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Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Services
00.01.60i

Policy

This policy applies to professional providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, and outpatient facility providers billing on a UB-04 claim form or the electronic equivalent, 837i, for members enrolled in all Company products.

Multiple Procedure Payment Reduction (MPPR) guidelines represent a methodology used to determine provider and outpatient facility provider reimbursement for eligible multiple diagnostic services.
 
The Company applies MPPR guidelines to certain diagnostic services identified by the Medicare Physician Fee Schedule Database (MPFSDB) Multiple Procedure Indicators 4, 6 and 7.

PROFESSIONAL PROVIDERS

MPPR guidelines apply to the following:
  • The technical component (TC) and professional component (PC) for Multiple Procedure Indicator 4 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 technical component (TC) for Multiple Procedure Indicators 6​ and 7 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 hierarchy for reimbursement of MPPR is determined based on the provider's allowance for each diagnostic service reported, as set forth below.

MULTIPLE PROCEDURE INDICATOR 4
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.​
MULTIPLE PROCEDURE INDICATORS 6 AND 7
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 service with Multiple Procedure Indicator 6 is eligible for 75 percent of the provider's allowance.
    • The TC of each subsequent service with Multiple Procedure Indicator 7 is eligible for 80 percent of the provider's allowance.​
FACILITY PROVIDERS

MPPR guidelines apply to the following:
  • Multiple Procedure Indicators 4, 6,​ and 7 when performed by the same outpatient facility, on the same individual, and on the same date of service.
The hierarchy for reimbursement of MPPR is determined based on the allowance for each diagnostic service reported, as set forth below.

MULTIPLE PROCEDURE INDICATOR 4
The following MPPR percentages are applied to services with Multiple Procedure Indicator 4:
  • The procedure with the highest allowance is eligible for reimbursement at 100 percent.
  • Each subsequent procedure is eligible for 75 percent of the facility provider's allowance.​
MULTIPLE PROCEDURE INDICATOR 6
The following MPPR percentages are applied to services with Multiple Procedure Indicator 6:
  • The procedure with the highest allowance is eligible for reimbursement at 100 percent.
  • Each subsequent procedure is eligible for 85 percent of the facility provider's allowance.
MULTIPLE PROCEDURE INDICATOR 7
The following MPPR percentages are applied to services with Multiple Procedure Indicator 7:
  • The procedure with the highest allowance is eligible for reimbursement at 100 percent.
  • Each subsequent procedure is eligible for 94 percent of the facility provider's allowance.
​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, records from the professional provider's office, hospital, nursing home, home health agencies, and therapies, as well as 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 identified by the Medicare Physician Fee Schedule Database (MPFSDB) ​Multiple Procedure Indicators 4, 6, 7. Claims are processed according to the statements in this policy. When a medical policy on this topic also exists, the medical necessity criteria listed in the medical policy must be met.

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

BILLING GUIDELINES

PROFESSIONAL PROVIDERS
  • ​For services identified with Multiple Procedure Indicator 4 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.​​
  • For services identified with Multiple Procedure Indicators 6 and 7 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.
  • 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.


FACILITY PROVIDERS

  • For services identified with Multiple Procedure Indicators 4, 6, 7 performed by same outpatient facility, on the same individual, and on the same date of service, the facility should submit on a single claim form.

Not following proper guidelines may result in claim underpayments or claim overpayments, which may result in subsequent retractions. In these situations, it is the facility provider's responsibility to resubmit appropriately.

Description

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

Diagnostic services typically comprise 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 nonprofessional 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

Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedules: PFS Relative Value Files. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files. Accessed August 16, 2023.​​

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 16, 2023.

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 16, 2023.

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 16, 2023.

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 16, 2023.

Coding

CPT Procedure Code Number(s)
​Refer to the "MULT PROC" column of the Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedules for procedure codes with Multiple Procedure Indicators 4, 6, 7:

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 00.01.60i​:
10/09/2023

This version of the policy will become effective 10/09/2023. The intent of the policy remains unchanged. The policy has been updated​ to rename Group A, B, and C with the multiple procedure indicators 6, 7, and 4​ from Medicare Physician Fee Schedule Database (MPFSDB) for the Company's Multiple Procedure Payment Reduction (MPPR) guidelines. 


The policy has been formatted in a numerical order​. The policy Attachment A with a list of procedure codes has been archived; therefore, the providers should refer to the link for the Physician Fee Schedule from CMS in the Coding Table for reference.​


Revisions From 00.01.60h​:
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 00.01.60g​:
10/01/2021

This policy has been identified and updated for the CPT/HCPCS code update effective 10/01/2021.

 ​

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

93241, 93242, 93243, 93245, 93246, 93247, 93285, 93286, 93985, 93986, 92229 and
0648T


The Following CPT code has been removed from the policy:

0508T


Revisions From 00.01.60f​:
09/01/2021

This version of the policy will become effective 9/1/2021. This policy is being issued to communicate a change in the Company's reimbursement position for Multiple Payment Procedure Reductions (MPPR) on certain diagnostic services (Attachment A), to include Outpatient Facility providers.


The following procedure codes have been added to attachment A of this policy:

Group A: 93050, 93260, 93261, 93702, 93895, 93985, 93986

Group B: 0506T, 0507T, 0509T, 92145, 92242

Group C: 74712, 76391, 76978, 76981, 76982, 77048, 77049

 

The following codes have been removed from Attachment A of this policy:

 Group A: 75791, 93965

______________________________________________________________________

This policy has been identified and updated for the CPT/HCPCS code update effective 07/01/2021.

 ​

Procedure code 0508T has been added to the policy​​


The Following CPT codes have been removed from the policy:

93241, 93242, 93243, 93245, 93246, 93247, 93985, 93986, and 92229

 
Revisions From 00.01.60e​:
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 00.01.60d:
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 00.01.60c:
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, 77047, 92273, 92274


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, 77059, 92275, 


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, ​93285, 93286, ​93288, ​93290, ​93291


Revisions From 00.01.60b:
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.
10/9/2023
12/21/2023
00.01.60
Claim Payment Policy Bulletin
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