We are all familiar with Medicare’s (and many other payers’) policy to reduce the allowed amount for surgical procedures when more than one procedure is performed at the same session. The second procedure is allowed at 50% of the usual amount. Did you know that Medicare has a similar, but not identical, reduction for ophthalmic diagnostic tests? Known as the Multiple Procedure Payment Reduction (MPPR),¹ this became effective for dates of service beginning Jan. 1, 2013.

It’s still causing some confusion among practices four years later — and a recent update (Multiple Procedure Payment Reduction on the Professional Component of Certain Diagnostic Imaging Procedures)² is likely to cause even more.

Q.What is the MPPR for diagnostic tests?

A. Medicare implemented a payment reduction when more than one test is performed at the same encounter. This payment policy reduces the technical component of the second and any subsequent ophthalmic diagnostic tests by 20% when more than one eligible diagnostic test is performed at a patient encounter on the same day by the same physician or group.

Q. Does this apply to all tests?

A. No. The list of tests³ includes ultrasounds, imaging and visual fields. Tests not on the list are not subject to the MPPR reduction. For example, any test that is personally performed by the physician, such as gonioscopy or extended ophthalmoscopy, is excluded

Only tests that are listed in the Medicare Physician Fee Schedule (MPFS) with separate technical (-TC) and professional (-26) components are affected by the MPPR.

Q. How does it work?

A. Medicare looks at multiple tests for the same patient on the same day and identifies the test(s) with the lesser technical component value, then the agency applies the reduction.

Let’s look at an example. A patient returns for her six-month glaucoma and cornea check; at her last visit, an OCT of the optic nerve head was ordered.

During today’s exam, you note that the vision in each eye has worsened and the OCT results indicate the glaucoma is not the cause; on refraction you note a scissored reflex indicative of keratoconus, OU.

CT is ordered and performed during the same visit. Both tests are properly interpreted. In 2017, Medicare payment for these two tests when done in the office would be as follows in Table 1:

The payment reduction is taken only on the lesser of the two technical portions — which is the OCT in this example. The professional component of the CT is lower than the OCT — professional services, however, are unaffected by MPPR.

They are paid in full for each test.

Q. How does this work if there are three tests on the same day?

A. In the example above, if there were also a visual field test performed, the breakdown would look like this (Table 2):

The payment reduction is applied to both the CT and the OCT, since they are the lower-valued technical components. The visual field is allowed in full.

Q. What should we look for on our Medicare Remittance Advice?

A. When the MPPR has been applied, the affected test(s) will show modifier 51 to indicate it was the test(s) on which the reduction was taken. Do not submit your claim with modifier 51; Medicare only shows this on the Remittance Advice to show you how the MPPR was applied.

Q. Do we have to separate the TC/26 components of a test on our claim?

A. Fortunately, no. Medicare contractors do this for all affected tests automatically. OM

References

1. CMS. Medicare Learning Network, MLN Matters MM7848, Eff. January 1, 2013. https://tinyurl.com/yd8szkrt . Accessed Sept. 8, 2017.
2. CMS. Multiple Procedure Payment Reduction (MPPR) on the Professional Component (PC) of Certain Diagnostic Imaging Procedures. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/mm9647.pdf . Accessed Sept. 11, 2017.
3. CMS Transmittal 1149, dated November 6, 2012, identifies the specific tests, by CPT code, that are subject to the MPPR. The Medicare Physician Fee Schedule multiple procedure indicator also identifies these codes each year (multiple procedure indicator 7). https://tinyurl.com/y7dfgj45 . Accessed Sept. 8, 2017.

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com .