Oncology & Hematology Coding Alert

CMS considers adding a modifier specific to overriding MPPR.

Hematology/oncology is expected to see a 2 percent increase in reimbursement for services paid under the 2013 Medicare Physician Fee Schedule (MPFS). That’s the "estimated impact on total allowed charges" according to the MPFS notice (final with comment period), published by CMS.

The actual fee impact will depend on the services your practice provides. For those practices providing imaging services, reimbursement may be affected by the expansion of the Multiple Procedure Payment Reduction (MPPR). The MPPR applies to designated imaging services and reduces reimbursement for second and subsequent imaging services at the same session. The 2013 MPFS states Medicare will now "apply the MPPR to both the PC [professional component] and the TC [technical component] of advanced imaging procedures to multiple physicians in the same group practice (same group NPI). Under this policy, the MPPR will apply when one or more physicians in the same group practice furnish services to the same beneficiary, in the same session, on the same day" (emphasis added).

Rationale: The CMS decision makers hope "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 notice reveals that CMS received plenty of comments about the MPPR rule. Some of the comments 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."

The MPFS notice goes on to say that image time can be used in some fashion to determine a "session" and should be something that is currently captured in most radiology medical record systems. Where documentation or billing systems do not currently capture this information in readily usable form, entities should plan to adapt or include information in the progress note to make this information readily available to coders. The information may be the basis to determine a justifiable separate session once it is further defined. Alternatively, CMS may modify the imaging MPPR to apply to all services on the same date rather than the same 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.