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Primary Care Coding Alert

CMS Automatically Pays 5-10 Percent Extra on These Services

Published on Tue Mar 01, 2005

Making these lists means you don't need modifiers, and you get more money

You can eliminate the extra step of using a specialty designation modifier and still receive a bonus payment - if your ZIP code appears on one of two lists.

But family practices that don't make the cut may also qualify for scarcity service allotments in 2005. Here's how to determine your designation and filing guidelines.

Surprise: You Could Qualify for Bonus Money

Even if you think your family physician doesn't provide care in a health professional shortage area (HPSA) or in a physician scarcity area (PSA), you should double-check your eligibility. "Many coders are unaware that CMS now classifies their ZIP code as an HPSA and/or PSA," says Connie Woods, CPC, consultant with Joy Newby and Associates in Indianapolis.

Problem: If you don't know that you qualify as an HPSA and/or PSA, you could receive numerous denials. You'll file claims without taking the added coding guidelines these designations may impose, which will trigger denials, Woods says.

Benefit: Despite changing some reporting methods, such as ECGs, you'll receive more money for your designation. CMS pays a 10 percent bonus to physicians rendering services in HPSAs and 5 percent to physicians providing care in PSAs.

Full-County HPSAs Don't Require Modifier

You may no longer need to report a modifier on HPSA claims to receive the bonus. Your modifier -QB (Physician providing service in a rural HPSA) or -QU (Physician providing service in an urban HPSA) use hinges on your ZIP code. 

Old way: Prior to Jan. 1, 2005, FPs rendering services in HPSAs had to include modifier -QB or -QU on claims to receive the 10 percent bonus payment for providing care in these regions.

New way: You will automatically receive your extra compensation without having to append a modifier, if your FP provides care in ZIP codes that fall entirely within a full-county or partial-county HPSA.

However, if you provide care in ZIP codes that CMS doesn't designate as full- or partial-county HPSAs, "you must continue to enter either the -QB or -QU modifier on your claim to receive the bonus," states the CMS article Medlearn Matters (SE0449).

5 Steps Reveal Your HPSA 'Q' Rule 

To determine if you qualify for an automatic bonus and no longer need to use modifier -QB or -QU, search for your ZIP code in the file "2005 Primary Care HPSA." If your ZIP code is on the list, you don't need to use modifier -QB or -QU.

If you don't find your ZIP, you may still be eligible for the HPSA bonus. Your search isn't over until you complete two additional tasks:
 

  • Go to your carrier's Web site for HPSA designations.
     
  • Verify whether the location where you render services is within an HPSA bonus area, but still requires using a modifier.

    Updates: CMS will only add and remove areas to the file list annually. If your FP renders services in a newly designated HPSA area (one added during the year), you should report modifier -QB or -QU to receive the bonus.

    County-Dominated PSAs Use No Modifier

    After checking your HPSA information, you should also see whether your practice falls under CMS' PSA designation. For 2005, Medicare will pay over 11,000 regions a 5 percent bonus for certain services.

    You will automatically receive this new bonus on a quarterly basis and won't have to use a modifier for services that your FP provides in ZIP code areas that:
     

  • fall fully within a county designated as a PSA
     
  • fall partially within a county designated as a PSA and are considered to be dominant for that county based on the USPS' determination
     
  • fall within a rural area of a metropolitan statistical area identified through the latest modification of the Goldsmith Modification that is determined to be a PSA.

    -AR Filing Depends on Search Results

    To find out whether you qualify for a PSA automatic payment and don't have to submit a modifier, download the zip file "Primary Care PSA ZIP codes" from the CMS bonus payment Web page.

    If your ZIP code is on the list, you don't need to use modifier -AR (Physician providing services in a physician scarcity area) to receive the PSA bonus payment.

    Watch out: Practices in ZIP codes that don't appear on the list may still qualify for the incentive money. To check whether you can receive the payment, download the file "Primary Care PSA Counties."

    Action: If you made this list, append modifier -AR on your claims to obtain the 5 percent bonus payment.

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