CMS Pub. 100-04, ch. 4, § 250.13.5

A. 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.