Information Regarding Medicare's Primary Care Incentive Payment Program (PCIP)

Physicians and non physician practitioners (NPPs), who bill Medicare Carriers or Medicare Administrative Contractors (A/B MACs) for primary care services rendered to Medicare beneficiaries, are affected by this information.

CMS has compiled the following list of questions and answers to respond to the inquiries it
has received on the PCIP:

Q1. How does Section 5501(a) of the Affordable Care Act change Medicare?
A1. Beginning with services rendered on or after January 1, 2011 and continuing through
December 31, 2015, Section 5501(a) of the Affordable Care Act authorizes an incentive
payment of 10 percent of Medicare's program payments to be paid to qualifying primary
care physicians and NPPs who furnish specified primary care services.
(Please note: coinsurance, copayments, and deductibles are not included in the calculation of PCIP incentive payments).

Q2. Which Medicare specialty designations may potentially qualify as primary care physicians or NPPs?
A2. A potentially qualified primary care physician or NPP, as defined in Section 1833 (x)
of the Social Security Act, is a physician with a Medicare specialty designation of family
medicine, internal medicine, geriatric medicine, or pediatric medicine or an NPP with a specialty designation of Nurse Practitioner(NP), Clinical Nurse Specialist(CNS), or Physician Assistant(PA).

Q3. How can I confirm my primary specialty designation in Medicare?
A3. You may contact your Medicare claims processing contractor to confirm your primary
Medicare specialty designation. Medicare allows two specialty designations upon enrollment’ however, PCIP payment eligibility is only determined onthe primary specialty
designation.

Q4. What are the additional qualifying criteria for the primary care incentive payment program?
A4. Physicians and NPPs of a potentially qualifying specialty whose primary care percentage from historical claims data for the specified period, calculated as primary care allowed charges divided by the total Physician Fee Schedule (PFS) allowed charges excluding hospital inpatient and emergency department visits, and then multiplied by 100, exceeds 60 percent will be eligible for the PCIP. For established physicians and NPPs enrolled in the Medicare program two years prior to the PCIP payment year, the primary care percentage is calculated based on claims data from 2 years prior to the PCIP payment year. Medicare annually identifies the national provider identification numbers (NPIs) of qualified primary care physician and nonphysician practitioners for each PCIP payment year.

Q5. What are the specific primary care services that are eligible for incentive payments?
A5. The specific services are defined by the following Current Procedural Terminology (CPT)codes:
• 99201 through 99215 (office and other outpatient visits).
• 99304 through 99340 (nursing facility, domiciliary, rest home, or custodial care).
• 99341 through 99350 (home services).
Only the services reflected in the CPT ranges above will be eligible for primary care incentive payments.

Q6. What if I am a physician or NPP newly enrolled in Medicare and do not have claims data from two years prior to the PCIP payment year?
A6. For newly enrolled Medicare practitioners who do not have claims data from two years prior to the PCIP payment year upon which an eligibility determination can be made, Medicare will make PCIP eligibility determinations based upon the claims data from the
year before the PCIP payment year. There is no minimum amount of claims data required
from that year and eligibility determination will be made based on the claims data available,
with no minimum time period.
Due to the lag-time in processing claims, PCIP eligibility for new physicians and NPPs will
be determined after the close of the third quarter of the PCIP payment year and a single cumulative PCIP payment for all eligible primary care services furnished in the PCIP payment year by that newly enrolled, eligible primary care physician or NPP will be made
after the close of the fourth quarter of the PCIP payment year.

Q7. How can I verify my percentage of primary care services from the claims data year used for eligibility determination (for example, CY 2009 data for the CY 2011 PCIP payment year)?
A7. You may contact your Medicare claims processing contractor to confirm your percentage of primary care services for CY 2009.

Q8. Do I need to enroll in the PCIP program to participate?
A8. No, there is no enrollment process for participation in the PCIP. The NPIs of qualified primary care physicians and NPPs are identified by CMS based on an analysis of historical
Medicare claims.

Q9. How can I confirm that I am eligible for the PCIP?
A9. In the beginning of the PCIP payment year, each Medicare claims processing contractor is provided a national PCIP eligibility file that identifies the NPIs of all eligible primary care physicians and NPPs. If your NPI is on the list, you are automatically eligible for PCIP payments in the applicable PCIP payment year. This file may be viewed on your Medicare contractor’s website.

Q10. If I qualify for the PCIP payments in Calendar Year (CY) 2011, will I have to qualify again for the remaining PCIP payment years?

A10. Yes, each physician or NPP must requalify for each PCIP payment year. Eligibility for established physicians and NPPs is determined using claims data from the most recent full calendar year (CY) of data available. For example, CY 2011 PCIP payment year eligibility was determined based on PFS claims from CY 2009.