HCPCS Modifier AQ

Description
Physician providing a service in an unlisted Health Professional Shortage Area (HPSA).

Guidelines/Instructions
Submit HCPCS modifier AQ in the following instances:

  • When you provide services in ZIP Code area that does not fall entirely within a designated full county HPSA bonus area
  • When you provide services in a ZIP Code area that falls partially within a full county HPSA but is not considered to be in that county based on the USPS dominance decision
  • When you provide services in a ZIP Code area that falls partially within a non-full county HPSA
  • When you provide services in a ZIP Code area that was not included in the automated file of HPSA based on the date of the data run used to create the file
  • When services are provided in areas that were eligible for the HPSA bonus on December 31 of the prior year but were not on the automated ZIP Code list 
  • Designated HPSAs change periodically, so it is important to verify that services fall in a HPSA before submitting claims. To verify whether a location is included in a HPSA, visit the CMS website and then review the ZIP Code file (located under downloads).

Do not submit HCPCS modifier AQ in the following instances:

  • You are submitting a technical-only component code (e.g., CPT code 93005)
  • The service was not rendered in a HPSA
  • The service was performed by someone that does not meet the definition of a physician (psychiatrists are included in the definition of a physician)
To determine if you qualify to automatically receive the bonus payment, you can review the information provided on the CMS website (refer to the link above). If the ZIP Code of the location where you render services does not appear there, check the Palmetto GBA website for HPSA designations to determine if the location where you render services is within a HPSA bonus area, but still requires the submission of the HCPCS modifier AQ. The most current source of HPSA designations is the HRSA website. Physicians may use the HRSA website designations when making the decision on whether or not to include HCPCS modifier AQ on their claims.

HPSA Overview
MMA Section 413(b) requires CMS to revise some of the policies that address HPSA bonus payments. Section 1833(m) of the Social Security Act provides bonus payments for physicians who furnish medical care services in geographic areas that are designated by the HRSA as primary medical care HPSAs under Section 332 (a)(1)(A) of the Public Health Service (PHS) Act. In addition, for claims with dates of service on or after July 1, 2004, psychiatrists (provider specialty 26) furnishing services in mental health HPSAs are also eligible to receive bonus payments. But keep in mind that if a ZIP Code falls within both a primary care and mental health HPSA, only one bonus will be paid on the service.

References

Contact Palmetto GBA JM Part B Medicare

Email Part B

Contact a specific JM Part B department

Provider Contact Center: 855-696-0705

TDD: 866-830-3188

Other Palmetto GBA Sites

Palmetto GBA Home

DMEPOS Competitive Bidding Program

Jurisdiction J Part A MAC

Jurisdiction J Part B MAC

Jurisdiction M Part A MAC

Jurisdiction M Part B MAC

Jurisdiction M Home Health and Hospice MAC

MolDX

National Supplier Clearinghouse MAC

PDAC

RRB Specialty MAC Providers

RRB Specialty MAC Beneficiaries

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