FeatureReimbursement roundsThe PC MPPR: Implications for Practices
Introduction
The multiple procedural payment reduction (MPPR) for diagnostic imaging applies when multiple services are furnished by the same physician on the same patient in the same session on the same date. In other words, same radiologist, same patient, same session, same day. CMS has expanded the MPPR to now include the professional component (PC) of radiologic services. Under this policy, the second and subsequent interpretations performed by the same physician have their payments reduced by 25%. The reduction does not apply when different physicians, even in the same group practice, provide the interpretations. CMS does not apply the reduction to PC services provided in different sessions on the same date of service. The MPPR policy creates 3 unique challenges for practices that I discuss in this column: (1) What is the definition of separate PC sessions? (2) Once defined, how does a practice identify the same vs a different PC session in its day-to-day operations? and (3) What are the compliance implications of this policy?
Section snippets
The Definition of a Separate PC Session
CMS has acknowledged that separate PC sessions may occur on the same date, such that the PC MPPR does not apply, and recommends appending the −59 modifier to the code. By convention, the −59 modifier is used to indicate a “distinct procedural service.” CMS also recognizes that identifying instances exempt from the PC MPPR will pose a challenge for providers. In the Medicare Physician Fee Schedule final rule, CMS [1] states,
In cases where the physician demonstrates the medical necessity of
Operationalize It
Once the criteria for the same vs separate sessions have been defined, the next challenge is ensuring that the information necessary for this determination is available at the time of billing. The determination of the same vs different PC sessions could be made prospectively by the interpreting radiologist and documented in the radiology report. It could also be made retrospectively by a coder based on the available data, such as time of interpretation. The ACR [2] has recommended the
Compliance Considerations
Practice leaders may decide to ignore the potential for different PC sessions and accept an across-the-board 25% reduction on all affected multiple studies. This would be shortsighted because 25% of a $100 Medicare PC payment for an advanced imaging study is $25. An experienced coder can review 20 or more cases in an hour, so identifying even 1 MPPR-exempt case among those 20 compensates for the extra collection expense. At the other extreme, practices may append the −59 modifier to every
Conclusions
The PC MPPR expansion serves as another example of a misguided CMS policy, the practical ramifications of which were not thoroughly considered upon implementation. Now that the policy is in place, practices are faced with new challenges regarding the billing of multiple studies and the evaluation of the compliance risks involved. As I have shown, the differentiation of the same vs different PC sessions will be especially challenging to define and subsequently apply to a group's billing
References (4)
Medicare program; payment policies under the Physician Fee Schedule and other revisions to part B for CY 2012; final rule
Fed Reg
(2011)MPPR policy applied to professional component in 2012
Cited by (3)
Impact of the Professional Component MPPR Policy on Interdivisional Finances in an Academic Radiology Department
2016, Journal of the American College of RadiologyCitation Excerpt :The GAO suggested that a systematic 25% MPPR be applied on the physician work component, with an exemption for the savings from the budget neutrality requirement, which would have required that the savings be redistributed by increasing fees for all other services [3]. Despite opposition by the AMA and the ACR, the Medicare Payment Advisory Commission (MedPAC) used the GAO report to recommend that the MPPR be extended to include the professional component [5,6]. In 2011, CMS applied a 25% MPPR to the entire professional component (ie, not just the physician work component) for multiple services performed by the same physician in the same session in the same day [1].
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