01/12/2012
Implementation of CMS MPPR Expansion Includes Professional Component
Despite significant commentary and continued challenges from the imaging industry, the Centers for Medicare & Medicaid Services (CMS) applied its proposed reductions to the professional component (PC) of Multi Procedure Payment Reduction (MPPR) imaging services furnished to the same patient in the same session, i.e. MR, MRA, CT, CTA, and Ultrasound, effective January 3, 2012. This reduction reflects CMS’s continued efforts to insure that payments for services provided to Medicare beneficiaries are appropriately valued. Now both the technical component (TC) and PC of MPPR imaging services paid under the Medicare Physician Fee Schedule (MPFS) will be reduced when furnished to the same patient at the same session regardless of imaging modality and regardless of whether contiguous body areas are scanned. The TC reduction is 50%, and the PC reduction is 25%.
The implementation was not without some successful results of industry comments after the publication of the MPFS Proposed Rule.
Reduction Amount: The PC of second and subsequent MPPR imaging services will be reduced by 25% instead of the proposed 50%.
Application to Physician Group: Citing operational difficulties, CMS has decided to rescind its plan to apply the reduction when the PC services are provided by different physicians in the same group. In order for the PC-MPPR to be applied, the services must be furnished by the same physician.
There are key elements of this new policy that are important to understand.
Service Location: The reduction in the PC when services are furnished to the same patient in the same session will apply regardless of whether the patient is in a freestanding center, physician practice, or hospital. As it may be more likely to have multiple procedures performed on the same date of service in a hospital, this policy change may have a more significant impact on hospital-based radiologists. This rule is in direct contrast to the application of the MPPR to the TC which only applies to TCs furnished in non-hospital settings because the TC of hospital imaging services are not paid under the MPFS.
Interpretations at Different Times: CMS acknowledged that there may be situations where interpretations of multiple procedures furnished at the same session might be performed at different times, even different dates. However, CMS assumes that when multiple TCs are performed at the same session, the PCs would generally be considered to have been performed at the same session. In spite of this assumption, CMS has stated that when the PCs for MPPR imaging services are provided at “widely different” times, it may be appropriate to use a -59 modifier (“Distinct Procedural Services”) on the professional services. The agency also cautions that the physician needs to “exercise judgment to determine when it is appropriate to use…” CMS further comments that it does not “expect the use of the modifier to be a frequent occurrence.” CMS has failed to provide clear instruction on this situation; it is likely that CMS will monitor the use of the -59 modifier.
Services by Members of a Physician Group: While the Final 2012 MPFS provided for the application of the MPPR to PCs performed by a physician or members of a group, the application to the group was rescinded by CMS after publication of the Final Rule. This change means that the MPPR will be applied to the PC of services furnished to the same patient in the same session only when the same physician is listed as the performing provider. The application to the group was not mentioned in the Proposed Rule.
Global Billing: The reductions in the TC and PC of the services will be applied regardless of whether the providers bill globally or separately. There is no need to split the bills into their respective components.
Combined CPT Codes: CMS was clear to state that the MPPR policy would not apply to combined imaging codes “when billed alone in a single session.” In other words, the separate procedures performed when a CT of the Abdomen and CT of the Pelvis are furnished in the same session would not be subject to the MPPR policy because they have already been combined into a single current procedural terminology (CPT) code when performed together. The same would apply to any future combined codes that are developed by CMS.
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