As surgical and medical services often include pre-procedure and post-procedure work, healthcare providers may perform multiple procedures during a single patient encounter. Multiple Procedure Payment Reduction (MPPR) means that multiple procedures performed by the same physician or other qualified health care professional on the same date of service during the same patient encounter may be subject to multiple procedure reduction for secondary and subsequent procedures. CMS and many third party payers will fully reimburse only the highest valued procedure. Coders in medical billing companies are aware of such payment reductions, payer rules, and guidelines and can help physician submit accurate claims that correctly describe health care services rendered.
The National Correct Coding Initiative (NCCI) Policy explains MPPR as follows: “Most medical and surgical procedures include pre-procedure, intra-procedure, and post-procedure work. When multiple procedures are performed at the same patient encounter, there is often overlap of the pre-procedure and post-procedure work. Payment methodologies for surgical procedures account for the overlap of the pre-procedure and post-procedure work”.
Using Modifiers to Report Multiple Procedures
Updated annually, National Correct Coding Initiative (NCCI) edits are based on AMA’s coding conventions, national and local payer policies, coding guidelines developed by national societies, and standard medical and surgical practices. The NCCI Coding Policy Manual contains procedure-to-procedure (PTP) edits that define when two codes should not be reported together for the same operative session. NCCI PTP edits aim to prevent improper payment when incorrect code combinations are reported.
Modifiers are used to report multiple procedures to payers. To prevent denials and ensure appropriate reimbursement, it is important to know if a set of codes require a modifier. Using a NCCI validator or claim scrubber will provide errors and alerts if modifiers are required with a set of CPT codes, explains a recent Find-a-code article. Other validators use government edits as well as private payer edits and may provide different results.
Understand CMS Standard Payment Adjustment Rules
Modifier 51 is used to bill surgical services, that is, when two or more surgical services were performed by the physician during the same treatment session.
51 – Multiple Procedures: When multiple procedures, other than E/M services, physical medicine, and rehabilitation services, or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s).
However, there is often much confusion about when to report modifier 51. To do so, coders need to understand two things, according to www.findacode.com: how CMS applies the standard payment adjustment rules for multiple procedures and the use of modifier 51. Key points:
- When assigning the standard payment adjustment rules, CMS uses Medicare Physician Fee Schedule (MPFS) Indicators to assign indicator codes to CPT codes.
- MPFS indicators are assigned to codes applicable to the multiple procedure reduction using the status #2 indicator. The description of the #2 indicator states: “Standard payment adjustment rules for multiple procedures apply.”
- If there is no NCCI edit for a code pair, then modifier 51 can be appended to the additional procedure code(s). If CMS assigns the #2 payment indicator, it means that the standard payment adjustment rules for multiple procedures apply to both codes.
- To report the 51 modifier correctly, the procedure with the highest RVU (highest paying) should be listed first, and modifier 51 should be used on the subsequent service(s) with lower RVU (lowest paying).
- Per Medicare’s MPPR) policy, surgeons can expect to get reimbursed 100 percent for the first procedure and 50 percent for the second through fifth procedures. If more than five different procedures are performed, an operative report will need to be submitted for payment of all the procedures, explains the American College of Surgeons.
- The rule is different for selected therapy codes which are time-based, where multiple units may be billed for a single procedure. Here MPPR is applied to units for time-based codes and multiple units are billed to the same patient on the same day. The first unit will get paid 100 percent (100%) of the plan allowance for the first unit and the payment reduction rule will be applied for all additional units of service.
- If payment reduction applies to only one code, there will be no reduction in payment.
With such complexities involved, reporting multiple procedures can be a challenge. Understanding correct and appropriate use of modifier 51 is key to filing correct claims for appropriate payment. It is also crucial to be aware about the latest payer guidelines, which may vary be state/location. All of this would be much easier with the support of an experienced medical billing service provider.