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Radiology Coding Alert

MPFS 2013:

MPPR Continues to Be a Sore Spot for Radiology Practices

Published on Mon Dec 03, 2012

A new modifier may be forthcoming to distinguish bypassing CCI from bypassing MPPR.

CMS released the 2013 Medicare Physician Fee Schedule (MPFS; final with comment period) for services furnished on or after January 1.

Not surprisingly, the American College of Radiology (ACR) is speaking up about 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 and the TC 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).

One of the reasons CMS gives 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."

ACR response: "These cuts primarily affect care for people with immediately life threatening illnesses or injuries -- those suffering from multiple trauma or heart attacks, stroke patients and people fighting cancer -- all of whom often need multiple imaging exams to survive. Interpretation of these scans many times requires expertise of different physicians. These cuts discourage doctors from working as a team, which is the direction that health care is supposed to be going, and pull the rug out from under physicians working to save these people's lives," said Paul Ellenbogen, MD, FACR, chair of the ACR Board of Chancellors in a statement.

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.

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