Definition of Primary Care Practitioners and Primary Care Services


Primary care practitioners are defined as:

(1) A physician who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine for whom primary care services accounted for at least 60 percent of the allowed charges under the PFS (excluding hospital inpatient care and emergency department visits) for the practitioner in a prior period as determined appropriate by the Secretary; or

(2) A nurse practitioner, clinical nurse specialist, or physician assistant for whom primary care services accounted for at least 60 percent of the allowed charges under the PFS (excluding hospital inpatient care and emergency department visits) for the practitioner in a prior period as determined appropriate by the Secretary.
Primary care services are defined as Procedure  Codes:

(1) Procedure code 99201 through 99215 for new and established patient office or outpatient evaluation and management (E/M) visits;

(2) 99304 through 99340 for initial, subsequent, discharge, and other nursing facility E/M services; new and established patient domiciliary, rest home or custodial care E/M services; and domiciliary, rest home or home care plan oversight services; and

(3) 99341 through 99350 for new and established patient home E/M visits.



Identifying Primary Care Services Eligible for the PCIP


CAHs paid under the optional method billing on TOB 85X for professional primary care services (revenue code 96X, 97X or 98X) furnished by primary care physicians and nonphysician practitioners who have reassigned their billing rights to the CAH are eligible for PCIP payments.

The National Provider Identifier (NPIs) of primary care practitioners eligible for PCIP payment in a given calendar year (CY) are posted on Medicare contractor Web sites in the Primary Care Incentive Payment Program Eligibility File by January 31 of the applicable incentive payment CY. Eligible practitioners for PCIP payment in a given calendar year who were newly enrolled in Medicare in the year immediately preceding the PCIP payment year will be identified later in the payment year and posted on their Medicare contractor’s Web site at that point in time. CAHs paid under the optional method should contact their contractor with any questions regarding the eligibility of physician and nonphysician practitioners for PCIP payments.

Primary care practitioners furnishing primary care services will be identified on CAH claims by the NPI of the rendering practitioner as follows:

• Line level ‘Rendering Provider’ field when populated or,

• Claim level ‘Rendering Provider’ field where a line level ‘Rendering Provider’ field is blank or,

• Claim level ‘Attending Provider’ field if the claim level ‘Rendering Provider’ field is blank.

In order for a primary care service to be eligible for PCIP payment, the CAH paid under the optional method must be billing for the professional services of physicians under their NPIs or of physician assistants, clinical nurse specialists, or nurse practitioners under their own NPIs because they are not furnishing services incident to physicians’ services.

Multiple primary care services rendered by different physicians may be present on a single claim. Providers shall ensure they identify each physician on the claim form per the ASC X12 837 Institutional Claim Implementation Guide.


 Coordination with Other Payments

Section 5501(a)(3) of the ACA authorizes payment under the PCIP as an additional payment amount for specified primary care services without regard to any additional payment for the service under Section 1833(m) of the Social Security Act, the established Health Professional Shortage Area (HPSA) Medicare physician bonus program. Therefore, a CAH paid under the optional method and billing for the professional  services of an eligible primary care physician or nonphysician practitioner furnishing a primary care service in a health professional shortage area (HPSA) may receive both a HPSA physician bonus payment (as described in the Medicare Claims Processing Manual, Pub. 100-04, Chapter 4, Section 250.2) under the HPSA physician bonus program and a PCIP incentive payment under the new program beginning in CY 2011.

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