evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
90.3 - Physicians Services Performed in Ambulatory Surgical Centers (ASC)  (Rev. 1604, Issued: 09- 26-08, Effective: 01 -08-08, Implementation: 01- 05-09)  See Chapter 14, for a description of services that may be billed by an ASC and services separately billed by physicians.  The ASC payment does not include the professional services of the physician. These are billed separately by the physician. Physicians services include the services of anesthesiologists administering or supervising the administration of anesthesia to ASC patients and the patients recovery from the anesthesia. The term p hysicians services also includes any routine pre - or postoperative services, such as office visits, consultations, diagnostic tests, removal of stitches, changing of dressings, and other services which the individual physician usually performs.   The physician must enter the place of service code (POS) 24 on the claim to show that the procedure was performed in an ASC.   The A/B MAC (B) pays the facility fee from the MPFSDB to the physician. The facility fee is for services done in a facility other than the physicians office and is typically less than the nonfacility fee for services performed in the physicians office.   90.4 - Billing and Payment in a Health Professional Shortage Area (HPSA)  (Rev. 1273; Issued:  06- 29-07; Effective/Implementation Dates:  10 -01-07)  In accordance with 1833(m)  of the Act, physicians who provide covered professional services in any rural or urban HPSA are entitled to an incentive payment.  Beginning January 1, 1989, physicians providing services in certain classes of rural HPSAs were entitled to a 5- percent incentive payment.  Effective January 1, 1991, physicians providing services in either rural or urban HPSAs are eligible for a 10- percent incentive payment.   Eligibility for receiving the 10 percent bonus payment is based on whether the specific location at which the service is furnished is within an area that is designated (under section 332(a)(1)(A) of the Public Health Services Act) as a HPSA. The Health Res ources and Services Administration (HRSA), within the Department of Health & Human Services, is responsible for designating shortage areas.
(Medicare Claims Processing Manual)
HRSA designates three types of HPSAs:  geographic, population, and facility- based.  Geographic -based HPSAs are areas with shortages of primary care physicians, dentists or psychiatrists.  Population -based HPSAs are designations based on underserved populat ions within an area.  Facility -based HPSAs are designations based on a public or non- profit private facility that is providing services to an underserved area or population and has an insufficient capacity to meet their needs.   Section 1833(m) of the Social Security Act (the 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 section of the PHS Act pertains to g eographic -based HPSAs.  Consequently, Medicare incentive payments are available only in geographic HPSAs.   Although section 1833(m) of the Act provides the authority to recognize the three types of geographic -based HPSAs (primary medical care, dental and mental health), only physicians, including psychiatrists, furnishing services in a primary medical care HPSA  are eligible to receive bonus payments.  In addition, effective for claims with dates of service on or after July 1, 2004, psychiatrists furnishing services in mental health HPSAs are eligible to receive bonus payments. CMS does not recognize dental HPSAs  for the bonus payment program.   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 is within an area designated as a HPSA.  On the ot her 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.  A/B MAC (B) responsibilities include:   Informing the physician community of these provisions;   Providing a link to the CMS Web site to access the HPSA automated ZIP code files;   Providing a direct link to HRSAs HPSA database
(Medicare Claims Processing Manual)
Informing the physician community of these provisions;   Providing a link to the CMS Web site to access the HPSA automated ZIP code files;   Providing a direct link to HRSAs HPSA database   Modifying the claims processing system to recognize and appropriately handle eligible claims;  Paying physicians the incentive payments; and   Performing post -payment reviews of samples of paid claims submitted using the AQ modifier.   90.4.1 - Provider Education  (Rev. 1639, Issued: 11- 21-08, Effective: 01 -01-09, Implementation: 01- 05-09)  ZIP Code files for the automated payment of the 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 following 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.   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.
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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 t he U.S. Census Bureau Web site at www.Census.gov or the Federal Financial
(Medicare Claims Processing Manual)
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 t he 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.
(Medicare Claims Processing Manual)
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 Professiona l 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.
(Medicare Claims Processing Manual)
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
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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 qualif ying 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
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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.