Policy

Effective Date

Applicable Products

New Policy Overview or Updated Policy Revisions

Multiple Procedure Payment Reduction (MPPR)

for Diagnostic Cardiovascular Procedures (CC.PP.065)

January 15, 2021

Allwell (HMO and HMO SNP), Ambetter,

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP

This policy is based on CMS reimbursement methodologies for MPPR and applies a multiple diagnostic cardiovascular procedure reimbursement reduction to procedures assigned a multiple procedure indicator (MPI) of 6 on the CMS National Physician Fee Schedule (NPFS). When this occurs, only the highest-valued procedure is reimbursed at the full payment allowance (100%) and payment for subsequent procedures/units is reimbursed at 75% of the allowance.

MPPR for Diagnostic Cardiovascular Procedures Will Apply When:

• The same physician (or by multiple physicians in the same group practice, i.e., same group national provider identifier (NPI)), performs multiple diagnostic cardiovascular procedures with an MPI of 6 to the same patient, in the same session, on the same day.
• A single diagnostic cardiovascular procedure with an MPI of 6 is submitted with multiple units by the same group physician and/or other health care professional.
• Multiple procedures performed.
• Applicable to both institutional and non-institutional providers

MPPR for Diagnostic Cardiovascular Procedures Will Not Apply When:

• Procedure codes with an MPI of 6 are billed with the modifier -26 for the professional component (PC).
• The modifier -26 represents the professional (interpretation and report) component of a procedure and not the technical component. Consequently, the policy does not apply to these services.
• Diagnostic Cardiovascular procedure codes are reviewed for medical necessity by National Imaging Associates (NIA)