Revenue Cycle

CMS system update to allow correct NPI reporting for PCIP for CAHs reimbursed under optional method

Medicare Update for CAHs, April 18, 2012

Earlier this year CMS released a transmittal that implements a system update to include the rendering provider field to allow correct physician national provider identifier (NPI) reporting for the primary care incentive program (PCIP) for critical access hospitals (CAHS) reimbursed under the optional method.

PCIP background

Section 5501(a) of the Affordable Care Act provides for an incentive payment for primary care services furnished on or after January 1, 2011, and before January 1, 2016, by a primary care practitioner. The incentive payment will be paid on a monthly or quarterly basis in an amount equal to 10% of the payment amount for such services under Part B, according to MLN Matters article MM7060. According to CMS, these payments will be paid to practitioners as follows:

  • In the case of physicians, enrolled in Medicare with a primary specialty designation of 08-family practice, 11-internal medicine, 37-pediatrics, or 38-geriatrics
  • In the case of non-physician practitioners, enrolled in Medicare with a primary care specialty designation of 50-nurse practitioner, 89-certified clinical nurse specialist, or 97-physician assistant
  • For whom the primary care services accounted for at least 60% of the allowed charges under the PFS for such practitioner during the time period that has been specified by the Secretary

CMS will provide contractors with a list of the NPIs of the primary care practitioners eligible to receive the incentive payments.

What it means for CAHs

If a claim for a primary care service is submitted by a CAH paid under the optional method (Method II) for an eligible primary care physician’s (PCP) or non-physician practitioner’s (NPP) professional services, the “rendering provider” field on the claim must be populated by the eligible PCP’s NPI in order for the service to qualify for the incentive payment, according to CMS. Primary care services that may be eligible for the incentive payment, but furnished on different days, must be submitted on separate CAH claims so that a determination about the eligibility of the service based on the rendering practitioner can be made. If a CAH claim for a single date of service includes more than one PCP service, the incentive payment for all primary care services for the date shall be made to the CAH on behalf of the eligible PCP based on the NPI in the rendering provider field, according to Transmittal R2403CP. In addition to the CAH NPI, the rendering provider NPI will be shown on the special incentive remittance for CAHs.

It is important for CAHs to understand that there is only one rendering provider field on the UB-04 claim form to enter the NPI. If several physicians or NPPs at a CAH are eligible to receive the PCIP, the billing staff will also need to be aware that separate claims must be filed even if those services were provided on the same date of service, says Debbie Mackaman, RHIA, CHCO, regulatory specialist at HCPro, Inc.

“If the CAH is filing a recurring or series type bill—which is used when the same service is performed over a period of days or weeks—each date of service for that eligible professional must be filed on separate claims,” she says. “Otherwise, the PCIP will only be paid once instead of multiple times for that series account.”

She continued, “This change will add to the claims processing burden, but in the long run it will pay for itself based on the volume of claims eligible for the 10% add-on payment. The PCIP is in addition to the 115% of the MPFS (Medicare physician fee schedule) of which a CAH billing under Method II will be reimbursed.”

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