Multiple Procedure Payment Reduction

$199 / year

This dataset shows the therapy payment amount reduced by MPPR (Multiple Procedure Payment Reduction) is applied toward the therapy caps. MPPR amount may increase the amount of medically necessary therapy services the beneficiary receives before exceeding the therapy caps. Medicare is applying MPPR to the non-facility Practice Expense (PE) payment of select therapy services paid under the Medicare Physician Fee Schedule (MPFS). The reduction applies to the Healthcare Common Procedure Coding System (HCPCS) codes contained on the list of “always therapy” services that are paid under the MPFS.

Complexity

The basic idea behind MPPR is that when a physician performs multiple (two or more) procedures, that are related, during the same session, Medicare and some commercial insurance companies won’t pay 100% of the fee schedule amount. Medicare allows 100% of the fee schedule amount for the first procedure reported, then 50% for the other procedures, up to five. If a physician performs more than five procedures in one session, when doing the physician billing, an operative report must be filed and Medicare will decide if additional reimbursement is allowed. Because of this, when doing physician billing, the highest value procedure should be listed first, then followed by the other procedures by value, with modifier 51 attached. Generally, the full value of each service should be listed and the payer will apply the MPPR. Most Medicare carriers do not require that modifier 51 be used for claims submitted to them. They will apply MPPR according to their RVU values for the procedures performed.

Date Created

2016-01-01

Last Modified

2018-03-26

Version

2018-03-26

Update Frequency

Annual

Temporal Coverage

2017 to 2018

Spatial Coverage

United States

Source

John Snow Labs => Centers for Medicare and Medicaid Services

Source License URL

John Snow Labs Standard License

Source License Requirements

N/A

Source Citation

N/A

Keywords

Medicare Fee, MPPR Payment Caps, MPPR Therapy Services, Medical RVUs, Medicare Fee Multiple Procedure Payment Reduction, MPPR Multiple-Procedure-Payment-Reduction

Other Titles

CPT Physical Multiple Procedure Payment Reduction, CMS Fee Multiple-Procedure-Payment-Reduction

Name Description Type Constraints
HCPCS_CODEHCPCS number for the service.string-
SHORT_DESCRIPTORShortened, fixed-length description of the codestring-
CARRIERA number assigned to a specific Carrierintegerlevel : Nominal
LOCALITYA number assigned to a specific localityintegerlevel : Nominal
FEE_AMOUNT_USDPayment amountnumber-
Reduction_50percentage_USD50% reductions amountsnumber-
PRACTICE_EXPENSE_RVUsRelative Value Unit (RVU) for the resource-based practice expense for CY 2016.numberlevel : Ratio
HCPCS_CODESHORT_DESCRIPTORCARRIERLOCALITYFEE_AMOUNT_USDReduction_50percentage_USDPRACTICE_EXPENSE_RVUs
97036Hydrotherapy1112524025.40.64
97036Hydrotherapy11827235.5230.64
97036Hydrotherapy240223723.780.64
97036Hydrotherapy310203321.680.64
97036Hydrotherapy11502031.7210.64
97026Infrared therapy3102064.230.1
97026Infrared therapy14112364.20.1
97036Hydrotherapy1320223925.140.64
97026Infrared therapy44122864.220.1
97026Infrared therapy11302064.230.1