MMA requires CMS to revise some of the policies that address HPSA bonus payments. The Social Security Act provides bonus payments for physicians who furnish medical care services in geographic areas that are designated by the HRSA as primary medical care HPSAs under section 332 (a)(1)(A) of the Public Health Service (PHS) Act. In addition, for claims with dates of service on or after July 1, 2004, psychiatrists (provider specialty 26) furnishing services in mental health HPSAs are also eligible to receive bonus payments. If a zip code falls within both a primary care and mental health HPSA, only one bonus will be paid on the service.
Effective January 1, 2005, a modifier no longer has to be included on claims to receive the HPSA bonus payment, which will be paid automatically, if services are provided in ZIP code areas that either:
- Fall entirely in a county designated as a full-county HPSA; or
- Fall entirely within the county, through a USPS determination of dominance; or
- Fall entirely within a partial county HPSA.
However, if services are provided in ZIP code areas that do not fall entirely within a full county HPSA or partial county HPSA, the AQ modifier must be entered on the claim to receive the bonus.
The following are the specific instances in which a modifier must be entered:
- When services are provided in ZIP code areas that do not fall entirely within a designated full county HPSA bonus area;
- When services are provided in a ZIP code area that falls partially within a full county HPSA but is not considered to be in that county based on the USPS dominance decision;
- When services are provided in a ZIP code area that falls partially within a non-full county HPSA;
- When services are provided in a ZIP code area that was not included in the automated file of HPSA areas based on the date of the data run used to create the file.
To determine if a service will automatically qualify to receive the bonus payment, review the information provided on the CMS Web site. The HRSA website should be reviewed for the most recent designations. Physicians may also use the HRSA website designations when making the decision on whether or not to include the HPSA modifier on their claims.
Some points to remember include the following:
- Medicare contractors will base the bonus on the amount actually paid (not the Medicare approved payment amount for each service) and the ten-percent bonus will be paid on a quarterly basis.
- The HPSA bonus pertains only to physician’s professional services. Should a service be billed that has both a professional and technical component, only the professional component will receive the bonus payment.
- The key to eligibility is not that the beneficiary lives in a HPSA nor that the physician’s office or primary location is in a HPSA, but rather that the services are actually rendered in a HPSA.
- A single service may be eligible for both the HPSA bonus payments and the PSA bonus payment.
- To be considered for the bonus payment, the name, address, and ZIP code of the location where the service was rendered must be included on all electronic and paper claim submissions.
- Physicians should verify the eligibility of their area for a bonus before submitting services with a HPSA modifier for areas they think may still require the submission of a modifier to receive the bonus payment.
- Services submitted with the AQ modifier will be subject to validation by Medicare.