Notification



Notification Issue Date:



Claim Payment Policy


Title:Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Services

Policy #:00.01.60c

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



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, 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.

NONCOVERED 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 professional providers in the same provider group, on the same individual, and on the same date of service in all places of service, the professional provider should submit a claim form with the multiple diagnostic procedure code(s) for the services performed on a single claim form.
  • 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 a claim form with the multiple diagnostic procedure code(s) for the services performed on a single claim form.
    • When multiple diagnostic services are performed in different sessions for Group C, modifier 59 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 August 3, 2018.

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 August 3, 2018.

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 August 3, 2018.

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 August 3, 2018.




Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

See Attachment A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A


Misc Code

Modifiers:

TC (Technical Component)
26 (Professional Component)



Coding and Billing Requirements


Cross References

Attachment A: Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Services
Description: Multiple Reduction Diagnostic Services



Policy History

Revisions from 00.10.60c
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)

99274: 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

99275: 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 01.00.60b
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 00.01.60a
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

Effective 10/05/2017 this policy has been updated to the new policy template format.
Version Effective Date: 01/01/2019
Version Issued Date: 01/03/2019
Version Reissued Date: N/A

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