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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 submit claims with HPSA modifier "AQ" (Physician providing a service in a HPSA). While the modifier is defined for physicians only, any Medicaid HPSA-eligible provider may use them with the following procedure codes.

Category Procedure Code(s)
E&M Services* New Patient

Established Patient

Emergency Department

Newborn Care
99201, 99202, 99203, 99204, 99205

99211, 99212, 99213, 99214, 99215

99281, 99282, 99283, 99284, 99285

99460, 99461, 99462, 99463, 99464, 99465
Preventive Medicine 94772, 96110, 99386, 99387, 99396, 99397
Obstetric Care 59020, 59025, 59050, 59300, 59400, 59409, 59410, 59412, 59414, 59425, 59426, 59430, 59510, 59514, 59515, 59525, 59610, 59612, 59614, 59618, 59620, 59622, 59812, 59820, 59821, 59830, 76801, 76802, 76805, 76810, 76811, 76815, 76816, 76818, 76819, 76825, 76826, 76827, 76828 99204 + modifier "TH" (for initial antepartum care visit)**

99213 + modifier "TH" (for two to three antepartum care visits, after initial visit)**
Vaccines 90702, 90704, 90705, 90706, 90707, 90708, 90712, 90713, 90718, 90744

*Providers should not submit claims with HPSA modifier "AQ" and modifier "TJ" (Program group, child and/or adolescent) for procedure codes 99201-99215 and 99281-99285. Providers should use only a HPSA modifier, when applicable. Wisconsin Medicaid will determine the member's age and determine the proper HPSA reimbursement for these procedure codes.

**Providers are required to use modifier "TH" (Obstetrical treatment/services, prenatal or postpartum) with procedure codes 99204 and 99213 only when those codes are used to indicate the first three antepartum care visits. Providers are required to use both the "TH" modifier and HPSA modifier "AQ" when these prenatal services are HPSA eligible for appropriate reimbursement.

Modifier

To obtain the HPSA-enhanced reimbursement, indicate modifier "AQ" along with the appropriate procedure code on the claim.

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 only the first three antepartum care visits are being billed and the service is HPSA eligible, the provider should bill the appropriate E&M procedure code (99204 or 99213) with the "TH" modifier (Obstetrical treatment/services, prenatal or postpartum) listed first and the HPSA modifier listed second. Claims without modifier "TH" will result in lower reimbursement.

Pediatric Services Performed in a Health Professional Shortage Area

Reimbursement for eligible procedure codes with the HPSA modifier automatically includes the pediatric incentive payment, when applicable, since the incentive payment is based on the age of the member. Do not submit claims with the "TJ" modifier (Program group, child and/or adolescent) in addition to the HPSA modifier for the same procedure code. The "TJ" modifier may be used when submitting claims for eligible services in situations that do not qualify for HPSA-enhanced reimbursement. Pediatric services include office and other outpatient services (procedure codes 99201-99215) and emergency department services (procedure codes 99281-99285) for members 18 years and younger.

HealthCheck Services Not Eligible for Health Professional Shortage Area Incentive Payment

Procedure codes 99381-99385 and 99391-99395 are not eligible for HPSA bonuses, 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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