Cardiology Coding Alert

Executive Summary: Many cardiology coders, who are located in urban settings, have heard about the 10 percent incentive bonus for physicians who treat Medicare patients in a Health Professional Shortage Area (HPSA), but they automatically presume that all HPSAs are located in rural areas. This incorrect assumption may be shortchanging their practice thousands of dollars per year in additional revenue. Your urban cardiology practice may also qualify as a HPSA. In this article, well tell you how to find out if youre entitled to the incentive bonus as well as how to code correctly.

Rural or urban, your cardiology practice may be eligible for the programs 10 percent incentive bonuses for certain services -- if you treat Medicare patients in a location designated by the Public Health Service as a HPSA. (Incentive payments are made for services on both assigned or non-assigned claims.)

Heres how to get your quarterly payment:

1. Determine HPSA status.
First, dont automatically eliminate your cardiology practice because it is in an urban setting. A HPSA is a HPSA whether its located in a metropolitan or rural area.

You could be in a HPSA and not even know it, says Sheila E. Sylvan, principal, IMPACT Medical Consulting in Atlanta. Some metropolitan HPSAs are as small as a city block.

For example, in the Bronx, Brooklyn, and Manhattan, HPSAs are identified by census tract numbers.

Your best bet is to call your states carrier and ask for a HPSA map, she advises. Then examine it carefully to see if your practice provides services within the designated areas.

Hani Seifin, MD, who practices cardiology in Carthage, TX, (a rural area) asks, Can I use the HPSA modifier for services rendered in my office, outpatient as well as in inpatient settings?"

Remember, your Medicare patients do not have to live in a HPSA, nor does your office or primary location have to be in a designated area. Its the point of contact between the physician and the provider that counts.

For example, if the cardiologist sees Medicare patients a in hospital, nursing home, skilled nursing facility, or patients home that is located within a HPSA, then services provided at that setting are subject to the bonus.

If your practice has a satellite facility, be sure to check its HPSA status as well, Sylvan says.

But, if you have an office in a HPSA, yet provide cardiology services outside the office, in a non-HPSA area, you would not be eligible for the incentive payment. Also be aware that, for HPSA purposes, it doesnt matter where your billing office is located.

If you do provide services in a location other than your main billing and/or mailing address, you must include the name and/or address of the other setting where the service was provided on the claim form. Otherwise, youll receive a reject code MA115: You billed one or more services in a HPSA, but you did not enter the physical location where the service was provided. Ask your carrier for specific information on how to enter the information electronically.

2. Use the correct HPSA modifier.
If you provide services to a Medicare patient in a rural HPSA, use modifier QB. For a metropolitan HPSA, use modifier QU. The modifier is attached to the professional component of the procedure code on the claim form.

Recall that, beginning April 1, 1998, HPSA incentive payments are made for professional services only.
Before billing, find out the professional component of each procedure by checking your Medicare Physician Fee Schedule. Look for the field labeled PC/TC, or Professional Component/Technical Component and check for the following numbers:

0 - indicates physician service codes. Since these services cant be split into a professional component and technical component, they are subject to the HPSA bonus.

1 - indicates diagnostic tests and radiology services. Only the professional component of this service qualifies or the HPSA bonus payment. If you bill the technical component of the globally-billed service, the services will be rejected as unprocessable.

2 - indicates that a code is a professional component only, and as such, is subject to the HPSA bonus.

3 - indicates a technical component only. It is not subject to the HPSA bonus and will be denied if billed with the HPSA modifiers.

4 - indicates global test codes, which describe the professional and technical component of the test. In this case, you cant use modifiers -26 (to report professional component separately) and TC (technical component). Only the professional component of the service qualifies for the HPSA bonus; all other services will be rejected as unprocessable.

5 - indicates incident to codes. If a physician assistant or other mid-level practitioner performed the service, you should not attach the QU or QB modifier because only services actually performed by a physician qualify for HPSA incentives.

6 - indicates laboratory physician interpretation codes, which are subject to the HPSA bonus.

7 - indicates physical therapy service, which will be denied because they are not subject to the HPSA bonus.

8 - indicates physician interpretation codes, which are subject to the HPSA bonus.

9 - means the concept of PC/TC does not apply. So if you attach the QU or QB modifier, the services will be denied.

(Note: For more coding tips, see box below.)

3. Check reimbursement bonuses carefully.
You wont receive the 10 percent incentive bonus along with the regular Medicare reimbursement. Instead, youll get one check that includes all HPSA payments for the quarter. The payment is 10 percent of the amount Medicare actually paid on the original claim, not the approved amount.

Be sure and review the check and itemized report thoroughly. If you dont review the quarterly check, how do you know if you are being paid the correct amount, notes Sylvan.

If you dont receive a HPSA incentive payment for a certain claim, but believe that you are entitled, check with your carrier. You may request that they reopen the claim and issue a revised remittance. Theres usually a time limit. For example, in New York, practices have one year from the date on the remittance to request a reopening of a HPSA payment. If you dont request a reopening within one year, then you forfeit your right to receive the bonus.

Tip: HPSA payments are taxable, and must be reported to the IRS.

4. Stay clear of a post-payment review.
Although using the HPSA modifiers could increase your pay-up, routinely or inappropriately attaching them could put your cardiology practice at risk for a post-payment audit.

For example, in New York, each quarter, the Medicare carrier prepares a ranked list of physicians who received incentive payments for the prior calendar quarter. They then select 25 percent of physicians on the list who received the highest payments and pull a sample of five claims for each physician. (If the physician provided services in a variety of settings such as the office, hospital, patients home, they select sample claims that represent those settings.)

This particular carrier reviews those selected claims to verify that the place of service shown was actually located in a rural or urban HPSA. If the auditors find that any of the claims should not have been coded for the incentive payment, they calculate and pursue the amount of any overpayment. They also contact the physician and his or her billing staff to resolve any discrepancies and correct any misunderstandings about the incentive program.

This process is repeated quarterly, but the carrier skips those physicians appearing higher on the list who were reviewed in an earlier quarter. An individual physician is not reviewed for more than one quarter within the same calendar year unless the carrier finds that a physician has claimed incentive payment erroneously. The physician would be subject to continuous monitoring until he or she is found to be in compliance. Physicians who are judged by the HCFA Regional Office as non-compliant can be sanctioned.

Tip: Remember, when you add that QU or QB modifier to the claim, youll also need to enter a 10 percent credit to the patients account and a 10 percent debit to the collection account in order to have an entry for the HPSA check to post against for your office accounting.