Services Eligible for HPSA and Physician Scarcity Bonus Payments

90.4.5 - Services Eligible for HPSA and Physician Scarcity Bonus Payments (Rev. 4431, Issued: 11-01-19, Effective: 02-04-20, Implementation: 02-04-20) A. Information in the Professional Component/Technical Component (PC/TC) Indicator Field of the Medicare Physician Fee Schedule Database A/B MACs (B) use the information in the Professional Component/Technical Component (PC/TC) indicator field of the Medicare Physician Fee Schedule Database to identify professional services eligible for HPSA and physician scarcity bonus payments. The following are the rules to apply in determining whether to pay the bonus on services furnished within a geographic HPSA or, physician scarcity bonus area. Should A/B MACs (B) receive notification from physicians that they have chosen to forego the bonus payments, the A/B MACs (B) shall make no bonus payments to that physician for any service. PC/TC Indicator Bonus Payment Policy 0 Pay bonus 1 Globally billed. Only the professional component of this service qualifies for the bonus payment. The bonus cannot be paid on the technical component of globally billed services. PC/TC Indicator Bonus Payment Policy ACTION: Effective for claims received prior to October 1, 2005, A/B MACs (B) return the service as unprocessable and notify the physician that the professional component must be re-billed if it is performed within a qualifying bonus area. If the technical component is the only component of the service that was performed in the bonus area, there wouldn’t be a qualifying service. Effective for claims received on or after October 1, 2005, A/B MACs (B) shall accept claims with services with a PC/TC indicator of 1 that are eligible for the HPSA or PSA bonus. They shall pay the bonus only on the professional component of the service. 1 Professional Component (modifier 26). A/B MACs (B) pay the bonus. 1 Technical Component (modifier TC). A/B MACs (B) do not pay the bonus. 2 Professional Component only. A/B MACs (B) pay the bonus. 3 Technical Component only. A/B MACs (B) do not pay the bonus. 4 Global test only. Only the professional component of this service qualifies for the bonus payment. ACTION: Effective for claims received prior to July 1, 2006, A/B MACs (B) return the service as unprocessable. They instruct the provider to re- bill the service as separate professional and technical component procedure codes. Effective for claims received on or after July 1, 2006, except for 93015, A/B MACs (B) shall accept claims with services with a PC/TC indicator of 4 that are eligible for the HPSA or PSA bonus. They shall pay the bonus only on the associated professional component of the service. Since 93015 has two associated professional components, A/B MACs (B) will not be able to make a determination as to which would be the correct component to use to calculate the bonuses. Therefore, A/B MACs (B) shall continue to treat 93015 as unprocessable. 5 Incident to codes. A/B MACs (B) do not pay the bonus. 6 Laboratory physician interpretation codes. A/B MACs (B) pay the bonus. 7 Physical therapy service. A/B MACs (B) do not pay the bonus. 8 Physician interpretation codes. A/B MACs (B) pay the bonus. PC/TC Indicator Bonus Payment Policy 9 Concept of PC/TC does not apply. A/B MACs (B) do not pay the bonus. NOTE: Codes that have a status of “X” on the Medicare Physician Fee Schedule Database (MFSDB) have been assigned PC/TC indicator 9 and are not considered physician services for MFSDB payment purposes. Therefore, neither the HPSA bonus payment nor the physician scarcity area bonus payment will be paid for these codes. B. Anesthesia Codes (CPT Codes 00100 Through 01999) That Do Not Appear on the MFSDB Anesthesia codes (CPT codes 00100 through 01999) do not appear on the MFSDB. However, when a medically necessary anesthesia service is furnished within a HPSA or physician scarcity area by a physician, a HPSA bonus and/or physician scarcity bonus is payable. To claim a bonus payment for anesthesia, physicians bill codes 00100 through 01999 with modifiers QY, QK, AD, AA, or GC to signify that the anesthesia service was performed by a physician along with the QB or QU modifier, or the AQ modifier for claims with dates of service on or after January 1, 2006, when required per §90.4.3 or the AR modifier as required per §90.5.3. C. Mental Health Services Physicians’ professional services rendered by any of the psychiatry provider specialties, are eligible for a HPSA bonus when rendered in a mental health HPSA. The service must have a PC/TC designation per the chart above. Should a zip code fall within both a primary care and mental health HPSA, only one bonus must be paid on the service.