Coding & Reimbursement

More Money For Docs in Under-Served Areas

By Suzanne L. Corcoran, COE

With all of the changes taking place in American medicine and the uncertainty about reimbursement, any possible additional payments to physicians are more important than ever. Here is something for which many ophthalmologists may already qualify. Medicare will make bonus payments to physicians caring for patients in underserved areas. Read on for what you need to know.

Q. Are physicians eligible to receive payments above and beyond the Medicare physician fee schedule?

A. Yes. The Omnibus Budget Reconciliation Act of 1987 provided incentive payments to physicians who furnish services to Medicare beneficiaries in rural and urban Health Professional Shortage Areas (HPSAs), beginning January 1, 1989.

These incentive payments were established to attract and retain physicians in under-served areas. Both ophthalmologists and optometrists are eligible for HPSA bonus payments.

Q. How are the bonus payments made to providers?

A. Bonus payments are made quarterly to providers for professional services. These include exams, surgical procedures and the professional component of diagnostic tests. The technical component of diagnostic tests is not eligible.

The bonus payment is based on the amount Medicare paid for the service, rather than the allowed amount. The HPSA bonus is 10%.

Q. How do I determine eligibility for these bonuses?

A. The CMS Web site lists ZIP codes that will automatically receive bonus payments.¹ The ZIP code in which the service is provided determines whether or not the bonus payment is made. For example, if the physician's office is located in a designated bonus area but the hospital is not, services provided in the office would be eligible for a bonus payment, but services performed at the hospital would not. The converse is also true.

Q. Are the ZIP code lists on the CMS Web site complete?

A. Unfortunately, no. Areas that do not fall fully within a designated HPSA area may not be listed, but still be eligible. CMS publishes a step-by-step guide to assist in determining eligibility for the bonus if the ZIP code is not listed on the CMS Web site.²

The HPSA automated file is updated on an annual basis. Individual Medicare Administrative Contractors (MACs) provide quarterly updates on their Web sites for changes to HPSA designations. These changes include both new designations as well as withdrawals of HPSA areas.

Q. Are there special modifier requirements for our claims?

A. Sometimes. Historically, services eligible for an HPSA bonus were submitted with a modifier (modifier QU for urban HPSA and QB for rural). The modifier is no longer necessary if your ZIP code is listed as HPSA-eligible; the bonus payment is automatic.

Eligible services provided at locations not included in the ZIP code list will continue to need a modifier. Modifier AQ indicates you are in an HPSA area but you are not included in a listed ZIP code area. Modifier AQ may also be required on newly designated areas not yet posted on the automatic listing.

Q. What about billing requirements for diagnostic tests?

A. Bonuses are paid for the professional component (PC, modifier 26) but not the technical component (TC) of diagnostic services. Many MACs previously required that claims for diagnostic tests with both PC and TC components be broken up, with the two components indicated on separate lines.

Instructions in the Medicare Claims Processing Manual, Chapter 12, section 90.4.5 (revised in July 2006), indicate that separating the test into two components is no longer necessary. MACs are now instructed to calculate the bonus on the professional component only so you don't have to separate your claims.

Q. Are there other bonuses available for physicians?

A. Yes, although some do not apply to eyecare professionals. HSIP (HPSA Surgical Incentive Payment) was created by the Affordable Care Act of 2010. It allows a 10% bonus for surgical services, but it is paid only to general surgeons—not to ophthalmologists or optometrists.

In addition to bonuses for services in under-served areas, keep in mind that there are several bonuses that ophthalmologists and optometrists may qualify for. These include electronic prescribing (E-Rx), the HIT bonus for electronic health records, and PQRS (physician quality reporting system, formerly PQRI). OM

References

1. http://www.cms.hhs.gov/HPSAPSAPhysicianBonuses/
2. http://www.cms.hhs.gov/HPSAPSAPhysician Bonuses/Downloads/instructions.pdf

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.