Saturday, March 6, 2010

Health Professional Shortage (HPSA) and Physician Scarcity (PSA) Area

HPSA For claims with dates of services prior to January 1, 2006, these modifiers are used by physicians to indicate the services reported were rendered in a qualified Health Professional Shortage Area (HPSA) and are eligible for the 10% incentive payment.

QB Physician providing service in a rural HPSA

QU Physician providing service in an urban HPSA

Effective for dates of service on or after January 1, 2006, a new modifier -AQ replaces the two existing modifiers (QB and QU) for physician services provided in HPSAs. Effective October 1, 2007, claims received for dates of service 01/01/2006 and after with modifiers QB or QU will be rejected/denied.

AQ Service performed in a Health Professional Shortage Area.


PSAIn some cases, a service may be provided in 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 will need to include the modifier AR.
Physician’s Voluntary Reporting Program

1P Performance Measure Exclusion Modifier due to Medical Reasons
2P Performance Measure Exclusion Modifier due to Patient Choice
3P Performance Measure Exclusion Modifier due to System Reasons



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.

Provider Education
Upon publication of the final rule of the 2005 Medicare Physician Fee Schedule, CMS will post on its Web site zip codes that are eligible for automatic payment of the physician scarcity bonus payment.

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


January 1, 2005 for the coding, testing, and implementation phases for the MCS Maintainer and Contractors

January 1, 2005 for all phases for the VIPS Maintainers and Contractors)

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.

Payment


January 1, 2005 for the coding, testing, and implementation phases for the MCS Maintainer and Contractors

January 1, 2005 for all phases for the VIPS Maintainers and Contractors)

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.

No comments:

Post a Comment

Most read cpt modifiers