As private insurance payers begin adopting the Multiple Procedure Payment Reduction (MPPR) methodology that was implemented by Medicare several years ago, practices that are not ready could face a revenue loss of 25% or more for some services.  Of specific interest to radiologists is United Healthcare, which announced in its May 2014 Network Bulletin that it would be expanding its MPPR to the professional component of imaging services in alignment with Medicare’s policy.  This change will apply to United Healthcare’s Commercial and Community Plan. Originally the policy was to take effect in the third quarter of 2014 but under pressure from radiology advocacy organizations, United has now reported that implementation of the policy will be delayed until the fourth quarter of 2014.  This brief reprieve provides radiology practices with an opportunity to lessen this detrimental impact on their revenue by improving their current processing methodologies before these changes take place.

United said in their May Bulletin that the services ranked as primary (those having the highest RVU value) will be paid at 100% of the allowable amount, with second and subsequent services paid at 75% of the allowable amount.  United is following the Medicare definition of multiple services.   The imaging reduction for the professional component, in addition to any reduction for the technical component, will apply when multiple services 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 Taxpayer Identification Number.  The reductions will apply whether the services are billed separately or globally.

Other insurance plans have adopted policies on a more regional basis that mirror all or part of the Medicare rules.  For example, Highmark Blue Shield reduces certain multiple procedures by 50% of the technical component, leaving the professional component at its full allowable amount, although in other regions some plans are reducing the professional component as well.  United appears to be among the first of the major national payers to fully follow the Medicare example; expect others to follow.

In our May 29, 2013 article Radiology Billing – Don’t Lose Legitimate Revenue to the MPPR, we pointed out that the lack of clarity surrounding the term ‘same session’ allows practices to use the billing modifier -59 to identify those cases where distinct services are rendered and the MPPR should not apply.  The Centers for Medicare and Medicaid Services (CMS) issued a Special Edition of MLN Matters (SE1418) to provide guidance on the use of Modifier -59.  It
describes two instances available to radiology practices that could reduce the
impact of the MPPR:

• Modifier -59 is used appropriately for different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day are performed on different organs or different anatomic regions.

• Modifier -59 is used appropriately when multiple procedures are performed in different encounters on the same day.

Identifying circumstances where these rules can reasonably be applied is up to the individual practice and their billing team.  It is imperative that the physician’s documentation is adequate to support the use of this modifier, and it should be specific enough to alert the practice’s coders to use the modifier.  Such applicable situations will arise in the normal course of patient care.  It would not be appropriate to alter practice patterns in order to avoid compliance with
these rules.

Although in past years CMS has indicated that the MPPR rule would continue to be expanded, the proposed rule for the 2015 CMS Medicare Physician Fee Schedule does not contain any such expansion.  That’s good news for radiology practices already hit hard by its unintended impact.  However, as the major insurance payers look for ways to reduce their claims costs, it is sure to continue to be an area of interest.

Through judicious definition and documentation of outlying circumstances, training of coders in the appropriate use of modifiers, and consistent implementation, radiology practices can legitimately lessen the impact of the MPPR rule on their revenue.