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.
CPT Copyright 2017 American Medical Association. All
rights reserved. CPT? is a registered trademark of the
American Medical Association.