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.
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.
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.
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.