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United Healthcare to implement several new multiple procedure payment reductions

September 02, 2015
Area(s) of Interest: Commercial Payors Payor Issues and Reimbursement Practice Management 


In its August 2015 Network Bulletin, United Healthcare (UHC) announced that, beginning with November 15, 2015, dates of service, multiple procedure payment reductions (MPPR) will be applied to several types of services, including: 

  • Technical component of diagnostic cardiovascular and ophthalmology procedures
  • Professional component of diagnostic imaging services
  • Some endoscopy procedures

 

UHC reports that it is implementing the reductions to better align with the Centers for Medicare & Medicaid Services (CMS). The new claim edits will apply for UHC commercial claims. Policy changes include:

 

Diagnostic cardiovascular – MPPR will apply to the technical component of cardiovascular services with a multiple procedure indicator (MPI) of 6, as indicated by CMS, when multiple services are provided to a patient on the same day by the same physician or multiple physicians in the same group practice reporting under the same federal tax identification number (TIN). Services will be ranked by the CMS Total Non-Facility Relative Value Unit (RVU). The services with the highest RVU will be considered primary service and will be processed at 100 percent of the allowable amount. Second and subsequent services will be reduced by 25 percent of the allowable amount. Procedure codes subject to this policy can be viewed by going to the CMS 2015 Physician Fee Schedule. Once there, click on the “2015 RVU15A” file, then download the “RVU15A (Updated 1/8/15)” file, then open the file titled “PPRRVU15_V1223c.csv.” The codes with a MPI of 6 (as indicated in column S “MULT PROC”) are subject to this new policy.

 

 

Diagnostic ophthalmology services – MPPR will apply to the technical component of ophthalmology services with MPI of 7, as indicated by CMS, when multiple services are provided to a patient on the same day by the same physician or multiple physicians in the same group practice reporting under the same federal TIN. Services will be ranked by the CMS Total Non-Facility RVU. The services with the highest RVU will be considered primary service and will be processed at 100 percent of the allowable amount. Second and subsequent services will be reduced by 20 percent of the allowable amount. Procedure codes subject to this policy can be viewed by going to the CMS 2015 Physician Fee Schedule. Once there, click on the “2015 RVU15A” file, then download the “RVU15A (Updated 1/8/15)” file, then open the file titled “PPRRVU15_V1223c.csv.” The codes with a MPI of 7 (as indicated in column S “MULT PROC”) are subject to this new policy.

 

 

Diagnostic imaging services – MPPR will apply to the professional component when multiple diagnostic imaging services assigned a MPI of 4 are furnished to the same patient in the same session by the same physician or multiple physicians in the same group practice reporting under the same federal TIN. Services will be ranked by the CMS Total Transitional Non-Facility RVU. The services with the highest RVU will be considered primary and processed at 100 percent of the allowable amount. Services with the lower RVU will be considered secondary and subsequent and reduced by 25 percent of the allowable amount. Procedure codes subject to this policy can be viewed by going to the CMS 2015 Physician Fee Schedule. Once there, click on the “2015 RVU15A” file, then download the “RVU15A (Updated 1/8/15)” file, then open the file titled “PPRRVU15_V1223c.csv.” The codes with a MPI of 4 (as indicated in column S “MULT PROC”) are subject to this new policy.

 

 

UHC reports that it will not apply professional component reductions when services are reported with modifier 59 or XE to identify different sessions.

 

 

Additionally, UHC announced it will also begin applying a multiple endoscopic reduction, in line with CMS, when multiple procedures are performed on the same day, by the same physician or multiple physicians in the same group practice reporting under the same federal TIN for commercial claims with a date of service on or after November 15, 2015. For more information on the details of the policy, see the UHC August Network Bulletin 2015 (page 25) on the UHC website.

 

 

Physicians are encouraged to review all of the multiple procedure reduction changes to understand how the changes will affect their individual practices.

 

 

Questions about any of the claims editing rules or payment policies can be directed to UHC at (877) 842-3210.

 

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