Tuesday, May 5, 2015

Health Professional Shortage Area (HPSA) and Physician Scarcity Area (PSA) Modifiers - BIlling guideline



 Modifier  &  Description

AQ  -  Service performed in a Health Professional Shortage Area. This modifier is 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.

AR   - Physician providing services in a physician scarcity area.

Provider Quality Reporting Initiative (PQRI) Modifiers

These modifiers are only to be used for PQRI, no other modifiers should be used when reporting PQRI.
Modifier &   Description
1P    Performance Measure Exclusion Modifier Due to Medical Reasons
2P    Performance Measure Exclusion Modifier Due to Patient Choic
3P    Performance Measure Exclusion Modifier Due to System Reasons
8P    Performance Measure Reporting Modifier - Action Not Performed, Reason Not Otherwise Specified

Ambulance Modifiers
For ambulance service claims, institutional-based providers and suppliers must report an origin and destination modifier for each ambulance trip provided in HCPCS/Rates.
Origin and destination modifiers used for ambulance services are created by combining two alpha characters. The first position alpha code equals origin; the second position alpha code equals destination.  

Origin/Destination    Description
D    Diagnostic or therapeutic site other than P or H when these are used as origin codes
E    Residential, domiciliary, custodial facility (other than 1819 facility)
G    Hospital based ESRD facility
H    Hospital
I    Site of transfer (e.g. airport or helicopter pad) between modes of ambulance transport
J    Freestanding ESRD facility
N    Skilled nursing facility
P    Physician’s office
R    Residence
S    Scene of accident or acute event
X    Intermediate stop at physician’s office on way to hospital

Note: This is a destination code only
In addition, institutional-based providers must report one of the following modifiers with every HCPCS code to describe whether the service was provided under arrangement or directly. 

Modifier    Description
QM    Ambulance service provided under arrangement by a provider of services
QN    Ambulance service furnished directly by a provider of services
QL    Patient pronounced dead after ambulance called




90.4- 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. Carrier responsibilities include:

Informing the physician community of these provisions;

Providing a link to the CMS Web site to access the HPSA automated ZIP code files;

Providing a direct link to HRSA’s HPSA database

Modifying the claims processing system to recognize and appropriately handle eligible claims;

Paying physicians the incentive payments; and

Performing post-payment reviews of samples of paid claims submitted using the AQ modifier.


Provider Education



ZIP Code files for the automated payment of the HPSA bonus payment will be developed and updated annually. Effective for claims with dates of service on or after January 1, 2009, only services provided in areas that are designated as of December 31 of the prior year are eligible for the HPSA bonus payment. Physicians providing services in areas that were designated as of December 31 of the prior year but not on the automated file may use the AQ modifier. Only services provided in areas that were designated as of December 31 of the prior year but not on the automated file may use the modifier.

Services provided in areas that are designated throughout the year will not be eligible for the HPSA bonus payment until the following year, provided they are still designated on December 31. Services provided in areas that are de-designated throughout the year will continue to be eligible for the HPSA bonus through the end of the calendar year.

CMS will post on its Web site ZIP Codes that are eligible to automatically receive the bonus payment as well as information on how to determine when the modifier is needed to receive the bonus payment. Through regularly scheduled bulletins and list serves, carriers must notify all physicians to verify their ZIP Code eligibility via the CMS Web site or the HRSA Website for the area where they provide physician services.

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