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Primary Care Providers and General Surgeons Benefit from Increased Medicare Reimbursement
April 28, 2011
Effective January 1, 2011, and continuing to December 31, 2015, qualifying primary care providers and general surgeons in health professional shortage areas will benefit from a 10% increase in their reimbursement for certain services from Medicare Part B. This increased reimbursement from the Patient Protection and Affordable Care Act (PPACA) creates incentives to general practitioners to provide much needed primary care and general surgery services. PPACA, Pub. L. No. 111-148, § 5501 [PDF]; 2011 Physician Fee Schedule, Final Rule, Fed. Reg. 73170, 73431-43 (Nov. 29, 2010) [PDF]).
A. Qualifying Primary Care Providers and the Primary Care Incentive Payment
In order for primary care providers to receive the 10% increased Medicare reimbursement, those providers must have both a qualifying enrollment code and have billed a sufficient quantity of qualifying HCPCS codes in 2009 and 2010. The 10% reimbursement increase applies only to physicians who enrolled with Medicare with the specialty code for family internal, geriatric, or pediatric medicine. Nurse practitioners, clinical nurse specialists, and physician assistants enrolled in Medicare are also eligible for the 10% increased reimbursement.
Primary care providers must have charged at least 60% of their allowable Medicare Part B physician fee schedule charges in qualifying HCPCS codes in 2009 and 2010 to be eligible for the 10% increase. The qualifying codes are 99201-99215 (new and established patient office visits), 99304 – 99340 (nursing facility, custodial and domiciliary visits), and 99341 – 99350 (home visits). Primary care providers who did not meet the 60% threshold in 2009 and 2010 now have an incentive to shift their practice habits to provide more primary care services to Medicare beneficiaries to be eligible in 2012 or future years.
Primary care practices should be aware that the incentive payment is based on the National Provider Identifier Number (NPIN) of the individual practitioner. Accordingly, the individual physician's NPIN must be included on the claims submission. Additionally, the nurse practitioner, clinical nurse specialist, and physician assistant services must be billed under their NPINs, and not incident to physician services, to be eligible for the incentive payment. An exception to the two year charge period will be made for primary care providers who enrolled in 2010 and have only one year of claims submissions to satisfy the 60% threshold. However, the payment and processing for those newly enrolled providers who satisfy the 60% threshold in only 2010 will be delayed until the end of the calendar year 2011 payment period.
For those primary care providers who qualify for the incentive program, Medicare Part B will increase their reimbursement only for the above qualifying codes. This increased payment will be provided on a quarterly annual basis.
B. General Surgery in a Health Professional Shortage Area (HPSA)
Surgeons who have enrolled in Medicare as general surgeons and perform surgery in a HPSA will also receive a 10% increase in their Medicare Part B reimbursement. Procedures with a 10 or 90 day global procedure reimbursement under the Physician Fee Schedule are eligible for the incentive payment. The incentive payments will be made quarterly.
However, surgeons should also be mindful of the billing requirements to receive this incentive payment. Similar to the primary care incentive payments, surgery groups should bill the surgery code using the NPIN of the general surgeon. The 10% incentive payment is available for procedures performed in zip codes identified by CMS as HPSAs, which means that physicians already receiving a HPSA bonus payment should also automatically receive the 10% surgery incentive in addition to the HPSA bonus payment. Surgery groups should also be aware that some zip codes are not eligible for automatic HPSA bonus payments even though the zip code is located within a HPSA. For those claims, the identifier "AQ" should be added to receive the incentive.
Ober|Kaler’s Comments
Primary care practitioners and general surgeons in HPSAs should enjoy a slight increase in Medicare Part B reimbursement until the end of 2015. Primary care physicians who have shifted their practices away from the qualifying HCPCS codes over the last few years may want to consider shifting their practice to the more traditional primary care services to be eligible for the new incentive.
However, physicians should be mindful that both of these incentive payments are subject to the budget neutrality provisions of Medicare Part B physician reimbursement. Accordingly, CMS may, in the future, decrease overall physician reimbursement to offset the increased payments under these two incentive plans and reduce the effect of these amounts on the solvency of the Supplemental Medical Insurance Trust Fund.
