CMS Releases Contractor Guidance on Applying the MPPR to Advanced Imaging Services Provided by Group Practices

On December 13, 2012, the Centers for Medicare and Medicaid Services (“CMS”) released Transmittal 1104. This Transmittal is a one-time update that provides guidance to contractors on applying the Multiple Procedure Payment Reduction (“MPPR”) to advanced imaging services provided for one beneficiary during one session by multiple providers in the same group practice. This transmittal was originally communicated to contractors on August 2, 2012, but was not released to the public at that time. Now that CMS has released the Final Medicare Physician Fee Schedule (“PFS”) for CY 2013, the agency is re-communicating this Transmittal and has published it on-line for the public along with a Medicare Learning Network (“MLN”) Article.

As confirmed in the final PFS, effective January 1, 2013, CMS will begin to apply the MPPR to the Technical Component (“TC”) and Professional Component (“PC”) of advanced diagnostic services provided by multiple physicians in the same group practice for the same beneficiary during the same session. The agency had originally proposed this rule in 2012 when it began to apply the MPPR to services provided by single providers. However, CMS delayed implementation of the rule for group practices in order to resolve technical issues.

Under the new rule and guidance, CMS will pay the full amount for the service with the highest payment under the PFS. Payments for any subsequent services provided by the same or another physician in a group practice performed on the same day for the same beneficiary will be at 75% for PC services and 50% for TC services. According to the guidance, CMS assumes that services provided for the same beneficiary on the same day are part of the same session. However, if the services are not part of the same session, the modifier 59 must be used and the MPPR will not be applied.

The transmittal includes an addendum with a list of the services subject to the MPPR.

For more information on this or related issues, please contact Adrienne Dresevic, Esq. or Carey Kalmowitz, Esq. at (248) 996-8510, (212) 734-0128 or visit the HLP website.