Description

Procedures subject to the multiple procedure payment reduction (MPPR) include diagnostic cardiovascular, radiology, ophthalmology, endoscopy, and therapy services. A list of these procedures can be found in the Medicare Physician Fee Schedule (MPFS).

Many diagnostic services are composed of a technical and a professional component.

The technical component refers to the equipment and technician performing the test. It is identified by adding Modifier TC to the procedure code.

The professional component refers to the interpretation of the results of the test. When the professional component is reported separately the service may be identified by adding Modifier 26 to the procedure code. Interpretation of a diagnostic procedure includes a written report.

When multiple diagnostic cardiovascular, radiology or ophthalmology services are performed during a single session, most of the clinical labor activities and most supplies are not performed or furnished twice. The following clinical labor activities are performed once during the session and are duplicated for subsequent procedures, creating an overlap in the services comprising the separately billed technical components:

• Greeting the patient
• Positioning and escorting the patient
• Providing education and obtaining consent
• Retrieving prior exams
• Setting up the IV
• Preparing and cleaning the room

In addition, the supplies used are not duplicated for subsequent procedures.

Policy

The multiple procedure payment reduction on diagnostic imaging applies when multiple services are furnished by the same physician, to the same patient, in the same session, on the same day. The MPPRs apply to TC only services and the TC of global services.

Radiology Services: Reimbursement for the technical and professional component of the primary procedure is 100% of the contracted allowed amount. Subsequent radiology services, furnished by the same physician to the same patient on the same day, a 50% reduction shall apply to the contracted allowed amount for the technical component and a 25% reduction shall apply to the contracted allowed amount for the professional component.

Cardiovascular Services: Reimbursement for TC service with the highest payment under the Medicare Physician Fee Schedule (MPFS) is 100% of the contracted allowed amount. For subsequent TC services, furnished by the same physician to the same patient on the same day, reimbursement is limited to 75% of the contracted allowed amount.

Ophthalmology Services: Reimbursement for TC service with the highest payment under the Medicare Physician Fee Schedule (MPFS) is 100% of the contracted allowed amount. For subsequent TC services, furnished by the same physician to the same patient on the same day, reimbursement is limited to 80% of the contracted allowed amount.

Endoscopy Services: Reimbursement for Endoscopy services will follow CMS guidance for reduction of multiple procedures furnished by the same physician to the same patient on the same day. Reimbursement for the primary procedure is 100% plus the difference between the subsequent endoscopies and the shared based code.

Therapy Services: Reimbursement for therapy services will follow CMS guidance for reduction of multiple procedures furnished by the same physician/practitioner to the same patient on the same day. Reimbursement for the primary procedure is 100% of the contracted allowed amount, practice expenses for subsequent services is limited to 50% of the contracted allowed amount. 

Reimbursement Guidelines

Blue Cross NC Medicare Advantage follows CMS editing, guidelines, and instructions related to MPPR for diagnostic cardiovascular, radiology, endoscopy, therapy, and ophthalmology services.

Rationale

In accordance with CMS, Blue Cross Blue Shield North Carolina (Blue Cross NC) will reduce reimbursement for multiple cardiovascular, radiology, and ophthalmology services.

Billing and Coding

Blue Cross NC Medicare Advantage follows MPFS for billing and coding guidelines related to multiple cardiovascular, radiology, ophthalmology, endoscopy, and therapy services.

For a current and complete code list, please see the Medicare Physician Fee Schedule cited in the reference section.

Related policy

Bundling Guidelines

Modifier Guidelines

Co-Surgeon, Assistant Surgeon, Team Surgeon and Assistant-At-Surgery Guidelines

Pricing and Adjudication Principles

References

Healthcare Common Procedure Coding System

American Medical Association, Current Procedural Terminology (CPT^®)

Centers for Disease Control and Prevention, International Classification of Diseases, 10th Revision

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1149OTN.pdf

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/mm9647.pdf

History

6/1/2022 - New policy developed. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022. (eel)

7/26/2022 - Policy renamed from “Multiple Cardiovascular, Radiology, and Ophthalmology Services” to “Multiple Procedure Payment Reduction Guidelines”. Addition of Endoscopy and Therapy Services into Policy and Guidelines Section. (cjw)

12/31/22 - Routine Policy Review. Minor revisions only. (cjw)

Application

These reimbursement requirements apply to all Blue Medicare HMO, Blue Medicare PPO, Blue Medicare Rx members, and members of any third-party Medicare plans supported by Blue Cross NC through administrative or operational services.

This policy relates only to the services or supplies described herein. Please refer to the Member's Evidence of Coverage (EOC) for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.