Tuesday, June 22, 2010

AQ modifier - Physician Providing a Service in a Health Professional Shortage Area

AQ Modifier

Description : Physician Providing a Service in a Health Professional Shortage Area (HPSA)

Required for Claims : Critical Access Hospitals (CAHs) Electing the Optional Payment Method
(Method II)

Type of Bill: 85X

Coding Guidelines : For services rendered in zip code areas subject to HPSA payment, the CAH must submit a QB or QU modifier to receive payment for claims with dates of service PRIOR TO January 01, 2006. Effective for claims with dates of service on or AFTER January 01, 2006, the modifier AQ must be submitted.

General Guidelines :
The following are the specific instances in which you will need to enter a modifier:

• When you provide services in zip code areas that do not fall entirely within a designated full county HPSA bonus area;

• When you provide services in a zip code area that falls partially within a full county HPSA but is not considered to be in that county based on the USPS dominance decision;

• When you provide services in a zip code area that falls partially within a nonfull county HPSA;

• When you provide services in a zip code area that was not included in the automated file of HPSA areas based on the date of the data run used to create the file.

Health Professional Shortage Area (HPSA) - Use of the AQ HCPCS Modifier May Reduce Cash Flow

Palmetto GBA is experiencing an increase in the number of providers that are submitting claims with the HPSA AQ HCPCS modifier incorrectly. In adding the HPSA AQ HCPCS modifier to a claim, you are attesting that you have researched www.hrsa.gov external link  for Medicare HPSA eligibility and determined that the physical address was a designated HPSA area where and when the services were rendered. If Palmetto GBA determines evidence to the contrary, you may begin to receive rejections on future claims submitted with the HPSA AQ HCPCS modifier in error. Additionally, identified overpayments will be collected on previously paid claims - This situation can drastically impact the cash flow for your office.


When a provider travels to a nursing home, hospital or 2nd office which is outside a HPSA those services are NOT eligible for the HPSA bonus, even if the provider’s primary office is within a HPSA designated area

To determine if you qualify to automatically (based on the rendered service zip code location) receive the bonus payment because the service location ZIP Code falls within a HPSA designated area, review the HPSA ZIP code for the correct year at: www.cms.gov external link  

If the ZIP code of the location where the services were rendered is not present, check the Palmetto GBA website for HPSA designations to determine if the location where you render services is within a HPSA bonus area, but still requires the submission of HCPCS modifier AQ

The most current source of HPSA designations is the Health Resources Services Administration (HRSA) website: http://hpsafind.hrsa.gov external link

If you have a question about a HPSA payment, you must submit a written inquiry to Palmetto GBA within 60 days of the date of the original HPSA payment, and include a copy of the Medicare remittance advice

The AQ HCPCS modifier for Mental HPSA locations may only be used by Psychiatrists. No other specialty may add the AQ HCPCS modifier for services rendered in a Mental HPSA

Only a “GEOGRAPHIC” HPSA is eligible for the Medicare HPSA bonus. Low income, population, Native American, Inmate, or any other type of HPSA does not qualify for the Medicare HPSA bonus. The AQ HCPCS modifier should never be submitted to Medicare for these types of non-eligible HPSA.

Submitting HPSA modifiers for services that do not qualify for the incentive payment could result in incentive payments being sent to you in error.

Please note: Providers that continue to incorrectly bill using the HPSA AQ HCPCS modifier are at risk of being referred to Benefit Integrity for fraudulent billing.

Date of Service (DOS)

Dates of service are also extremely important in determining HPSA eligibility. HPSA locations for Medicare payments purposes (may) change each January 1st. Therefore, even if you determine that your location became eligible during a year, you cannot begin using the AQ HCPCS modifier until January 1 of the following year.

For example, an address becomes a HPSA designated area on July 1, 2014. Any services rendered at that address are NOT eligible for the HPSA 10 percent bonus until January 1st, 2015.

Similarly, if the HPSA location is removed at any point during a year, Medicare will continue to pay the HPSA bonus until December 31 of that year. Refer to MLN CR 6106 at www.cms.gov external link  for complete details regarding dates of eligibility.

Helpful Tips:

Physicians/practitioners should ensure their billing service/clearinghouse is familiar with the proper use of the HPSA AQ HCPCS modifier

Providers with office locations in HPSA areas should have procedures in place to identify services rendered outside of the HPSA area to assure the HPSA AQ HCPCS modifier is not appended on those services

Check the HRSA website frequently for updated locations

HRSA submits designated bonus locations to the Federal Register on or by September of each year

The annual zip code bonus file is posted to CMS’ website on or around December 1

General Overview

The HPSA physician bonus program guidelines are contained in Publication 100-04, Chapter 12, and Section 90.4. Refer to that manual for payment and claims processing guidance for the HPSA physician bonus program that was established in 2005.

The following guidelines pertain only to qualifying 02- general surgeons who have reassigned their billing rights to CAHs paid under the optional method, and who are eligible to receive the additional 10 percent HSIP payment for major surgical procedures furnished in HPSAs from January 1, 2011 through December 31, 2015.

Contractors shall only identify eligible services with a 10 - or 90 - day global period rendered in eligible zip code areas based on the HPSA physician bonus program ZIP code file for the appropriate date of service.

Providers may report modifier AQ when submitting claims for major surgical procedures that were furnished in approved HPSAs, where those HPSAs are not recognized for automatic payment. The modifier must be appended to the major surgical procedure HCPCS code in order for the CAH paid under the optional method to be paid the 10 percent additional incentive payment for the surgical procedure on behalf of the general surgeon.

B. Method of Payment:

• Calculate and pay CAHs paid under the optional method on behalf of 02- general surgeons furnishing 10 - and 90 - day global surgical procedures in a recognized HPSA an additional 10 percent incentive payment based on 115 percent of the amount that would be paid for the surgeon’s professional services under the PFS;

• Calculate the payment based on the amount actually paid for the service, not the Medicare approved amount;

• Combine the additional payment with the HPSA physician bonus payment;

• Accept and pay services submitted with modifier AQ and;

• Revise the “special incentive remittance for CAHs” that is forwarded with the incentive check so that physicians can identify which type of incentive payment (HPSA physician, HSIP, or PCIP) was paid for which service.

C. Changes for Contractor Systems

The Medicare Carrier System, (MCS), Common Working File (CWF,) and National Claims History (NCH) shall be modified to accept a new HSIP and a new PCIP indicator on the claim line.

Once the type of incentive payment has been identified by the shared systems, the shared system shall modify their systems to set the indicator on the claim line as follows:

1 = HPSA;

2 = PSA;

3 = HPSA and PSA;

4 = HSIP;

5 = HPSA and HSIP

6 = PCIP;

7 = HPSA and PCIP;

Space = Not Applicable.

The contractor shared system shall send the HIGLAS 810 invoice for incentive payment invoices, including the new HSIP payment. The contractor shall also combine the practitioner’s HPSA physician bonus, Physician Scarcity (PSA) bonus (if it should become available at a later date), and HSIP payment invoice per practitioner. The contractor shall receive the HIGLAS 835 payment file from HIGLAS showing a single incentive payment per practitioner.

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