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Health Professional Shortage Area (HPSA) and Physician Scarcity Area (PSA) Bonus payment eligibility and billing instructions, information, and updates: Billing and Payment in a Health Professional Shortage Area (HPSA) Claims Coding Requirements for HPSA Billing and Payment in a Physician Scarcity Area (PSA) Identifying Physician Scarcity Area Locations Claims Coding Requirements for PSA Services Eligible for HPSA and Physician Scarcity Bonus Payments
To determine the County, County Subdivision, and or Census Tract of a particular area go to http://datawarehouse.hrsa.gov/geoHPSAAdvisor/, http://www.ffiec.gov/geocode/default.htm or http://factfinder.census.gov/home/saff/main.html?_lang=en. For the most current HPSA designations, you may access the Health Resources and Services Administration ( HRSA) homepage at www.bhpr.hrsa.gov/shortage/ or the HPSA query system directly at: http://hpsafind.hrsa.gov and use the advanced search feature. HRSA is an agency of the U.S. Department of Health and Human Services that makes the designation determinations. Please check the CMS Web site at www.cms.hhs.gov/HPSAPSAPhysicianBonuses to determine whether the HPSA/PSA bonus payment will automatically be paid for services rendered in your area.
Billing and Payment in a Health Professional Shortage Area (HPSA) 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 Resources and Services Administration ( HRSA), within the Department of Health & Human Services, is responsible for designating shortage areas. 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 populations 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 geographic-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 patient’s 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 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.
HPSA Designations Beginning with 2005, an automated file of designations 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 beginning January 1, 2005, through December 31, 2005. Physicians will be allowed to self-designate throughout the year for newly designated HPSAs and HPSAs not included in the automated file based on the date of the data run used to create the file. The bonus will be effective for services rendered on or after the date of designation by HRSA. The carriers 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 fall within a HPSA bonus area for both mental health and primary care services. After the implementation of this new process effective January 1, 2005, a recurring update notification will be issued for each annual update. Carriers will be informed of the availability of the file and the file name via an email notice. Carriers 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 health HPSA, only one bonus will be paid on the service. Bonuses for mental health HPSAs will only be paid when performed by the provider specialty of 26 – psychiatry. 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; are partially within a partial county HPSA; or are designated after the annual update is made to the automated file, physicians must still submit an 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 may 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 carrier and should verify the eligibility of their area for a bonus with their carrier 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.
Claims Coding Requirements for HPSA 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 Professional 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.
HPSA Payments The incentive payment is 10 percent of the amount actually paid, not the approved amount. Carriers pay the incentive payment for services identified on either assigned or unassigned claims. They do not include the incentive payment with each claim payment.
Billing and Payment in a Physician Scarcity Area (PSA) Section 413a of the MMA requires that a 5 percent bonus payment be established for physicians in designated physician scarcity areas for dates of service January 1, 2005, through December 31, 2007. The Medicare, Medicaid, and State Children’s 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. Physician scarcity designations will be based on the lowest primary care and specialty care ratios of Medicare beneficiaries to active physicians in every county. In addition, based on rural census tracts of metropolitan statistical areas identified through the latest modification of the Goldsmith Modification (i.e., Rural-Urban Commuting Area Codes), additional physician scarcity areas will be identified based on the lowest primary care and specialty care ratios of Medicare beneficiaries to active physicians in each identified rural census area.
Identifying Physician Scarcity Area Locations The CMS shall provide to the standard systems and carriers a file of zip codes for the automated payment of the primary care and specialty physician scarcity bonus. The file will be effective for claims with dates of service on or after January 1, 2005, through December 31, 2007. Carriers and shared systems will be notified by e-mail of the name of the file and when it will be available for downloading. The Medicare, Medicaid, and State Children’s Health Insurance Program (SCHIP) Extension Act of 2007 amended §1833(u)(1) of the Social Security Act and has extended payment of the Physician Scarcity Area bonus through June 30, 2008, using the same file used for prior years.
Claims Coding Requirements for PSA Medicare will automatically pay the physician scarcity bonus on a quarterly basis for services provided in zip code areas that fully fall within a county designated as a PSA, partially fall within a county designated as a PSA area and are considered to be dominant for that county based on a determination by the United States Postal Service (USPS), or fall within a rural census tract of a metropolitan statistical area identified through the latest modification of the Goldsmith Modification that is determined to be a PSA. In some cases, a service may be provided in a county that is considered to be a PSA, but the zip code is not considered to be dominant for that area. The bonus payment cannot automatically be made. In order to receive the bonus for those areas, physicians must include the following modifier on the claim: AR - Physician providing service in a Physician Scarcity Area. 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.
PSA Payments Section 413a of the MMA adds subsection (u)(6) to Section 1833 of the Social Security Act. For the payment of the physician scarcity bonus, this section defines physicians as doctors of medicine or osteopathy described per Section 1861(r)(1). Therefore, dentists, chiropractors, podiatrists, and optometrists are not eligible for the physician scarcity bonus as either primary care or specialty physicians Only the provider specialty designations of General Practice - 01, Family Practice - 08, Internal Medicine - 11, and Obstetrics/Gynecology – 16, will be paid the bonus for the zip codes designated as primary care PSAs. All other physician provider specialties will be eligible for the specialty physician scarcity bonus for the zip codes designated as specialty PSAs. The bonus is to be paid based on date of service. Accommodations must be made in payment systems to maintain an active file for a current period as well as an active file for a previous period so that the bonus can be paid based on date of service. Also, the carriers and standard systems maintainers shall program systems to be able to maintain files for the periods prior to the two active periods as an archive for reference purposes. A quarterly 5 percent bonus payment is made to the physician based on the amount actually paid, not the Medicare approved amount of the service.
Services Eligible for HPSA and Physician Scarcity Bonus Payments A. Information in the Professional Component/Technical Component (PC/TC) Indicator Field of the Medicare Physician Fee Schedule Database Carriers 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 following 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 carriers receive notification from physicians that they have chosen to forego the bonus payments, the carriers shall make no bonus payments to that physician for any service.
NOTE : Codes that have a status of “X” on the 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 payment nor the physician scarcity area bonus payment will be paid for these codes. B. Anesthesia Codes (CPT Codes 00100 Through 01999) That Do Not Appear on the MFSDB Anesthesia codes (CPT codes 00100 through 01999) do not appear on the MFSDB. However, when a medically necessary anesthesia service is furnished within a HPSA or physician scarcity area by a physician, a HPSA bonus and/or physician scarcity bonus is payable. To claim a bonus payment for anesthesia, physicians bill codes 00100 through 01999 with modifiers QY, QK, AD, AA, or GC to signify that the anesthesia service was performed by a physician along with the QB or QU modifier, or the AQ modifier for claims with dates of service on or after January 1, 2006, when required per §90.4.3 or the AR modifier as required per §90.5.3. C. Mental Health Services Physicians’ professional services rendered by the provider specialty of 26 – psychiatry, are eligible for a HPSA bonus when rendered in a mental health HPSA. The service must have a PC/TC designation per the chart above. Should a zip code fall within both a primary care and mental health HPSA, only one bonus must be paid on the service.
10/02/2008 |
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