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Reimbursement : Amounts

Topic #648

Health Professional Shortage Areas

Enhanced reimbursement is provided to Medicaid-enrolled primary care providers and emergency medicine providers for selected services when one or both of the following apply:

  • The rendering or billing provider is located in a HPSA-eligible ZIP code.
  • The member has a residential address (according to enrollment records) within a HPSA-eligible ZIP code.

Primary care providers and emergency medicine providers include the following:

  • Physicians with specialties of general practice, obstetrics and gynecology, family practice, internal medicine, or pediatrics.
  • Physician assistants.
  • Nurse practitioners.
  • Nurse midwives.

Standard enhanced reimbursement for HPSA-eligible primary care procedures is an additional 20 percent of the physician maximum allowable fee. The enhanced reimbursement for HPSA-eligible obstetrical procedures is an additional 50 percent of the physician maximum allowable fee.

Health Professional Shortage Area-Eligible Procedure Codes

Providers may use HPSA modifier AQ (Physician providing a service in a HPSA) with the following categories of procedure codes (while the AQ modifier is defined for physicians only, any Medicaid HPSA-eligible provider may use the modifier when appropriate):

  • E&M Office Visits, New Patient.
  • E&M Office Visits, Established Patient.
  • E&M Home Visits, New Patient.
  • E&M Home Visits, Established Patient.
  • Emergency Department Services.
  • Newborn Care.
  • Preventive Medicine.
  • Obstetric Care.
  • Vaccines.

Use of Modifier AQ

To obtain the HPSA-enhanced reimbursement, providers are required to indicate modifier AQ along with the appropriate procedure code on the claim. (Refer to the Pediatric Services Performed in a Health Professional Shortage Area section of this topic for information regarding use of modifier AQ for pediatric services.)

Medicare Crossover Claims

Medicare HPSA policy differs from Wisconsin Medicaid's HPSA policy in many ways. Medicaid covers more services than Medicare, allows a broader range of providers to receive the incentive payment, pays a higher bonus, and defines HPSA differently than Medicare. Most importantly, Wisconsin Medicaid pays the enhanced reimbursement to physicians, physician assistants, nurse practitioners, and nurse midwives while Medicare pays the HPSA incentive payment only to physicians.

For these reasons, Medicare crossover claims that are eligible for the Medicaid HPSA incentive payment may not automatically be forwarded to ForwardHealth from Medicare. Providers may have to submit these claims directly to ForwardHealth.

Antepartum Care Visits Performed in a Health Professional Shortage Area

If a provider renders three or fewer antepartum care visits, the provider is required to bill the appropriate E&M service code with modifier TH (Obstetrical treatment/services, prenatal or postpartum) listed first and the HPSA modifier AQ listed second.

Pediatric Services Performed in a Health Professional Shortage Area

Pediatric services include office and other outpatient services and emergency department services for members 18 years of age and younger.

Reimbursement for eligible procedure codes with HPSA modifier AQ automatically includes the pediatric incentive payment, when applicable, since the incentive payment is based on the age of the member. Providers should not submit claims with modifier TJ in addition to HPSA modifier AQ for the same procedure code. Providers should only include the HPSA modifier in situations where both of these modifiers apply. Wisconsin Medicaid will determine the member's age and determine the proper HPSA reimbursement for these procedure codes.

Modifier TJ may be used when submitting claims for eligible services in situations that do not qualify for HPSA-enhanced reimbursement.

HealthCheck Services Not Eligible for Health Professional Shortage Area Incentive Payment

Procedure codes 99381-99385 and 99391-99395 are not eligible for HPSA incentive payments, regardless of the billing or rendering provider's or member's location, since reimbursement for these procedure codes includes enhanced reimbursement for HealthCheck services.

Claims Submitted Inappropriately for Health Professional Shortage Area Incentive Payment

Providers who submit claims for the HPSA-enhanced reimbursement inappropriately are reimbursed the lesser of the provider's usual and customary fee or the maximum allowable fee, assuming that all other ForwardHealth policies are followed. The enhanced reimbursement amount is not paid when the HPSA modifier is submitted but the provider or member is not eligible for HPSA designation.

 
 
 


 
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