Do You Know what PCIP is? Do you Qualify?

By Elizabeth W. Woodcock, MBA, FACMPE, CPC

While the debates about implementing the national health care reform law rage on, many medical practices will start feeling tangible and positive impacts from the legislation starting this spring. The Patient Protection and Affordable Care Act, passed by Congress in March 2010, created the Primary Care Incentive Payment (PCIP) Program. While the HITECH Act provides incentives to a broad range of eligible professionals for the adoption of certified electronic health record systems, this program is focused on providing bonus payments to office-based primary care providers. Although it will not require primary care physicians or other eligible professionals to invest in new technologies or complete lengthy forms, there are some facts you need to check to make sure you receive the funds you may be due.

The program pays cash bonuses to eligible professionals in the following primary care specialties as designated by the primary taxonomy code registered with Medicare .

  • Family practice (code 08),
  • Internal medicine (code 11),
  • Pediatrics (code 37), and
  • Geriatrics (code 38).

Eligible midlevel providers and their taxonomy codes are:

  • Nurse practitioners (code 50),
  • Certified clinical nurse specialists (code 89), and
  • Physician assistants (code 97).

Successful participation, however, is not tied to specialty alone. To be considered an “office-based” primary care provider, the government established a requirement that 60 percent of the eligible professional's allowed charges under the Medicare physician fee schedule must fall within the evaluation and management (E/M) codes for:

  • New and established patient office or other outpatient visits (CPT codes 99201 through 99215);
  • Nursing facility care visits, and domiciliary, rest home, or home care plan oversight services (CPT codes 99304 through 99340); or
  • Patient home visits (CPT codes 99341 through 99350).

The designated E/M services must constitute at least 60 percent of the eligible providers Medicare allowed charges for services rendered over the previous two years.

The PCIP Program specifically excludes hospital inpatient care and emergency department visits from the calculation of eligible services. This means that hospitalists are not eligible, nor are a limited number of other primary care providers.

Of interest, however, to specialists is that the midlevel providers you employ may be eligible because the government will pay the incentives based on taxonomy designation and procedure codes – not by the specialty of the medical practice. Of course, in order to be eligible, the midlevel provider must bill the eligible primary care services for Medicare patients under his or her provider number, instead of incident to the specialist.

What's at stake? For those who are eligible, the cash bonuses are equal 10 percent of their Medicare allowed charges for the specified E/M codes. Bonuses are paid quarterly, based on the previous quarter's claims history.

There's also good news for providers who are also eligible for the incentives paid to health care professionals practicing in a government-designated Healthcare Professional Shortage Area (HPSA): they can receive both payments if they qualify.

New Physicians
Because the PCIP Program is focused on boosting the number of providers who choose to practice in primary care specialties, steps were taken to make sure it doesn't leave out new physicians who have not yet built two years' worth of claims experience. The program was amended to allow new office-based primary care providers to become eligible almost immediately after they start practice. The eligibility criteria remain the same, but new providers do not need two years' worth of claims history before the quarterly bonus payments kick in.

If you qualify, don't assume that the check is in the mail. Although the Centers for Medicare and Medicaid Services submitted the identification of providers eligible to receive the incentive payments to all Medicare carriers, it's important to verify that you are on the list. Check your eligibility for the PCIP Program on your Medicare carrier's website. Each Medicare carrier has posted an online tool that you can use to search its database. ( Example – from National Government Services .) Use the tool to make sure your National Provider Identifier (NPI) is in the carrier's database of eligible professionals for the PCIP Program bonuses.

If you're not on your Medicare contractor's PCIP bonus eligibility list, but think you should be, submit a written request to your Medicare carrier. Along with your letter of explanation, include your designated taxonomy code, as well as claims documentation that illustrates you billed the appropriate amount of the E/M codes required to be eligible for the PCIP bonus.