Palmetto GBA - Jurisdiction 11 Part A - Incentive Payment Program for Major Surgical Procedures Furnished in Health Professional Shortage Areas (HPSAs), Section 5501(b) of The Affordable Care Act, Payment to a Critical Access Hospital (CAH) Paid under th

Palmetto GBA

^ Back to Top

LICENSES AND NOTICES

End User Point and Click Agreement

You, your employees, and agents are authorized to use CPT only as contained in the following authorized materials (web pages, PDF documents, Excel documents, Word documents, text files, Power Point presentations and/or any Flash media) internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA Web site, http://www.ama-assn.org/ama/pub/category/3113.html.

Applicable FARS/DFARS restrictions apply to government use.

U.S. Government Rights

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)(June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities

CPT is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. The AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. The AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with Palmetto GBA or CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of CMS. THE CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. THE CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled “I Accept.”

LICENSE FOR USE OF “DENTAL PROCEDURE CODES” (CPT) FOURTH EDITION

End User Point and Click Agreement

These materials contain Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2011 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED “I ACCEPT”, YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED “I DO NOT ACCEPT” AND EXIT FROM THIS COMPUTER SCREEN. IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, “YOU” AND “YOUR” REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association web site, http://www.ADA.org.
Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use.
U.S. Government Rights. This product includes CDT, which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense by the American Dental Association, 211 East Chicago Avenue, Chicago, Illinois, 60611. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.
ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT and other content contained therein, is with Palmetto GBA or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.
CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled “I ACCEPT”. If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled “I DO NOT ACCEPT” and exit from this computer screen.

Palmetto GBA Corporate Palmetto GBA Medicare

Top Links
Claims Processing Issues Log
Fee Schedules
Forms
Medicare Advisory
Provider Enrollment

CERT

CMS e-News

Learning & Education

Medical Policies

New to Medicare?

Online Provider Services

Publications

Resources

Stay Connected
Keep up with the latest information about Palmetto GBA by taking advantage of the Internet's connectivity.

Incentive Payment Program for Major Surgical Procedures Furnished in Health Professional Shortage Areas (HPSAs), Section 5501(b) of The Affordable Care Act, Payment to a Critical Access Hospital (CAH) Paid under the Optional Method

MLN Matters® Number: MM7146
Related Change Request (CR) #: 7146
Related CR Release Date: October 28, 2010
Effective Date: April 1, 2011
Related CR Transmittal #: R2078CP
Implementation Date: April 4, 2011

Provider Types Affected
This article is for general surgeons and CAHs submitting claims to Medicare contractors (Fiscal Intermediaries (FIs) and/or A/B Medicare Administrative Contractors (A/B MACs)) for services provided in HPSAs to Medicare beneficiaries.

Provider Action Needed
STOP – Impact to You
This article is based on Change Request (CR) 7146 regarding the new HPSA Surgical Incentive Payment Program (HSIP) and the new Primary Care Incentive Payment Program (PCIP) that will be implemented in conjunction with one another for Calendar Year (CY) 2011.

CAUTION – What You Need to Know
CR 7115 gives specific requirements for the PCIP, and CR 7146 includes the business requirements for the actions and costs associated with these incentive payments. Once CR 7115 is released, a related MLN Matters® article will be available at http://www.cms.gov/MLNMattersArticles/downloads/MM7115.pdf on the Centers for Medicare & Medicaid Services (CMS) website.

GO – What You Need to Do
See the Background and Additional Information Sections of this article for further details regarding these changes.

Background
The Affordable Care Act (Section 5501(b)) (http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_public_laws&docid=f:publ148.111.pdf) revises The Social Security Act (Section 1833(m); http://www.ssa.gov/OP_Home/ssact/title18/1833.htm) and authorizes an incentive payment program for major surgical services furnished by general surgeons in Health Professional Shortage Areas (HPSAs). The section provides for additional payments (on a monthly or quarterly basis) in an amount equal to 10 percent of the payment for physicians’ professional services under Part B.

The incentive payment also applies to surgical procedures (defined as 10- and 90-day global procedures on the Payment Policy Indicator File) furnished in an area designated as a HPSA (on or after January 1, 2011 and before January 1, 2016) by an 02-general surgeon who has reassigned their billing rights to a Critical Access Hospital (CAH) paid under the optional method.

The HPSA areas are those ZIP codes designated as such by The Secretary of Health and Human Services as of December 31 of the prior year. This list of ZIP codes is also utilized for automatic payments under the HSIP program.

HCPCS modifier AQ should be appended to the 10- or 90-day global surgical procedure on claims submitted for payment, similar to the current process for payment of the Medicare HPSA physician bonus when the HPSA is not a HPSA identified for automatic payment.

Medicare Contractors will use the existing HPSA HCPCS modifier (AQ) submitted on claims along with the physician specialty code 02 to identify circumstances when general surgeons furnish services in areas that are designated as HPSAs as of December 31 of the prior year, but that are not on the list of ZIP codes eligible for automatic payment.

Information regarding the Payment Policy Indicator File and other aspects of the Medicare Physician Fee Schedule is available at http://www.cms.gov/apps/physician-fee-schedule/overview.aspx on the CMS website.

To be consistent with the Medicare HPSA physician bonus program, HSIP payments are calculated by Medicare contractors based on the identification criteria for payment discussed below and paid on a quarterly basis to CAHs, on behalf of the qualifying general surgeon for the qualifying surgical procedures.

The additional HSIP payment will be combined, as appropriate, with the HPSA physician bonus payment. The special remittance advice for the incentive payments to CAHs will be revised to inform CAHS as to the type(s) of incentive payments, i.e., the HPSA physician, HSIP, or PCIP. In addition the remittance for the optional method CAHs will identify the NPI of the surgeon in the “operating provider” field.

Coordination with Other Payments
The Affordable Care Act (Section 5501(b)(4)) provides payment under the HSIP as an additional payment amount for specified surgical services without regard to any additional payment for the service under The Social Security Act (Section 1833(m)). Therefore, a general surgeon may receive both a HPSA physician bonus payment under the established program and an HSIP payment under the new program beginning in CY 2011.

NOTE: The current HPSA physician bonus program requirements for contractors will remain intact. The additions mentioned in the requirements below are for the HSIP and are based on The Affordable Care Act.

Payment to Critical Access Hospitals (CAHs)
Physicians and non-physician practitioners billing on Type of Bill (TOB) 85X (CAH) for professional services rendered in a CAH paid under the optional method have the option of reassigning their billing rights to the CAH. When the billing rights are reassigned to CAHs paid under the optional method, payment is made for professional services (revenue codes (RC) 96X, 97X or 98X).

For major surgical services furnished on January 1, 2011 and before January 1, 2016, CAHs paid under the optional method will be paid an additional 10 percent incentive based on the amount actually paid for those services when furnished by general surgeons in HPSAs. Quarterly incentive payments will be made to CAHs paid under the optional method on behalf of physicians.

Additional Information
The official instruction, CR 7146, issued to your FIs and/or A/B MACs regarding this change may be viewed at http://www.cms.gov/Transmittals/downloads/R2078CP.pdf on the CMS website.

If you have any questions, please contact the Palmetto GBA Provider Contact Center at their toll-free number, (866) 830-3455.

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2009 American Medical Association.

last updated on 11/18/2010

ver 1.0.37