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Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Services
MA01.005g

Policy

This policy applies to professional providers billing on a CMS-1500 claim form or the equivalent form, 837p, for members enrolled in all Company products.

Multiple Procedure Payment Reduction (MPPR) guidelines represent a methodology used to determine the provider's reimbursement for eligible multiple diagnostic reduction services.

The diagnostic services included in MPPR are displayed in three groups: Groups A, B, and C. Refer to Attachment A for the approved CMS procedure codes associated in each group.

MPPR guidelines apply to the following:
  • The technical component (TC) for Groups A and B when performed by the same professional provider or professional providers in the same provider group, on the same individual, in the same session, and on the same date of service in all places of service.
  • The technical component (TC) and professional component (PC) for Group C when performed by the same professional provider, on the same individual, in the same session, and on the same date of service in all places of service.
The hierarchy for reimbursement of MPPR is determined based on the provider's allowance for each diagnostic service reported, as set forth below.

GROUPS A AND B
  • MPPR applies to TC only services and to the TC of global services.
  • The following MPPR percentages are applied:
    • The TC with the highest allowance is eligible for reimbursement at 100 percent.
    • The TC of each subsequent Group A service is eligible for 75 percent of the provider's allowance.
    • The TC of each subsequent Group B service is eligible for 80 percent of the provider's allowance.
GROUP C
  • MPPR applies to PC only services, TC only services, and to the PC and TC of global services.
  • The following MPPR percentages are applied to the TC:
    • The TC with the highest allowance is eligible for reimbursement at 100 percent.
    • The TC for each subsequent service is eligible for 50 percent of the provider's allowance.
  • The following MPPR percentages are applied to the PC:
    • The PC with the highest allowance is eligible for reimbursement at 100 percent.
    • The PC of each subsequent service is eligible for 95 percent of the provider's allowance.
Refer to Attachment A for the CMS procedure codes to see which MPPR guidelines apply.

NON-COVERED AND NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

MPPR guidelines are not applied to services that are non-covered or not eligible for separate reimbursement consideration. When diagnostic services that are non-covered or not eligible for separate reimbursement are reported, the services will process in accordance with the coverage and eligibility of the particular service(s).

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, the following: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

This claim payment rationale applies only to the procedure codes in the attachments to this policy and does not apply to any other codes. Claims are processed according to the statements in this policy. When another policy on the performed MPPR exists, the criteria and coverage information listed in that medical policy must also be met.

Network and capitation rules will continue to apply to the services identified in this policy.

BILLING GUIDELINES

In order to receive the appropriate reimbursement MPPR should be reported as follows:
      • For services identified in Groups A and B performed by the same professional provider or providers in the same provider group, on the same individual, in the same session, and on the same date of service in all places of service, the professional provider should submit, on a single claim form, the multiple diagnostic procedure code(s) for the services performed.
      • For services identified in Group C performed by the same professional provider, on the same individual, in the same session, and on the same date of service in all places of service, the professional provider should submit, on a single claim form.
      • When multiple diagnostic services are performed in different sessions, modifier XE must be reported for the subsequent session(s).
Not following proper guidelines may result in claim underpayments or claim overpayments which may result in subsequent retractions. In these situations, it is the professional provider's responsibility to resubmit appropriately.

Description

The Company has established claims processing methodologies and guidelines for the reimbursement of certain multiple diagnostic reduction services. The application of these methodologies and guidelines determines the hierarchy for reimbursement when multiple diagnostic reduction services are reported.

Diagnostic services are typically comprised of the professional component (PC) and technical component (TC).
  • The professional component (PC) is the portion of the procedure or service performed by a professional provider. This includes the interpretation and analysis, as well as a detailed signed written report of the results of the procedure or service.
  • The technical component (TC) comprises the portion of the procedure or service performed by a technician or other non-professional provider personnel, as well as the equipment used for the procedure or service, and, in most cases, the ownership of the equipment used for the procedure or service. The TC does not involve any direct professional provider care.

References

CMS Manual System Transmittal 3578, Pub 100-04 Medicare Claims Processing
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3578CP.pdf. Accessed October 7, 2019.

News Flash from the Medicare Learning Network (MLN): Multiple Procedure Payment Reduction (MPPR) on the Technical Component (TC) of Diagnostic Cardiovascular and Ophthalmology Procedures http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7848.pdf. Accessed October 7, 2019.

News Flash from the Medicare Learning Network (MLN): Multiple Procedure Payment Reduction (MPPR) on Imaging Services to Physicians in the Same Group Practice http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7747.pdf. Accessed October 7, 2019.

News Flash from the Medicare Learning Network (MLN): Multiple Procedure Payment Reduction (MPPR) on the Professional Component (PC) of Certain Diagnostic Imaging Procedures
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/mm9647.pdf. Accessed October 7, 2019.

Coding

CPT Procedure Code Number(s)
See Attachment A.
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
N/A
HCPCS Level II Code Number(s)
N/A
Revenue Code Number(s)
N/A

Modifiers

26 Professional Component

TC Technical Component

XE Separate encounter, a service that is distinct because it occurred during a separate encounter

Coding and Billing Requirements

Policy History

Revisions From MA01.005g​:
01/01/2022

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2022.


The following Procedure codes have been added to the policy​​

0683T, 0684T, 0685T, 0689T, and 0697T

The Following CPT code has had narrative revisions:
0648T and 75573

​Revisions From ​MA01.005f:
10/01/2021
This policy has been identified and updated for the CPT/HCPCS code update effective 10/01/2021.

The following procedure codes were added to Attachment A of this policy:
93050, 93260, 93261, 93702, 93895, 93985, 93986, 0506T, 0507T, 0509T, 92145, 92242, 0648T, 74712, 76391, 76978, 76981, 76982, 77048, and 77049

The following procedure codes have been removed from Attachment A of this policy:
75658, 75791, 93965

Revisions From ​MA01.005e:
01/01/2021
This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2021.

The following procedure codes were added to attachment A of this policy:
71271​, 92229, 93241, 93242, 93243, 93245, 93246, and 93247

The following procedure codes in attachment A of this policy had narrative revisions:
71250, 71260, 71270, 76510, 76511, 76512, 76513, and 92228​

Revisions From MA01.005d:
12/16/2019This version of the policy becomes effective 12/16/2019. The policy update clarifies the Company's Multiple Procedure Payment Reduction (MPPR) guidelines for reimbursement for eligible multiple diagnostic reduction services. The clarification states the following:
  • The MPPR guidelines apply to services identified in Groups A and B of Attachment A that are billed during the same session on the same claim form.
  • The MPPR guidelines apply to services identified in Group C of Attachment A that are billed on the same claim form.
  • When multiple diagnostic services are performed in different sessions, modifier XE must be reported for the subsequent session(s).

Revisions From MA01.005c:
01/01/2019This policy has been identified and updated for the CPT code update effective 01/01/2019.

The following CPT codes have been added to the policy:

77046: Magnetic resonance imaging, breast, without contrast material; unilateral

77047: Magnetic resonance imaging, breast, without contrast material; bilateral

92273: Electroretinography (ERG), with interpretation and report; full field (ie, ffERG, flash ERG, Ganzfeld ERG)

92274: Electroretinography (ERG), with interpretation and report; multifocal (mfERG)

This policy has been identified and updated for the CPT code update effective 01/01/2019.

The following CPT codes have been termed from the policy:

77058: Magnetic resonance imaging, breast, without and/or with contrast material(s); unilateral

77059: Magnetic resonance imaging, breast, without and/or with contrast material(s); bilateral

92275: Electroretinography with interpretation and report

This policy has been identified and updated for the CPT code update effective 01/01/2019.

The following CPT narratives have been revised in this policy:

93279

FROM: Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; single lead pacemaker system

TO: Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; single lead pacemaker system or leadless pacemaker system in one cardiac chamber

93285

FROM: Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; implantable loop recorder system

TO: Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; subcutaneous cardiac rhythm monitor system

93286

FROM: Peri-procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure, or test with analysis, review and report by a physician or other qualified health care professional; single, dual, or multiple lead pacemaker system

TO: Peri-procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure, or test with analysis, review and report by a physician or other qualified health care professional; single, dual, or multiple lead pacemaker system, or leadless pacemaker system

93288

FROM: Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; single, dual, or multiple lead pacemaker system

TO: Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; single, dual, or multiple lead pacemaker system, or leadless pacemaker system

93290

FROM: Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; implantable cardiovascular monitor system, including analysis of 1 or more recorded physiologic cardiovascular data elements from all internal and external sensors

TO: Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; implantable cardiovascular physiologic monitor system, including analysis of 1 or more recorded physiologic cardiovascular data elements from all internal and external sensors

93291

FROM: Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; implantable loop recorder system, including heart rhythm derived data analysis

TO: Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; subcutaneous cardiac rhythm monitor system, including heart rhythm derived data analysis


Revisions From MA01.005b:
09/07/2018Effective retroactive to 01/01/2017, this policy has been updated to align with CMS stipulations regarding payment of the professional component of subsequent services at 95 percent instead of 75 percent.

Revisions From MA01.005a:
01/01/2018This policy has been identified for the CPT code update.

The following CPT code has been added deleted from this policy, effective 12/31/2017:

75658: Angiography, brachial, retrograde, radiological supervision and interpretation

Revisions From MA01.005:
01/01/2015This is a new policy.
1/1/2022
2/8/2022
MA01.005
Claim Payment Policy Bulletin
Medicare Advantage
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