Cardiology Coding Alert

Identify affected codes by checking for multiple procedure value ‘6.’

CMS has posted the 2013 Medicare Physician Fee Schedule (MPFS; final with comment period), and an element getting a lot of attention from cardiologists is the Multiple Procedure Payment Reduction (MPPR).

MPPR overview: "For cardiovascular services, full payment is made for the TC [technical component] service with the highest payment under the MPFS. Payment is made at 75 percent for subsequent TC services furnished by the same physician (or by multiple physicians in the same group practice, i.e., same Group National Provider Identifier (NPI)) to the same patient on the same day" (www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7848.pdf).

In Transmittal 1149, CR 7848 , CMS instructs that "Contractors shall apply the reduction to procedures with a multiple procedure value of ‘6’ on the MPFSDB layout billed in the same session, on the same date of service, with the same individual National Provider Identifier (NPI) or the same Group NPI, to the same beneficiary" (www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1149OTN.pdf).  

Reaction: "This year’s final rule cuts payments for important cardiovascular services at a time when many cardiology practices are already vulnerable," said ACC President William Zoghbi, MD, FACC, in a statement. "Further cuts in reimbursement targeted at physicians only will make health care delivery unsustainable."

Affected codes: The list of affected cardiovascular codes is several pages, including services such as cardiac and vascular imaging, ECGs, device evaluations, echo, and Doppler. To review the list, see attachment 1 of Transmittal 1149, CR 7848, at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1149OTN.pdf.

Group practice: The application of MPPR to services provided by physicians in the same group is a sore point for many practices. One of the reasons CMS gives for the group practice rule is that "application of the imaging MPPR to physicians in the same group practice will ensure that there is no financial incentive for physicians in a group practice to change their behavior to split imaging interpretation services for a beneficiary among different physicians in the group."

Coding challenges: The MPFS reveals that CMS received plenty of comments about the MPPR rule. Some expose the challenges coders face in trying to apply the rule to real-world claims.

The challenges boil down to:

(1) Lack of a clear definition for "same session"

(2)
Inability to distinguish between bypassing MPPR and bypassing CCI edits when using modifier 59 (Distinct procedural service).

CMS responded in the MPFS: "We are aware of the conflict between use of modifier 59 for CCI edits and for purposes of bypassing the MPPR when multiple procedures are furnished. We are considering creating a new modifier for the MPPR to resolve this problem. In creating a new MPPR modifier, we would refine the definition of what constitutes a session."

Resource: You can locate 2013 MPFS information at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1590-FC.html.