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Primary Care Incentive Payment Program (PCIP)

According to Section 5501(a) of the Affordable Care Act the Primary Care Physicians (PCP) and NPPs who furnish specified primary care services will receive 10 percent of incentive payment for the services rendered on or after January 1, 2011 and continuing through December 31, 2015

Eligibility of New Providers for Payment under PCIP

For primary care services furnished on or after January 1, 2011, and before January 1, 2016, Medicare-enrolled primary care practitioners are eligible for a 10 percent PCIP payment for the primary care services they furnish if they:

Have a primary specialty designation of 08 (family practice), 11 (internal medicine), 37 (pediatrics), 38 (geriatrics), 50 (nurse practitioner), 89 (certified clinical nurse specialist), or 97 (physician assistant); 
Provided the following eligible primary services:

Evaluation and management (E/M) codes 99201 through 99215 for new and established patient E/M office or outpatient visits;

E/M codes 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; or

E/M codes 99341 through 99350 for new and established patient home E/M visits; and

Provided PCIP eligible primary care services that account for at least 60 percent of the allowed charges under Part B (excluding hospital inpatient care and emergency department visits) for such practitioners during the time period that has been specified by the Secretary.

Participation in the Health Professional Shortage Area (HPSA) and PCIP Programs

Beginning in CY 2011, an eligible primary care physician furnishing a primary care service in a HPSA may receive both a HPSA physician bonus payment and the PCIP payment. The PCIP incentive payment is based on the amount paid, and not the Medicare approved amount. Providers will receive a special remittance form with the incentive payment so that they will be able identify which type of incentive payment (HPSA physician and/or PCIP) was paid for each program.

Checking PCIP eligibility status

The Centers for Medicare & Medicaid Services (CMS) provides contractors with a list of the national provider identifiers (NPIs) of the eligible primary care practitioners around the beginning of the incentive year. 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. Physicians and NPPs should contact their claims processing contractor with any questions regarding their eligibility for the PCIP

Primary Care Incentive Program (PCIP) payments for the state of Florida

Primary Care Incentive Program (PCIP) payments for the state of Texas

FAQs on Primary Care Incentive Program (PCIP) payments

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