The multiple procedure payment reduction policy (MPPR) becomes effective on January 1, 2011. This policy is a direct result of the Affordable Care Act which allows CMS to "identify potentially misvalued codes by examining multiple codes that are frequently billed in conjunction with furnishing a single service." CMS will reduce payment for multiple therapy services paid as part of the Medicare fee schedule. Please be aware of this change.
When multiple therapy procedures are provided on the same date, a payment reduction will be assessed when there is more than one unit billed. The reduction will be 20% (this was originally scheduled to be 25%, but the Physician Payment and Therapy Relieve Act of 2010 changed it to 20%) for NON-institutional settings and 25% for institutional settings.
This payment reduction applies to both multiple therapy procedures as well as multiple units of the same procedure.
When the MPPR is applied to a claim, providers will see the Claim Adjustment Reason Code of 45 (Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement) and a Group Code of Contractual Obligation (CO).
The following statement was issued by CMS:
Many therapy services are time-based codes, i.e., multiple units may be billed for a single procedure. The Centers for Medicare & Medicaid Services (CMS) is applying a MPPR to the practice expense payment when more than one unit or procedure is provided to the same patient on the same day, i.e., the MPPR applies to multiple units as well as multiple procedures. Full payment is made for the unit or procedure with the highest PE payment. For subsequent units and procedures, furnished to the same patient on the same day, full payment is made for work and malpractice and 80 percent payment for the PE for services furnished in office settings and other non-institutional settings and at 75 percent payment for the PE services furnished in institutional settings.
For therapy services furnished by a group practice or “incident to” a physician’s service, the MPPR applies to all services furnished to a patient on the same day, regardless of whether the services are provided in one therapy discipline or multiple disciplines; for example, physical therapy, occupational therapy, or speech-language pathology.
The reduction applies to the HCPCS codes contained on the list of “always therapy” services that are paid under the MPFS, regardless of the type of provider or supplier that furnishes the services (e.g. hospitals, Home Health Agencies (HHAs), and Comprehensive Outpatient Rehabilitation Facilities (CORFs), etc.).
FindACode.com has included this information as part of their "Additional Code Information" section. If you see the multiple procedure flag of "5", then the MPPR adjustment applies to that service. This information is part of their subscription service.
If you have additional questions, contact your Medicare carrier. Their toll-free numbers can be found at www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip