Definition of Primary Care Practitioners and Primary Care Services - CPT code 99304

Primary care practitioner is defined as:

1. A physician who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine for whom primary care services accounted for at least 60 percent of the allowed charges under the PFS (excluding hospital inpatient care and emergency department visits) for the practitioner in a prior period as determined appropriate by the Secretary; or

2. A nurse practitioner, clinical nurse specialist, or physician assistant for whom primary care services accounted for at least 60 percent of the allowed charges under the PFS (excluding hospital inpatient care and emergency department visits) for the practitioner in a prior period as determined appropriate by the Secretary.

Primary care services are defined as HCPCS Codes:

1. 99201 through 99215 for new and established patient office or outpatient evaluation and management (E/M) visits;

2. 99304 through 99340 for initial, subsequent, discharge, and other nursing facility E/M services; new and established patient domiciliary, rest home or custodial care E/M services; and domiciliary, rest home or home care plan oversight services; and

3. 99341 through 99350 for new and established patient home E/M visits.

Practitioner Identification

Primary care practitioners will be identified using the National Provider Identifier (NPI) number of the rendering practitioner on claims. If the claim is submitted by a practitioner’s group practice, the rendering practitioner’s NPI must be included on the line-item for the primary care service and reflect an eligible HCPCS as identified. In order to be eligible for the PCIP, physician assistants, clinical nurse specialists, and nurse practitioners must be billing for their services under their own NPI and not furnishing services incident to physicians’ services. Regardless of the specialty area in which they may be practicing, the specific nonphysician practitioners are eligible for the PCIP based on their profession and historical percentage of allowed charges as primary care services that equals or exceeds the 60 percent threshold.

The claims data used for the primary care percentage calculations depend on the potential primary care practitioner’s date of enrollment in Medicare. We will use Medicare claims data 2 years prior to the PCIP payment year to determine PCIP eligibility for those potential primary care practitioners who were enrolled in Medicare in that year. For example, for CY 2011, we will use Medicare claims data from CY 2009 for practitioners who were already enrolled in Medicare in CY 2009. We will use claims data from the year immediately preceding the PCIP payment year in order to determine PCIP eligibility for potential primary care practitioners who newly enroll in Medicare in the year immediately preceding the PCIP payment year. For example, for CY 2011, we will use the available Medicare claims data from CY 2010 only for potential primary care practitioners who newly enrolled in Medicare in CY 2010.

Eligible practitioners for PCIP payments in a given calendar year who were enrolled in Medicare 2 years earlier will be listed by eligible NPI in the Primary Care Incentive Payment Program Eligibility File, available after January 31 of the PCIP payment year on their Medicare contractor’s website. Eligible practitioners for PCIP payments in a given calendar year who were newly enrolled in Medicare in the year immediate preceding the PCIP payment year will be identified in the PCIP Payment for New Providers Enrolled in Medicare File, available after October 1 of the PCIP payment year. Practitioners should contact their contractor with any questions regarding their eligibility for the PCIP.