Monday, October 19, 2015

How and when multiple procedure payment reducation calculated.

Multiple Procedure Reductions

Multiple procedures subject to the multiple procedure concept (as described above) performed by the Same Group Physician and/or Other Health Care Professional on the same date of service are ranked to determine applicable reductions. There are no modifiers that override the multiple procedure concept other than those services which are appropriately reported with modifier 78.


When two or more procedure codes subject to reductions are performed on the same date of service and are subject to the reduction list, only one of the procedure codes will be considered as the primary procedure, and all the remaining procedures will be considered secondary. The procedure with the highest CMS-based Relative Value Unit will be considered the primary procedure. All other procedures performed during the session, and not billed with the multiple procedure modifier (-51) will be adjusted, and an identical new claim line(s) will be added with a -51 modifier appended to the code. The fee for the procedures not considered primary will be reduced.

Oxford providers should bill appropriate -51 modifiers on secondary procedures. If modifiers are not billed or accurately assigned, the primary and secondary procedures are determined based on CMS-based RVU's. Oxford's claims processing system automatically makes the reimbursement reduction calculation to procedures with a -51 modifier.


Reimbursement will be calculated as follows:

1. Primary procedure:

Reimbursement of primary procedure will be based on 100% the applicable fee schedule minus any applicable cost share. No modifier or adjustment is necessary.


2. Secondary procedures:

Reimbursement of secondary procedures will be based on 50% of the applicable fee. This is accomplished by adding the modifier -51 following the procedure code, which will automatically calculate reimbursement based on 50% of the applicable fee schedule minus any applicable cost share.


Note: Multiple procedure reductions and Endoscopic Adjustment Rules are applicable to percent of charge or discount contracts. For percent of charge or discount contracts, the Allowable Amount is determined as the billed amount, less
the discount.

Exception for New York Commercial Lines of Business: Oxford will determine the Primary Procedure based on the code with the highest maximum allowable amount for contracted providers. For services supplied by providers who are not contracted with Oxford, Oxford will compare the UCR amounts for each code and use the code with the highest UCR as the primary procedure.


Multiple Procedure Reduction Codes with Assigned RVUs Reported with Modifiers 26, 53, TC For certain codes that are subject to multiple procedure reductions CMS has assigned separate RVU values when reported with modifiers 26, 53, and TC. When these modified services are billed with other services subject to the multiple procedure concept, the CMS RVUs associated with the reported modifier 26, 53, or TC are used in determining which services should be reduced according to the multiple procedure concept.

Learn More about Multiple Procedure Payment Reduction (MPPR)

Effective Sept. 13, 2014, Humana plans apply multiple procedure payment reduction (MPPR) for diagnostic cardiovascular services, diagnostic ophthalmology services, diagnostic imaging (radiology) services and therapy practice expense (PE). MPPR is a reduction to a portion of the base allowable amount for a service (or a component of service) when more than one unit or procedure of a particular type is provided to the same patient on the same date of service. MPPR applies only to multiple procedures and multiple units.

Covered practitioner services are often priced based on the “inputs” involved in performing the services, such as labor, utilities and supplies. A widely recognized way of calculating pricing involves grouping inputs into three categories: work, malpractice and practice expense (PE).

When multiple services are rendered to a patient by a provider on the same day, some clinical labor activities and supplies that are common to multiple services are not separately provided for each service; so it is appropriate to offset the pricing of services to account for that fact. MPPR adjusts pricing in these situations.

How does Humana apply an MPPR?

Humana applies MPPR for certain services in order to more appropriately recognize the efficiencies health care providers experience when combinations of services are provided together.

For therapy practice expense (PE) MPPR, full payment is made for the unit or procedure with the highest PE payment; all subsequent units and/or procedures are paid at a reduced amount for the PE portion of the services. For other MPPRs, full payment is made for the component (technical or professional) with the highest payment; all subsequent units and/or procedures are paid at a reduced amount for the specific component.

When does Humana apply MPPR?'

In most cases, Humana applies MPPR at the time of initial adjudication or redetermination. This provides more accurate initial processing of claims and reduces the need to recoup payments after initial processing.

The following are some procedures with examples of when and how Humana applies MPPR to them:

Diagnostic cardiovascular services — MPPR applied to the technical component.
Diagnostic ophthalmology services — MPPR applied to the technical component.
Diagnostic imaging (radiology) — MPPR applied to the technical and professional components.
Therapy — practice expense

For current dates of service, Humana applies a 50 percent MPPR to the practice expense (PE) payment of “always therapy” services. The following table shows a sample calculation of therapy PE MPPR. Note that one unit allowed “always therapy” services is not subject to the MPPR; however, for six units of allowed “always therapy” services, only five units are reduced.

  BA* PE** Total reduction calculation (for office or other noninstitutional setting) Total allowed amount (assuming no other reductions)

Procedure code 1 $30 $0.50 3 (units) X $ 0.50 X 50% = $ 0.75 reduction 3 (units) X $30.00 = $90.00 (0.75) $89.25

Procedure code 2 $29 $1.00 2 (units) X $ 1.00 X 50% = $ 1.00 reduction 3 (units) X $29.00 = $87.00 (1.00) $86.00



Multiple Procedure Reduction Codes with no assigned CMS RVU

Services that CMS indicates may be carrier-priced, or those for which CMS does not develop RVUs are considered Gap Fill Codes and are addressed as follows:

** Gap Fill Codes: When data is available for Gap Fill Codes, Oxford uses the relative values published in the first quarter update of the Optum, The Essential RBRVS publication for the current calendar year.

** 0.00 RVU Codes: Some codes cannot be assigned a gap value or remain without an RVU due to the nature of the service (example: unlisted codes). These codes are assigned an RVU value of 0.00.


Multiple Procedures Reported with Modifier 78

Per CPT, it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first, and requires the use of an operating/procedure room, it should be reported by adding modifier 78 to the related procedure.

In accordance with CMS guidelines, procedures reported with a modifier 78 that have a 10 or 90 day global period are not subject to the multiple procedure concept.


Multiple Procedures for Assistant Surgeon Services Reported with Modifiers 80, 81, 82, AS

When services are reported by more than one assistant surgeon using modifiers 80, 81, 82 or AS those services will be ranked collectively if reported by the Same Group Physician and/or Other Health Care Professional. Assistant surgeon services will be ranked separately from the services reported by the primary surgeon.

Refer to Oxford’s Assistant Surgeon policy for information on when assistant surgeon services are reimbursable.

Refer to the Questions and Answers section, Q&A #3, for an example of multiple procedure ranking on an assistant surgeon claim.

Multiple Procedures for Co-Surgeon/Team Surgeon Services Reported with Modifiers 62, 66


Multiple procedures performed by a co-surgeon (modifier 62) or team surgeon (modifier 66) are subject to the multiple procedure concept as defined above when performed by the Same Individual Physician or Other Health Care Professional on the same date of service. Co-surgeon and team surgeon services are ranked separately and independently of any other co-surgeon or team surgeon services.

Multiple Procedures for Bilateral Surgeries Reported with Modifier 50


Selected bilateral eligible services may also be subject to multiple procedure reductions when billed alone or with other multiple procedure reduction codes.

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