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

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 6 (Group A), 7 (Group B), and 4 (Group C).
 
Refer to Attachment A for a list of procedure codes subject to MPPR guidelines.

PROFESSIONAL PROVIDERS

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.​

FACILITY PROVIDERS


MPPR guidelines apply to the following:

  • Groups A, B, and C, 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.

 

GROUP A

The following MPPR percentages are applied to services included in Group A:

  • 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.

GROUP B

The following MPPR percentages are applied to services included in Group B:

  • 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.

GROUP C

The following MPPR percentages are applied to services included in Group C:

  • 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.

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 in Attachment A of this policy and does not apply to any other codes. 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 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.


FACILITY PROVIDERS

  •  For services identified in Groups A, B and C 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 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 May 3, 2021.

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 May 3, 2021.

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 May 3, 2021.

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 May 3, 2021.

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

1/1/2022
2/8/2022
00.01.60
Claim Payment Policy Bulletin
Commercial
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No
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