Multiple Procedure Payment Reduction (MPPR) for Diagnostic ... · patient, results in a written narrative report to be included in the patient’s medical record, and directly contributes

Reimbursement Policy

CMS 1500 Policy Number 2020R0085A

Proprietary information of UnitedHealthcare Community Plan. Copyright 2020 United HealthCare Services, Inc. 2020R0085A

Multiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging Policy, Professional

IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY

You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare Community Plan reimbursement policies uses Current Procedural Terminology (CPT®*), Centers for Medicare and Medicaid Services (CMS) or other coding guidelines. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement. This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when specified, to those billed on UB04 forms. Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy. This information is intended to serve only as a general reference resource regarding UnitedHealthcare Community Plan’s reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare Community Plan may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare Community Plan enrollees. Other factors affecting reimbursement supplement, modify or, in some cases, supersede this policy. These factors include, but are not limited to: federal &/or state regulatory requirements, the physician or other provider contracts,

the enrollee’s benefit coverage documents, and/or other reimbursement, medical or drug policies. Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare Community Plan due to programming or other constraints; however, UnitedHealthcare Community Plan strives to minimize these variations. UnitedHealthcare Community Plan may modify this reimbursement policy at any time by publishing a new version of the policy on this Website. However, the information presented in this policy is accurate and current as of the date of publication. *CPT Copyright American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association .

Application

This reimbursement policy applies to UnitedHealthcare Community Plan Medicaid Product. This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent or its successor form. This policy applies to all products and all network and non-network physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals.

Table of Contents

Application

Policy Overview Reimbursement Guidelines

Multiple Diagnostic Imaging Reductions Multiple Diagnostic Imaging Reduction Percentages Multiple Diagnostic Imaging Procedures Billed Globally

Definitions Questions and Answers Attachments Resources History




Policy

Overview

The UnitedHealthcare Community Plan policy is based on the Centers for Medicare and Medicaid Services (CMS) Multiple Procedure Payment Reduction (MPPR) Policy for those diagnostic imaging procedures where CMS assigns a Multiple Procedure Indicator (MPI) of 4 on the National Physician Fee Schedule (NPFS).

UnitedHealthcare Community Plan has adopted CMS guidelines that when multiple diagnostic imaging procedures are performed in a single session, most of the clinical labor activities and most supplies, with the exception of film, are not performed or furnished twice. Equipment time and indirect costs are allocated based on clinical labor time; therefore, these inputs should be reduced accordingly. Specifically, UnitedHealthcare Community Plan considers that the following clinical labor activities, among others, are not duplicated for subsequent procedures:

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 Payment at 100% for secondary and subsequent diagnostic imaging procedure(s) would represent reimbursement for duplicative components of the primary procedure. CMS Physician Fee Schedule Relative Value Files Since June 2006, in accordance with CMS, UnitedHealthcare Community Plan has considered multiple diagnostic imaging procedures assigned a MPI of 4, subject to a reduction for the Technical Component (TC) of imaging procedures ranked as secondary and subsequent as described below in the Multiple Diagnostic Imaging Reductions section.

In accordance with CMS, UnitedHealthcare Community Plan will apply reductions to the secondary and subsequent Professional Component (PC) of multiple diagnostic imaging procedures assigned a MPI of 4. Reductions will be applied as described below in the Multiple Diagnostic Imaging Reductions section.

Reimbursement Guidelines

Multiple Diagnostic Imaging Reductions (MDIR)

UnitedHealthcare Community Plan utilizes the CMS NPFS MPI of 4 and Non-Facility Total Relative Value Units (RVUs) to determine which radiology procedures are eligible for MDIR. Different MDIR percentages apply to the PC and TC of global services.

MDIR applies when: Multiple diagnostic imaging procedures with a MPI of 4 are performed on the same patient by the Same Group

Physician and/or Other Health Care Professional during the Same Session. A single imaging procedure subject to MDIR is submitted with multiple units. For example, code 73702 is

submitted with 2 units. MDIR would apply to the second unit. The units are also subject to UnitedHealthcare Community Plan's Maximum Frequency Per Day Policy.

MDIR will not apply when: The diagnostic imaging procedure is the primary procedure as ranked based on the RVU assigned to the code

(and modifier, when applicable), compared to other diagnostic imaging procedures billed during the Same Session.

Multiple diagnostic imaging procedures are billed, appended with Modifier 59 or Modifier XE to indicate the procedure was performed on the same day but not during the Same Session.

Multiple diagnostic imaging procedures are billed for the same patient on the same day but not by the Same Group Physician and/or Other Health Care Professional during the Same Session.

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.htmlhttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html




The imaging service does not have an MPI of 4. See the Diagnostic Imaging Procedures Subject to Multiple Imaging Reduction Lists in the attachment section below.

Multiple Diagnostic Imaging Reduction Percentages

When the TC for two or more imaging procedures subject to MDIR are performed on the same patient by the Same Group Physician and/or Other Health Care Professional during the Same Session, UnitedHealthcare Community Plan will reduce the Allowed Amount for the TC of the second and each subsequent procedure by 50%. UnitedHealthcare Community Plan will regard the TC portion of the procedure(s) with the lower TC total (RVUs) as subject to MDIR. In addition, when the PC for two or more imaging procedures subject to MDIR are performed on the same patient by the Same Group Physician and/or Other Health Care Professional at the Same Session, UnitedHealthcare Community Plan will reduce the Allowed Amount for the PC of the second and each subsequent procedure by 25% for dates of service 11/15/2015 through 12/31/2016. Effective for dates of service on or after 1/1/2017, a 5% reduction is applied to the Allowed Amount for the PC component of the second and subsequent procedures. UnitedHealthcare Community Plan will regard the PC portion of the procedure(s) with the lower PC total RVUs, as subject to MDIR.

Multiple Diagnostic Imaging Procedures Billed Globally

When a provider bills globally for two or more procedures subject to MDIR, for a patient at the Same Session, the charge for the Global Procedure Codes will be divided into the PC and TC (indicated by modifiers 26 and TC) using UnitedHealthcare Community Plan's standard Professional/Technical percentage splits. The RVUs assigned to each component (26 or TC) will determine which code will be ranked as primary, with no reduction applied, and those that will be ranked as secondary or subsequent, with reductions applied in accordance with this policy. The components (26 or TC) will be ranked independently of each other utilizing the CMS Non-Facility Total RVUs.

State Exceptions

Arizona This policy only applies to participating providers for Arizona Medicaid

Kansas Kansas is exempt from Multiple Diagnostic Imaging Reductions

Washington Per state regulations, Washington Medicaid does not apply MDIR to the professional component (PC) of diagnostic imaging services

Definitions

Allowable Amount Defined as the dollar amount eligible for reimbursement to the physician or health care professional on the claim. Contracted rate, reasonable charge, or billed charges are examples of Allowable Amounts. For percent of charge or discount contracts, the Allowable Amount is determined as the billed amount, less the discount.

Global Service A Global Service includes both a Professional Component and a Technical Component. When a physician or other health care professional bills a Global Service, he or she is submitting for both the Professional Component and the Technical Component of that code. Submission of a Global Service asserts that the Same Individual Physician or Other Health Care Professional provided the supervision, interpretation and report of the professional services as well as the technician, equipment, and the facility needed to perform the procedure. In appropriate circumstances, the Global Service is identified by reporting the appropriate professional/technical split eligible procedure code with no modifier attached or by reporting a standalone code for global test only services

Modifier 59 Distinct Procedural Service. Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances.




Modifier XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter

Professional Component The Professional Component represents the physician or other health care professional work portion (physician work/practice overhead/malpractice expense) of the procedure. The Professional Component is the physician or other health care professional supervision and interpretation of a procedure that is personally furnished to an individual patient, results in a written narrative report to be included in the patient’s medical record, and directly contributes to the patient’s diagnosis and/or treatment. In appropriate circumstances, it is identified by appending modifier 26 to the designated procedure code or by reporting a standalone code that describes the Professional Component only of a selected diagnostic test.

Same Group Physician and/or Other Qualified Health Care Professional

All physicians and/or other health care professionals of the same group reporting the same Federal Tax Identification number.

Same Session A single patient encounter that encompasses all of the services performed by the same physician or other health care professional.

Technical Component The Technical Component is the performance (technician/equipment/facility) of the procedure. In appropriate circumstances, it is identified by appending modifier TC to the designated procedure code or by reporting a standalone code that describes the Technical Component only of a selected diagnostic test.

Questions and Answers

1

Q: Which procedure would be primary when code 76604 (Ultrasound, chest) and code 76831 (Saline infusion sonohysterography) are billed together by the Same Group Physician and/or Other Health Care Professional, and how would the multiple imaging reduction be applied?

A: First, the PC/TC percentage splits would be applied to each code reported globally using UnitedHealthcare Community Plan’s standard Professional/Technical percentage splits. Then the PC and TC portions with the lesser RVU(s) will be considered reducible as shown in the table below.

76831-TC has the higher TC total RVU of 2.47; therefore, it would be primary and would be reimbursed at 100% of the Allowable Amount for the TC

76604-TC with the lower TC total RVU of 1.73 would be secondary and reimbursed by applying a 50% reduction to the Allowable Amount for the TC

76831-26 has the higher PC total RVU of 1.03; therefore, it would be primary and would be reimbursed at 100% of the Allowable Amount for the PC

76604-26 with the lower PC total RVU of .78 would be secondary and reimbursed by applying a 5% reduction to the Allowable Amount for the PC with a date of service on or after 1/1/2017; for dates of service prior to 1/1/2017, a 25% reduction is applied to the Allowable Amount

Note: RVU values in this example may not accurately reflect the current NPFS and are intended for illustrative purposes only.

Code Modifier PC Non-

Facility Total RVU

TC Non-Facility Total

RVU

RVU used for Ranking

Multiple Diagnostic Imaging Ranking

76604 26 .78 Not applicable .78 2 - Secondary

76604 TC Not applicable 1.73 1.73 2 - Secondary

76831 26 1.03 Not applicable 1.03 1 - Primary

76831 TC Not applicable 2.47 2.47 1 - Primary




2

Q: Does UnitedHealthcare Community Plan apply a multiple imaging reduction based on the place of service in which services are rendered?

A: This policy will apply to all claims reported on a CMS-1500 claim form, regardless of place of service. However, it should be noted that procedures reported for the TC portion are additionally subject to UnitedHealthcare Community Plan’s Professional/Technical Component Policy which does not allow reimbursement for the TC portion in a facility setting.

3

Q: If the Same Group Physician and/or Other Healthcare Professional performs a complete ultrasound exam of the abdomen during a single session and reports code 76700, and it becomes necessary to then perform a repeat service later on the same day during a separate session which is reported with code 76700-76, will a multiple imaging reduction be applied to the repeated service reported as 76700-76?

A: Yes, multiple imaging reductions will apply as the use of modifier 76 does not indicate that the imaging procedure was done at a separate session. The repeat procedure code 76700 should be appended with either Modifier 59 or XE (but not both) to indicate a distinct service was performed during a different session. Multiple imaging reductions will not apply to services appropriately billed with Modifier 59 or XE.

4

Q: How will the Same Group Physician and/or Other Health Care Professional, contracted at percent of charge rates, be reimbursed when reporting the Global Procedure Code for multiple imaging procedures which are subject to the MDIR during the Same Session?

A: The charges for the Global Procedure Code(s) will be divided into the PC and TC portions using UnitedHealthcare Community Plan’s standard Professional/Technical splits, with MDIR applied to the Allowed Amount for the PC and TC portion of the second and each subsequent procedure.

5

Q: When the Same Group Physician and/or Other Health Care Professional bills globally for two or more procedures which are subject to MDIR for a patient at the Same Session, and is also contracted with a specific rate for modifier TC, how is the Technical Component to be reduced determined?

A: The charge for the Global Procedure Codes will be divided into the Professional and Technical Components using UnitedHealthcare Community Plan’s standard Professional/Technical percentage splits. Then the Technical Component(s) with the lesser RVU(s) will be considered reducible. The Allowable Amount is then determined based on the lesser of the charges assigned for modifier TC using UnitedHealthcare Community Plan’s standard Professional/Technical percentage splits or the contracted rate, with an imaging reduction applied.

6

Q: A patient comes in for multiple chest studies, first an ultrasound (CPT code 76604) is completed, and the patient is then moved to a different room for a CT angiography (CPT code 71275), would this be considered a separate session?

A: No, the need to move a patient to a different room does not constitute a separate session; it is a continuation of the same encounter.

Attachments: Please right-click on the icon to open the file.

UnitedHealthcare Community Plan Diagnostic Imaging Procedures Subject to

Multiple Imaging Reduction Technical Component List

This table identifies codes that are subject to MDIR of the Technical Component and their TC Non-Facility Total RVUs, as published in the CMS NPFS.

UnitedHealthcare Community Plan Diagnostic Imaging Procedures Subject to Multiple Imaging Reduction Professional

Component List

This table identifies codes that are subject to MDIR of the Professional Component and their PC Non-Facility Total RVUs, as published in the CMS NPFS.

2020 Diagnostic Imaging Procedures Subject to Multiple Diagnostic Imaging Reduction Technical Component List

Proc Code Modifier RVU

70336 TC 6.58

70450 TC 2.04

70460 TC 2.99

70470 TC 3.58

70480 TC 3.83

70481 TC 4.69

70482 TC 5.18

70486 TC 2.70

70487 TC 3.10

70488 TC 3.93

70490 TC 2.81

70491 TC 3.74

70492 TC 4.58

70496 TC 5.87

70498 TC 5.86

70540 TC 5.44

70542 TC 6.41

70543 TC 7.93

70544 TC 5.20

70545 TC 5.51

70546 TC 8.35

70547 TC 5.22

70548 TC 5.61

70549 TC 8.41

70551 TC 4.17

70552 TC 6.16

70553 TC 7.02

70554 TC 9.17

71250 TC 2.81

71260 TC 3.75

71270 TC 4.58

71275 TC 5.95

71550 TC 9.08

71551 TC 9.86

71552 TC 12.40

71555 TC 8.27

72125 TC 2.96

72126 TC 3.77

72127 TC 4.68

72128 TC 2.96

72129 TC 3.81

72130 TC 4.69

72131 TC 2.94

72132 TC 3.78

72133 TC 4.66

72141 TC 4.00

72142 TC 6.34

72146 TC 4.00

72147 TC 6.29

72148 TC 4.01

72149 TC 6.21

72156 TC 7.10

72157 TC 7.12

72158 TC 7.08

72159 TC 8.66

72191 TC 6.54

72192 TC 2.55

72193 TC 5.17

72194 TC 5.93

72195 TC 5.41

72196 TC 6.28

72197 TC 7.89

72198 TC 8.34

73200 TC 3.61

73201 TC 4.62

73202 TC 6.09

73206 TC 6.70

73218 TC 8.01

73219 TC 8.66

73220 TC 10.44

73221 TC 4.52

73222 TC 7.97

73223 TC 9.68

73225 TC 8.66

73700 TC 2.94

73701 TC 3.81

73702 TC 4.84

73706 TC 7.34

73718 TC 5.34

73719 TC 6.27

73720 TC 7.95

73721 TC 4.52

73722 TC 7.99

73723 TC 9.66

73725 TC 8.33

74150 TC 2.51

74160 TC 5.15

74170 TC 5.86

74174 TC 8.30

74175 TC 6.53

74176 TC 3.16

74177 TC 6.62

74178 TC 7.51

74181 TC 4.26

74182 TC 7.44

74183 TC 7.91

74185 TC 8.38

74261 TC 10.04

74262 TC 11.57

74712 TC 9.08

75557 TC 5.73

75559 TC 8.48

75561 TC 8.21

75563 TC 9.83

75571 TC 2.13

75572 TC 4.55

75573 TC 5.84

75574 TC 6.78

75635 TC 9.14

76391 TC 4.96

76604 TC 1.41

76700 TC 2.31

76705 TC 1.74

76770 TC 2.15

76775 TC 0.84

76776 TC 3.32

76831 TC 2.34

76856 TC 2.12

76857 TC 0.67

76870 TC 2.06

76978 TC 6.92

76981 TC 2.20

76982 TC 1.87

77046 TC 4.84

77047 TC 4.81

77048 TC 7.96

77049 TC 7.93

G0297 TC 5.25

2020 Diagnostic Imaging Procedures Subject to Multiple Diagnostic Imaging Reduction Technical Component List

kfeltFile Attachment120319_C&S Diag Imaging Technical Component List_20200101.pdf

2020 Diagnostic Imaging Procedures Subject to Multiple Diagnostic Imaging Reduction Professional Component List

Proc Code Modifier RVU

70336 26 2.10

70450 26 1.21

70460 26 1.60

70470 26 1.80

70480 26 1.81

70481 26 1.60

70482 26 1.79

70486 26 1.22

70487 26 1.60

70488 26 1.80

70490 26 1.82

70491 26 1.96

70492 26 2.31

70496 26 2.48

70498 26 2.48

70540 26 1.90

70542 26 2.31

70543 26 3.03

70544 26 1.70

70545 26 1.70

70546 26 2.11

70547 26 1.71

70548 26 2.13

70549 26 2.56

70551 26 2.11

70552 26 2.53

70553 26 3.25

70554 26 2.99

71250 26 1.64

71260 26 1.77

71270 26 1.95

71275 26 2.58

71550 26 2.08

71551 26 2.45

71552 26 3.18

71555 26 2.54

72125 26 1.42

72126 26 1.73

72127 26 1.80

72128 26 1.42

72129 26 1.73

72130 26 1.80

72131 26 1.42

72132 26 1.73

72133 26 1.79

72141 26 2.11

72142 26 2.54

72146 26 2.11

72147 26 2.53

72148 26 2.11

72149 26 2.53

72156 26 3.25

72157 26 3.25

72158 26 3.25

72159 26 2.56

72191 26 2.54

72192 26 1.54

72193 26 1.64

72194 26 1.73

72195 26 2.08

72196 26 2.46

72197 26 3.10

72198 26 2.52

73200 26 1.42

73201 26 1.64

73202 26 1.73

73206 26 2.54

73218 26 1.92

73219 26 2.32

73220 26 3.04

73221 26 1.95

73222 26 2.32

73223 26 3.04

73225 26 2.47

73700 26 1.42

73701 26 1.64

73702 26 1.72

73706 26 2.66

73718 26 1.91

73719 26 2.31

73720 26 3.03

73721 26 1.92

73722 26 2.32

73723 26 3.04

73725 26 2.55

74150 26 1.69

74160 26 1.81

74170 26 1.99

74174 26 3.10

74175 26 2.57

74176 26 2.47

74177 26 2.59

74178 26 2.84

74181 26 2.08

74182 26 2.46

74183 26 3.10

74185 26 2.53

74261 26 3.40

74262 26 3.54

74712 26 4.24

75557 26 3.28

75559 26 4.03

75561 26 3.61

75563 26 4.17

75571 26 0.82

75572 26 2.46

75573 26 3.59

75574 26 3.35

75635 26 3.35

76391 26 1.58

76604 26 0.82

76700 26 1.16

76705 26 0.83

76770 26 1.04

76775 26 0.82

76776 26 1.09

76831 26 1.02

76856 26 0.97

76857 26 0.70

76870 26 0.90

76978 26 2.29

76981 26 0.84

76982 26 0.84

77046 26 2.06

77047 26 2.27

77048 26 2.97

77049 26 3.26

G0297 26 1.45

2020 Diagnostic Imaging Procedures Subject to Multiple Diagnostic Imaging Reduction Professional Component List

kfeltFile Attachment120319_C&S Diag Imaging Professional Component List_20200101.pdf




Resources

Individual state Medicaid regulations, manuals & fee schedules

American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services

Centers for Medicare and Medicaid Services, Physician Fee Schedule (PFS) Relative Value Files

History

1/1/2020 Policy Version Change Policy List Change: Updated both Diagnostic Imaging Procedures Subject to Multiple Diagnostic Imaging Reduction Technical Component and Professional Component Lists History Section: Entries prior to 1/1/2018 archived

7/16/2019 State Exceptions Section: Exception added for Washington

5/3/2019 Annual Anniversary Date and Version Change

Title section: Removed Annual Approval information & moved policy # to the header

Application: Removed pathway to policies for other lines of business

1/1/2019 Policy Version Change Application: Removed pathway to policies for other lines of business Attachments: Updated both attachments History Section: Entries prior to 1/1/2017 archived

10/31/2018 State Exceptions Section: Exception added for Kansas

9/30/2018 Policy Version Change Policy Verbiage Change: Removed reference to other UnitedHealthcare policies under Reimbursement Guidelines.

8/27/2018 Policy Version Change: Added “Professional” to the policy title Definitions: Global Procedure Code has been changed to Global Service. Same Group Physician and/or Other Health Care Professional has been updated to Same Group Physician and/or Other Qualified health Care Professional

8/9/2019 State Exceptions Section: Exception added for Arizona

7/11/2018 Annual Approval Version Change

1/1/2018 Annual Policy Version Change Policy List Change: Updated both Diagnostic Imaging Procedures Subject to Multiple Diagnostic Imaging Reduction Technical Component and Professional Component Lists Policy Overview Section: CMS NPFS Link Added

Documents

Multiple Procedure Payment Reduction (MPPR) for Diagnostic ... · patient, results in a written narrative report to be included in the patient’s medical record, and directly contributes