Physician billing can be complicated, especially if you work with Medicare. But even commercial companies impose a Multiple Procedure Payment Reduction, or MPPR, in some instances. And although our team of experts at Healthcare Information Services know the ins and outs of how MPPR works, we want to make sure you understand this insurance procedure, and why it occurs.
The basic idea behind MPPR is this: when a physician performs multiple (two or more) related procedures during the same session, Medicare (and some commercial insurance companies) won’t necessarily pay 100% of the fee schedule amount. For example, Medicare allows 100% of the fee schedule amount for the first procedure reported, then 50% for the other procedures – but only up to five. If a physician performs more than five procedures in one session, when doing the physician billing, an operative report must be filed and Medicare will decide if additional reimbursement is allowed. Part of the reason for MPPR is that the insurance carriers will not pay for the pre and post operative period on all of the procedures, but just on one procedure.
Because of this, when completing physician billing, the highest value procedure should be listed first, followed by other procedures in order of value, with modifier 51 attached. Generally, the full value of each service should be listed and the payor will apply the multiple procedure payment reduction. Most Medicare carriers do not require modifier 51 to be used for claims submitted. They will apply MPPR according to their RVU values for the procedures performed.
Non-Medicare payors may have different rules when they apply MPPR. For example, some commercial insurance companies only pay 50% for the first additional procedure, and 25% for each additional procedure after two. They may also have different limits to the number of procedures that may be done in one session, for reimbursement.
There are some exceptions to MPPR. For example, Medicare has a separate set of rules for endoscopy procedures. But MPPR does not apply to evaluation and management or physical medicine and rehabsilitation services. It also cannot be used in order to reduce payment for supplies.
Modifier 51 should not be used for “add-on” codes, or procedures found in Appendix D of the CPT manual. Any code listed with a “+” preceding it is not subject to MPPR. There are also “modifier 51 exempt” procedures. A good rule of thumb for figuring out when to not use modifier 51 is that any procedure that includes the phrase “each additional” in the code description should be exempt.
Keep in mind, though, that MPPR does apply to office procedures like injections. Physician billing can get tricky when trying to report and calculate reimbursement for patients requiring injections in multiple sites, or injections and other treatments.
Before doing any physician billing, it’s very important to understand MPPR, along with other coding procedures. Some insurance companies will tell physicians not to use the 51 modifier when submitting their billing, as the payor will apply the discount. However, many medical societies recommend practices append the modifier anyway, making sure it is appropriate.
As many insurance companies use different MPPR rules, before signing a managed care contract, the practice should be fully aware of their MPPR policy. Managed care contracts are based on Tax ID and not a per physician basis. There is one contract per practice
The more you educate yourself on multiple procedure payment reduction and it’s rules and exceptions, the more efficient and profitable your practice can be. If you need assistance or guidance, we’re happy to help.