MA PPO

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


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

12/16/2019
12/16/2019
MA01.005
Claim Payment Policy Bulletin
Medicare Advantage
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Yes