evekhm/cms_iom_500 huggingface dataset:
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 [(facility -specific MPFS amount times the nonphysician practitioner services reduction (0.85) minus (deductible and coinsurance)] times 1.15.   SB - Services rendered in a CAH by a certified nurse- midwife  For dates of service prior to January 1, 2011, certified nurse -midwife services billed with the SB modifier are paid based on the lesser of the actual charge or a reduced fee schedule amount of 65 percent.  Payment is calculated as follows:   For dates of service on or after January 1, 2011, Medicare covers the services of a certified nurse- midwife.  The SB modifier is used to bill for the services and payment is based on the lesser of the actual charge or 100 percent of the MPFS.  MPFS Payme nt is calculated as follows :   [(facility -specific MPFS amount) minus (deductible and coinsurance)] times 1.15.  AH -  Services rendered in a CAH by a clinical psychologist  Payment for the services of a clinical psychologist is based on the lesser of the actual charge or 100 percent of the MPFS.   Payment is calculated as follows:    [(facility -specific MPFS amount) minus (deductible and coinsurance)] times 1.15.   AE -  Services rendered in a CAH by a nutrition professional/registered dietitian.  Services billed with the AE modifier are paid based on the lesser of the actual charge or a reduced fee schedule amount of 85 percent. Payment is calculated as follows:    [(facility -specific MPFS amount times the registered dietitian reduction (0.85) minus (deductible and coinsurance)] times 1.15. Outpatient services, including ASC type services, rendered in an all -inclusive rate provider should be billed using the 85X type of bill (TOB).  Non- patient laboratory specimens are billed on TOB 14X.  MPFS rates contained in the HHH abstract file are used for payment of all physician/professional services rendered in a CAH that has elected the optional method.  If a HCPCS code has a facility rate and a non -facility rate, the facility rate is paid.  See Chapter 23 of Pub. 100- 04, section 50.1 for the record layout for the HHH abstract file.
(Medicare Claims Processing Manual)
Physician Fee Schedule Payment Policy Indicator File  The information on the Physician Fee Schedule Payment Policy Indicator file is used to identify endoscopic base codes, payment policy indicators, global surgery indicators, diagnostic imaging family indicators, or the preoperative, intraoperative and postoperative percentages that are needed to determine if payment adjustment rules apply to a specific CPT code and the associated pricing modifier(s). See Chapter 12 of Pub. 100-04 for more information on payment policy indicators and payment adjustment rules.  See Chapter 23 of Pub. 100- 04, section 50.6 for the record layout of the Payment Policy Indicator file.   Health Professional Shortage Area (HPSA) Incentive Payments for Physicians   Section 1833 (m) of the Social Security Act, provides incentive payments for physicians who furnish services in areas designated as HPSAs under section 332(a)(1)(A) of the Public Health Service (PHS) Act.  This statute recognizes geographic -based, primary medical care and mental health HPSAs, are areas for receiving a 10 percent bonus payment.  The Health Resources and Services Administration (HRSA), within the Department of Health & Human Services, is responsible for designating shortage areas.
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Physicians, including psychiatrists, who provide covered professional services in a primary medical care HPSA, are entitled to an incentive payment.  In addition, psychiatrists furnishing services in mental health HPSAs are eligible to receive bonus paymen ts.  The bonus is payable for psychiatric services furnished in either a primary care HPSA, or a mental health HPSA.  Dental HPSAs remain ineligible for the bonus payment.  Physicians providing services in either rural or urban HPSAs are eligible for a 10 percent incentive payment.  It is not enough for the physician merely to have his/her office or primary service location in a HPSA, nor must the beneficiary reside in a HPSA , although, frequently, this will be the case.  The key to eligibility is where the service is actually provided (place of service).  For example, a physician providing a service in his/her office, the patients home, or in a hospital, qualifies for the incentive payment as long as the specific location of the service provision is within an area designed as a HPSA.  On the other hand, a physician may have an office in a HPSA, but go outside the office (and the designated HPSA area) to provide the service.  In this case, the physician would not be eligible for the incentive payment.   If the CAH electing the Optional Method (Method II) is located within a primary medical care HPSA, and/or mental health HPSA, the physicians providing (outpatient) professional services in the CAH are eligible for HPSA physician incentive payments. Therefo re, payments to such a CAH for professional services of physicians in the outpatient department will be 115 percent times  the amount payable under fee schedule times  110 percent.  An approved Optional Method CAH that is located in a HPSA County should noti fy you of its HPSA designation in writing .  Once you receive the information, place an indicator on the provider file showing the effective date of the CAHs HPSA status. The CMS will furnish quarterly lists of mental health HPSAs to A/B MACs (A).
(Medicare Claims Processing Manual)
The HPSA incentive payment is 10 percent of the amount actually paid, not the approved amount.  Do not include the incentive payment in each claim.  Create a utility file so that you can run your paid claims file for a quarterly log.  From this log you wil l send a quarterly report to the CAHs for each physician payment, one month following the end of each quarter.  The sum of the 10% of line Reimbursement column should equal the payment sent along with the report to the CAH.  If any of the claims included on the report are adjusted, be sure the adjustment also goes to the report.  If an adjustment request is received after the end of the quarter, any related adjustment by the A/B MACs (A) will be included on next quarters report.  The CAHs must be sure to keep adequate records to permit distribution of the HPSA bonus payment when received.  If an area is designated as both a mental health HPSA and a primary medical care HPSA, only  one 10 percent bonus payment shall be made for a single service.   250.2.1 - Billing and Payment in a Physician Scarcity Area (PSA)  (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)  Section 413a of the MMA 2003 requires that a new 5 percent bonus payment be established for physicians in designated physician scarcity areas.  The payment should be made on a quarterly basis and placed on the quarterly report that is now being produced for the HPSA bonus payments.
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Section 1861(r)(1), of the Act, defines physicians as doctors of medicine or osteopathy.  Therefore, dentists, chiropractors, podiatrists, and optometrists are not eligible for the physician scarcity bonus as either primary care or specialty physicians.  O nly the primary care designations of general practice, family practice, internal medicine, and obstetrics/gynecology, will be paid the bonus for the ZIP codes designated as primary care scarcity areas.  All physician provider specialties are eligible for t he specialty physician scarcity bonus except the following:  oral surgery (dentist only); chiropractic; optometry; and podiatry.  The bonus is payable for dates of service January 1, 2005, through December 31, 2007.  T he Medicare, Medicaid, and State Childrens Health Insurance Program (SCHIP) Extension Act of 2007 amended 1833(u)(1) of the Social Security Act and has extended payment of that bonus through June 30, 2008.  One of the following modifier(s) must accompany the HCPCS code to indicate type of physician:   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).
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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.
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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
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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)
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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
(Medicare Claims Processing Manual)
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).   Example 2:   Physician medically directs two concurrent cases involving CRNAs Base units plus time -  4+4=8  Total units multiplied by the anesthesia conversion factor times. 50 equal allowed amount minus any remaining deductible  8 x $17 = $136 x .50 = $68.00 - (deductible*) = $68.00  Allowed amount Times 80 percent times 1.15  $68.00 x .80 = $54.40 x 1.15 = 62.56 (Payment amount)  $62.56 x .10 = $6.26 (HPSA bonus payment)  *Assume the deductible has already been met for the calendar year.   NOTE:   For specific guidance on payment for Anesthesia and Teaching Services please review the following sections:   -   Payment for Anesthesiology Services Pub.100- 04, Chapter 12, Section 50
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NOTE:   For specific guidance on payment for Anesthesia and Teaching Services please review the following sections:   -   Payment for Anesthesiology Services Pub.100- 04, Chapter 12, Section 50   - Teaching Physician Services Pub.100- 04, Chapter 12, Section 100.1.2 (4) Anesthesia.   250.3.3 - Anesthesia and CRNA Services in a Critical Access Hospital (CAH)  (Rev. 616, Issued: 07- 22-05, Effective: 10 -01-02, Implementation: 01- 03-06)  250.3.3.1 - Payment for CRNA Pass -Through Services  (Rev.4295, Issued: 05- 03-19, Effective: 08 -27-19, Implementation: 08- 27-19)  CAHs are eligible to receive CRNA pass -through payments (pass -through exemption) for both inpatient and outpatient services if they meet criteria discussed at 42 CFR  412.113(c) of the regulations. CRNA pass -through payments and the Method II election for outpatient CAH services are applied as described below. Note that for CAHs that have a CRNA pass -through exemption, all CRNA services provided to CAH swing- bed patients must be included on the CAH swing- bed bill. (See MCPM, Ch. 3, 60 and 100.2 for more information)   If a CAH meets the criteria for a pass -through exemption and is interested in selecting Method II for its physicians and/or other practitioners, it can choose Method II for all outpatient professionals except the CRNA, and still retain the approved CRNA pa ss-through exemption for both inpatient and outpatient CRNA professional services.   Alternatively, a CAH, with an approved pass -through exemption, can choose to give up its pass -through exemption for both inpatient and outpatient CRNA professional services in order to include its CRNA outpatient professional services under Method II. By c hoosing to include the CRNA under Method II for outpatient services, the CAH loses its CRNA pass -through exemption for not only the outpatient CRNA services, but also the inpatient CRNA services. In this case the CAH would have to bill the A/B MAC (B) for the CRNA inpatient professional services. All A/B MAC (A) payments for CRNA services are subject to cost settlement.