Multiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging Policy, Professional - Reimbursement Policy - UnitedHealthcare Commercial Plans
The UnitedHealthcare 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 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 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.
Since June 2006, in accordance with CMS, UnitedHealthcare 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.
For claims with dates of service beginning November 15, 2015, in accordance with CMS, UnitedHealthcare 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.
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Questions and Answers
Q: Which procedure would be primary when code 76604 (Ultrasound) and code 76831 (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'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
Q: Does UnitedHealthcare 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's Professional/Technical Component Policy which does not allow reimbursement for the TC portion in a facility setting.
Q: If the Same Group Physician and/or Other Health Care Professional performs 76700 (Ultrasound) during a single session 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.
Q: How will the Same Group Physician and/or Other Health Care Professional, who is 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'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.
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's standard Professional/Technical percentage splits. Then the Technical Component(s) with the lesser RVU(s) will be considered reducible. The Allowable Amount is determined based on the lesser of the charges assigned for modifier TC using UnitedHealthcare's standard Professional/Technical percentage splits or the contracted rate, with an imaging reduction applied.
Q: A patient comes in for multiple chest studies, first an ultrasound is completed, and the patient is then moved to a different room for a CT angiography. 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.