One of the many parts of the Affordable Care Act is the quarterly incentive payment program by Medicare for primary care services. This program is for primary care practitioners. The program began on January 1, 2011 and will sunset on December 31, 2015. The Primary Care Incentive Payment (PCIP) equals to 10% of the Medicare payment amount for primary care services. This amounted to $560 million for 2011. Who is eligible to receive the PCIP from Medicare? Primary care practitioners with a Medicare specialty designation of:

  • Family Medicine
  • Internal Medicine
  • Pediatric Medicine
  • Geriatric Medicine
  • Nurse Practitioner
  • Certified Clinical Nurse Specialist
  • Physician Assistant

What other conditions are necessary to meet for the incentive payment? The services have to be primary care services such as:

  • Office/Outpatient Visit – New and follow-up (CPT codes 99201-99215)
  • Nursing Facility Services (CPT 99304-99318)
  • Domiciliary, Rest, Home, (e.g., Boarding Home), or Custodial Care Services (CPT 99321-99337)
  • Domiciliary, Rest, Home, (e.g., Assisted Living Facility), or Home Care Plan Oversight Services (CPT 99339-99340)
  • Home Service (CPT 99341-99350)

The above services should be accounted for at least 60% of the practitioner’s total allowed charges under the physician fee schedule in the qualifying calendar year. This is how CMS measures if you qualify for the incentive. To calculate a practitioner’s primary care percentage, CMS uses Medicare claims data from the calendar year that is 2 years prior to the PCIP incentive payment year. Emergency, hospital inpatient, drug and laboratory charges are excluded when calculating the practitioner’s total allowed charges under the physician fee schedule. Source: CMS The top two specialty categories for 2011 PCIP were general internists at 50% and family physicians at 38%. Specialties in urban areas received the majority of the funds (86%), and the remaining portion (14%) went to specialties in rural areas, according to CMS data. In terms of actual participation numbers and dollar amounts, 61,728 family physician practices received nearly $213 million from the PCIP program in 2011 compared to 55,329 general internist offices that received nearly $280 million. Nearly 2,200 pediatric offices received about $1.7 million from the program in 2011, and 1,391 geriatricians got 1.7% of the funds. Of the $560 million distributed by CMS, Californian providers have received $48,634,595.

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