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CMS Multiple Procedure Payment Reduction Policy - Advanced Imaging

CMS’ Change Request (CR) 9647 announces that its Multiple Procedure Payment Reduction (MPPR) for the professional component (PC) of certain second and subsequent advanced imaging studies has been lowered from 25% to 5% effective January 1, 2017.

To summarize the background, CMS finalized a policy in the CY 2012 Final Rule to apply the MPPR of 25% to the second and subsequent studies of certain advanced imaging procedures (CT, MRI and ultrasound) rendered to the same patient in the same session by a single physician, or multiple physicians in the same group practice.  Due to operational restrictions at that time, however, it was unable to apply the policy when multiple physicians in a group were interpreting the multiple imaging studies, so ultimately the MPPR was applied only in instances when the same physician performed all of the patient’s interpretations.

By 2013, CMS had resolved that limitation and indicated it would begin applying the MPPR as originally intended – to services rendered by individual physicians as well as multiple physicians in the same group.  Currently, the procedure with the highest PC reimbursement is paid in full with the reimbursement for each subsequent procedure reduced by 25%.

CR 9647 released August 5, 2016, states that effective January 1, 2017, payment will be made at 95% of the physician fee schedule amount, instead of 75%, for the PC of each additional procedure furnished by one or more radiologists in the same group practice to the same patient, in the same session on the same day.  This change applies to the professional component only; the reduction rate on the technical component (TC) remains at 50%.  The policy continues to apply to those advanced imaging studies with a multiple surgery indicator of ‘4’ in the Physician Fee Schedule Database.

The release goes on to summarize an example of the effect this change will have on reimbursement of the PC service:

Service Procedure 1 Procedure 2 Current Total Payment Revised Total Payment
PC $100 $80 $160 ($100 + (.75 x $80)) $176 ($100 + (.95 x $80))
TC $500 $400 $700 ($500 + (.50 x $400)) $700 ($500 + (.50 x $400))
Global $600 $480 $860 ($600 + (.75 x $80) + (.50 x $400)) $876 ($600 + (.95 x $80) + (.50 x $400))

This is welcomed news for radiology practices.  As always, we at APS will ensure our clients realize this increase through our contract management program which validates that correct payment is being made on every CPT code on every claim.

Change Request 9647 can be accessed at:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3578CP.pdf

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