Medicare expanding Multiple Procedure Payment Reductions to eye care services starting next year

December 16, 2012
Box 2

Box 2

Effective Jan. 1, 2013, Medicare will expand its Multiple Procedure Payment Reduction (MPPR) policy to the technical component (TC) of selected eye care procedures.

The new payment reduction policy will apply largely to ophthalmic imaging services. (For a complete list, see Box 1.)

The multiple payment reductions are applied when multiple services are furnished to the same patient on the same day.

The reductions apply to TC-only services and the technical component of global services. The reductions do not apply to professional component (PC) services.

Box 1

Box 1

When multiple ophthalmic imaging services subject to this policy are provided by a physician or group practice to the same patient on the same day, the most expensive service will be paid at the normal Medicare physician fee schedule rate, while the TC of the other services will be paid at 80 percent of the fee schedule.

An example of how the payment procedure policy will be applied in ophthalmology codes is provided in Box 2.

“The AOA argued against expanding the MPPR policy to ophthalmic imaging and succeeded in reducing the discount from 25 percent to 20 percent,” said AOA Federal Relations Committee Chair Roger Jordan, O.D. “Although there is no scientific basis for these reductions, the CMS has slowly subjected more and more procedures and services to these reductions based on the theory that services performed together can be provided more efficiently.”

When payments are reduced due to the MPPR policy, practitioners will receive a Claim Adjustment Reason Code of 59 on remittance advice.

The policy change comes as part of an overall effort, authorized under the Affordable Care Act, to reduce costs in Medicare and other federal health insurance programs.

The act requires the Secretary of Health & Human Services to identify potentially misvalued billing codes by examining codes that are frequently billed together in conjunction with the furnishing of a single service.

Health care practitioners should make sure billing personnel are aware of these changes, according to the U.S. Centers for Medicare & Medicare Services (CMS).

For further information, see Medicare Learning Network (MLN) Matters article MM7848, Multiple Procedure Payment Reduction (MPPR) on the Technical Component (TC) of Diagnostic Cardiovascular and Ophthalmology Procedures (http://tinyurl.com/cemmglz) and CMS Regulation and Guidance Transmittal R1149OTN (http://tinyurl.com/R11490).

One comment

  1. […] The budget deal also prevents lower Medicare payments to physicians, including ODs, in geographic areas with relatively low practice costs. Also, the agreement extends exceptions to caps on OD-provided therapy services, but allows new reductions to be imposed when certain multiple procedures are provided.  Effective Jan. 1, Medicare will expand its Multiple Procedure Payment Reduction policy to the techni… […]

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