Primary Care Incentive Payment Program (PCIP)

The PCIP incentive will allow physicians in primary care practices a 10% bonus regardless of which zip code they practice in. The 10% will be paid quarterly and will be based on the actual amount paid, not the allowed amount. If the EP practices in a Health Professional Scarcity Area (HPSA) they will qualify for both the PCIP and HPSA bonus payments.

PCIP services are defined as new or established patient office visits or other outpatient visits within CPT code range 99201 through 99215; nursing facility care visits, domiciliary, rest home or home care plan oversight services within code range of 99304 through 99340; and patient home visit codes 99341 through 99350.

Primary care physicians are defined as physicians who have a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; as well as nurse practitioners (NP), clinical nurse specialists (CNS), and physician assistants (PA). For these professionals to qualify for the PCIP, primary care services as described by the codes in the preceding paragraph must account for at least 60% of the practitioner's Medicare Physician Fee Schedule (MPFS) allowed charges for a prior period as determined by Secretary of Health and Human Services. Primary care practitioners furnishing PCIP services will need to be identified on Critical Access Hospital (CAH) claims by adding the National Provider Identifier (NPI) of the rendering practitioner in Form Locator (FL) 82 and/or attending practitioner in FL 79.

Eligibility for Payment under the Primary Care Incentive Payment Program (PCIP)

The CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 250.12, explains that Section 5501(a) of The Affordable Care Act (ACA) provides a 10 percent incentive payment for primary care services furnished on or after January 1, 2011 and before January 1, 2016. This payment will be provided to primary care practitioners, identified as:

  1. In the case of physicians, enrolled in Medicare with a primary specialty designation of 08-family practice, 11-internal medicine, 37-pediatrics, or 38-geriatrics; or
  2. In the case of nonphysician practitioners, enrolled in Medicare with a primary care specialty designation of 50-nurse practitioner, 89-certified clinical nurse specialist, or 97-physician assistant; and
  3. For whom the primary care services displayed in the above table accounted for at least 60 percent of the allowed charges under Part B for such practitioners during the time period that has been specified by the Secretary.

CMS has provided all Medicare contractors with a list of the NPIs of the 2011 eligible primary care practitioners. If a claim for a primary care service is submitted by a physician or group practice, the primary care professional service must be reported under a practitioner with a qualifying NPI in order for the service to qualify for the incentive payment.

The PCIP payments will be calculated by the Medicare contractors (Noridian) and made quarterly on behalf of the eligible primary care practitioner for the primary care services furnished by the practitioner in that quarter. The primary care practitioners' professional services are paid under the MPFS based on a claim for professional services.

The below Primary Care Incentive Program Eligibility files are in text format [TXT], "Ctrl F" to find an NPI of an eligible primary care practitioner.

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Last Updated Apr 09, 2018