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Update to multiple procedure payment reductions on certain diagnostic services 

September 14, 2018    

In order to maintain consistency with the revised provisions issued by the Centers for Medicare & Medicaid Services (CMS) in 2017, AmeriHealth is updating its reimbursement position for multiple procedure payment reductions (MPPR) for certain diagnostic services. See specific details of this reimbursement change below.

Background

The CMS revisions resulted in reduction of certain multiple procedures from 25 percent to 5 percent. It is applicable to all places of services, where providers bill certain procedure codes for the same individual, in the same session, and on the same date of service. It is a favorable reimbursement change for affected providers.

Note: Due to inadvertent system limitations and issues with the implementation of the original MPPR reimbursement position, which became effective in 2015, certain claims may not have been reimbursed correctly, resulting in overpayments to providers. We continue to work through these system limitations; therefore, certain claims may continue to process incorrectly while the system is being fully coded to correctly implement the existing and updated policies. Once the system has been corrected and the change has been fully coded, claims will be reprocessed in accordance with the requirements of the current updated reimbursement position. All adjustments will be processed consistent with the terms of your provider agreement with AmeriHealth.

MPPR reimbursement methodology

Effective retroactive to January 1, 2017, the following methodology is used to determine a provider’s reimbursement for eligible multiple diagnostic reduction services for certain CPT codes approved by CMS.

MPPR applies as follows when professional component (PC)-only services, technical component (TC)-only services, and when the PC and TC of global services are billed:

  • The following MPPR percentages are applied to the PC:
    • The PC with the highest allowance is eligible for reimbursement at 100 percent.
    • The PC of each subsequent service is eligible for 95 percent of the provider’s allowance.
  • The following MPPR percentages are applied to the TC:
    • The TC with the highest allowance is eligible for reimbursement at 100 percent.
    • The TC for each subsequent service is eligible for 50 percent of the provider’s allowance.

Policy

For more information about how certain diagnostic services are reimbursed under the MPPR guidelines, refer to the AmeriHealth Claim Payment Policy #00.01.60b: Multiple Procedure Payment Reduction on Certain Diagnostic Services.

Refer to Attachment A, Group C of this policy document to see the list of CPT codes for multiple reduction diagnostic services to which the updated methodology described above applies.

To view this policy, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online and then type the policy name or number in the Search field.

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