Rev 41, 12- 08-03)  Payment for anesthesia services is based on the HCPCS FILE, the Anesthesia Conversion Factor File, and the CORF extract of the MPFS Summary File.   250.3.1 - Anesthesia File  (Rev. 41, 12- 08-03) Conversion Factor File = MU00.@BF12390.MPFS.CY04.ANES.V1023   Record Layout for the Anesthesia Conversion Factor File  Data Element Name  Picture  Location  Length A/B MAC (B) Number  X (5)  1-5 5 Locality Number  X (2)  13-14 2 Locality Name  X (30)  19-48 30 Anesthesia CF 2002  99V99 74-77 4  250.3.2 - Physician Rendering Anesthesia in a Hospital Outpatient Setting  (Rev. 2452, Issued: 04- 26-12, Effective: 01 -10-12, Implementation: 10 -01-12)  When a medically necessary anesthesia service is furnished within a HPSA area by a physician, a HPSA bonus is payable. In addition to using the PC/TC indicator on the CORF extract of the MPFS Summary File to identify HPSA services, pay physicians the HPSA bonus when CPT codes 00100 through 01999 are billed with the following modifiers: QY, QK, AA, or GC and QB or QU in revenue code 963. Modifier QB or QU must be submitted to receive payment of the HPSA bonus for claims with dates of service prior to Jan uary 01, 2006. Effective for claims with dates of service on or after January 01, 2006, the modifier AQ, physician providing a service in a health professional shortage area, may be required to receive the HPSA bonus. Refer to 250.2.2 of this chapter for more information on when modifier AQ is required.   The modifiers signify that a physician performed an anesthesia service.  Using the Anesthesia File (See Section above) the physician service will be 115 percent times the payment amount to be paid to a CAH on Method II payment plus 10 percent HPSA bonus payment.   Anesthesiology modifiers:   AA = anesthesia services performed personally by anesthesiologist.  GC =service performed, in part, by a resident under the direction of a teaching physician.  QK = medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals.  QY = medical direction of one CRNA by an anesthesiologist.   Modifiers AA and GC result in physician payment at 100% of the allowed amount. Modifiers QK and QY result in physician payment at 50% of the allowed amount.   Data elements needed to calculate payment:    HCPCS plus Modifier,   Base Units,   Time units, based on standard 15 minute intervals,   Locality specific anesthesia Conversion factor, and   Allowed amount minus applicable deductions and coinsurance amount.   Formula 1: Calculate payment for a physician performing anesthesia alone   HCPCS = xxxxx  Modifier = AA  Base Units = 4  Anesthesia Time is 60 minutes. Anesthesia time units = 4 (60/15)  Sum of Base Units plus Time Units = 4 + 4 = 8  Locality specific Anesthesia conversion factor = $17.00 (varies by localities)  Coinsurance = 20%   Example 1:   Physician personally performs the anesthesia case   Base Units plus time units -  4+4=8  Total units multiplied by the anesthesia conversion factor times .80  8 x $17= ($136.00 -  (deductible*) x .80 = $108.80  Payment amount times 115 percent for the CAH method II payment.  $108.80 x 1.15 = $125.12 (Payment amount)  $125.12 x .10 = $12.51 (HPSA bonus payment)  *Assume the Part B deductible has already been met for the calendar year   Formula 2:  Calculate the payment for the physicians medical direction service when the physician directs two concurrent cases involving CRNAs. The medical direction allowance is 50% of the allowance for the anesthesia service personally performed by the physician.   HCPCS = xxxxx  Modifier = QK  Base Units = 4  Time Units 60/15=4  Sum of base units plus time units = 8  Locality specific anesthesia conversion factor = $17(varies by localities)  Coinsurance = 20 %   (Allowed amount adjusted for applicable deductions and coinsurance and to reflect payment percentage for medical direction).