Clarification on Primary Care Incentive Program Clears Up Confusion

CMS Now Says Docs New to Medicare in 2010 Eligible for 2011 Bonus

March 02, 2011 04:10 pm News Staff

Primary care physicians new to Medicare in 2010 may be eligible for the 2011 primary care incentive program, or PCIP, bonus based on claims submitted in 2010. Furthermore, eligibility will be based on the available claims data with no minimum time of Medicare enrollment required.

That's the gist of a recent MLN Matters article( that answers questions about how CMS will handle newly enrolled Medicare primary care physicians who do not have -- as PCIP rules dictate -- a two-year claims history with which to determine eligibility for the bonus program.

CMS' action should be good news to those AAFP members who had concerns about the program that even AAFP staff had been unable resolve with CMS officials.

The PCIP, which is called for in the Patient Protection and Affordable Care Act, authorizes incentive payments equal to 10 percent of the Medicare-paid portion -- typically 80 percent -- of a primary care physician's allowed charges under Medicare Part B for primary care services provided on or after Jan. 1, 2011, and before Jan. 1, 2016.

The rules for how CMS will handle physicians new to Medicare in 2010 apply to all new Medicare physicians for the duration of the bonus program.

Each year of the PCIP, CMS will determine eligibility for physicians new to Medicare after the third quarter of the incentive year based on the physician's claims data from the prior year. The physician's incentive payment for the entire year will be paid in one lump sum after the fourth quarter of the bonus year.

According to CMS, the payment delay is necessary to allow the agency time to process claims data from physicians who recently signed up to participate in Medicare. All other physicians will receive their PCIP payments on a quarterly basis.

Individual Medicare contractors will post lists of new physicians in their coverage areas who are eligible for the incentive program by Nov. 28 each year.

Cynthia Hughes, C.P.C., an AAFP coding specialist, noted that there are additional details about the PCIP AAFP members should keep in mind. For example,

  • bonus payments will be based on the total amount paid to a physician for an entire year for CPT codes 99201-99215 and 99304-99350;
  • the Medicare claim must contain a medical group's National Provider Identifier, or NPI, number, as well as the NPI of the individual physician rendering services -- this does not apply in the case of solo physicians with no group number;
  • incentive program eligibility and payment amounts are based on the rendering physician's NPI number; and
  • bonus payments will be made to the medical group's NPI number.