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Policy No: 101

Date of Origin: 11/01/2008

Section: Modifiers

Last Reviewed:  04/01/2019

Last Revised:  04/01/2019

Approved: 04/04/2019

Effective Date:  05/01/2019

This policy applies only to physicians and other qualified health care professionals.

Definitions

Modifier 51

Current Procedural Terminology (CPT®) modifier 51 - when multiple procedures are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or services(s) may be identified by appending modifier 51 to the additional procedure or service codes(s) when appropriate.

Modifier 51 should not be appended to designated "add-on" codes.

MPFS

Medicare Physician Fee Schedule

PC

Professional Component

TC

Technical Component

MU 

Centers for Medicare & Medicaid Services (CMS) multiple surgery indicator

Multiple Procedure Payment Reduction (MPPR)

Centers for Medicare & Medicaid (CMS) Multiple Procedure Indicators (MULT PROC) are found in the CMS National Physician Fee Schedule Relative Value File. Values which are currently in the CMS file are:

0 - No payment adjustment rules for multiple procedures apply.
2 - Standard payment adjustment rules for multiple procedure apply.
3 - Special rules for multiple endoscopic procedures apply.
4 - Special rules for the technical component (TC) of diagnostic imaging procedures apply if procedure is billed with another diagnostic imaging procedure in the same family.
5 - Special reduction rule for the practice expense component for certain therapy services.
6 - Special reduction rule for the technical component (TC) of cardiovascular services.
7 - Special reduction rule for the technical component (TC) of ophthalmology services.
9 - Concept does not apply.

Primary code

It is defined as a code with the highest maximum allowable amount in relation with other procedure codes that are subject to the same MPPR methodology. When multiple units of the same code are being reported on a single line and the units are within CMS limit, our health plan will use the maximum allowable applicable to 1 unit of that code to determine primacy.

Policy statement

MPPR is applied when multiple procedures that are subject to MPPR are performed at the same session or same day by the same provider on the same member.

Our health plan administers MPPR based on CMS guidelines.

Surgical procedures*:

When a code with a CMS multiple procedure (MU) indicator of 2 is reported with another procedure(s) of 2 or 3, the primary code will be 100% of the allowable amount.  A 50% reduction will be applied to all other subsequent codes.  

Endoscopic procedures*:

When multiple procedures with a MU of 3 are reported, reimbursements are as follows:

  1. Endoscopic codes in the same family (i.e. the same base code) – reimbursement will be 100% of the allowable amount for the primary code, plus the difference in allowable amount between the next highest endoscopy service(s) and its base endoscopy code. 
  2. Endoscopic codes in different families – reimbursement will be 100% of the allowable amount of the primary code.  A 50% reduction will be applied to the subsequent codes.
  3. When multiple series of ‘unrelated' endoscopies are reported – multiple endoscopy rules will first be applied to each family as described in bullet (a). The ‘total' allowed for each set of endoscopies are considered as one service.  The primary service will be 100% of the allowable amount.  A 50% reduction will be administered to all subsequent sets.
  4. If an endoscopic code is reported with only its base code, the base code is not separately reimbursable.

*(Applies to Surgical procedures and endoscopic procedures section)*

In the event where surgical /endoscopic codes eligible for bilateral 150% adjustment (CMS bilateral indicator - BI of 1) are reported along with codes with MU of 2 or 3 on the same day, bilateral (identified as modifier 50) adjustment will be applied first prior to ranking the codes for MPPR.

When a member returns to the operating room after the initial operative sessions on the same days due to complications from the original surgical or endoscopic procedures (identified as modifier 78), the complications rules will be applied to each procedure required to treat the complications.  The multiple surgery rules would not apply. (Please refer to Reimbursement policy Mod 112 on Modifier 78).

Diagnostic imaging procedures:

When multiple diagnostic imaging procedure codes with a MU of 4 are reported, the primary code is 100% of its allowed amount.  A 50% reduction will be applied to the technical component portion; and a 5% reduction will be applied to the professional component portion of all subsequent codes.

For multiple procedures billed globally, the components (modifier 26 or TC) will be ranked independently of each other to determine primacy.

A diagnostic imaging procedure that is eligible for bilateral adjustment (CMS BI indicator of 3) and is billed bilaterally will be subject to MPPR.  Standard bilateral procedure payment rules do not apply.

For CMS policy on the interaction of the MPPR on imaging procedures and the Outpatient Prospective Payment System (OPPS) cap related to Imaging Procedures please see the web link included in the policy's reference section.

MPPR does not apply when the diagnostic imaging procedures are performed on the same day, but at a different session. These are identified as modifier 59 or XE/XP/XU/XS appended to the appropriate procedure code.

Selected therapy procedures:

When multiple therapy codes with a MU of 5 are reported, the primary procedure is 100% of its allowed amount.  A 50% reduction will be applied to the practice expense portion of the maximum allowable of all the subsequent codes.

Diagnostic cardiovascular procedures:

When multiple diagnostic cardiovascular procedure codes with a MU of 6 are reported, the primary code will be 100% of its allowed amount.  A 25% reduction will be applied to the technical component portion of all other subsequent codes.

Diagnostic ophthalmology procedures:

When multiple diagnostic ophthalmology procedure codes with a MU of 7 are reported, the primary code will be 100% of its allowed amount.  A 20% reduction will be applied to the technical component portion of all other subsequent codes.  

A diagnostic imaging procedure that is eligible for bilateral adjustment (CMS BI indicator of 3) and is billed bilaterally will be subject to MPPR.  Standard bilateral procedure payment rules do not apply.

For CMS policy on the in the interaction of the MPPR on imaging procedures and the Outpatient Prospective Payment System (OPPS) cap related to Imaging Procedures please see the web link included in the policy's reference section.

References

Application of the Multiple Procedure Payment Reduction (MPPR) on Imaging Services to Physicians in the Same Group Practice, MLN Matters Number: MM9647, 01/01/2017, Centers for Medicare & Medicaid Services (CMS)

Interaction of the Multiple Procedure Payment Reduction (MPPR) on Imaging Procedures and the Outpatient Prospective Payment System (OPPS) Cap on the Technical Component (TC) of Imaging Procedures (PDF), MLN Matters Number: MM7703, 01/03/2012, Centers for Medicare & Medicaid Services (CMS)

Medicare Claims Processing Manual, Chapter 12 – Physicians/Nonphysician Practitioners. Section 40.6.C.13. 10/13/2017, Centers for Medicare & Medicaid Services (CMS)

Multiple Procedure Payment Reduction (MPPR) on the Technical Component (TC) of Diagnostic Cardiovascular and Ophthalmology Procedures, MLN Matters Number: MM7848, 01/01/2013, Centers for Medicare & Medicaid Services (CMS)

Multiple Procedure Payment Reduction (MPPR) on the Professional Component (PC) of Certain Diagnostic Imaging Procedures, MLN Matters Number: MM9647, 08/05/2016, Centers for Medicare & Medicaid Services (CMS)

Multiple Procedure Payment Reduction (MPPR) for Selected Therapy Services, MLN Matters Number: MM8206, 04/01/2013, Centers for Medicare & Medicaid Services (CMS)

National Physician Fee Schedule Relative Value File Calendar Year 2018, Centers for Medicare & Medicaid Services (CMS)

Cross References

Modifier 50; Bilateral Procedure

Modifier 78; Unplanned Return to the Operating/Procedure Room By the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.