MPPR Policy Applied to Professional Component in 2012

01.01.2012 
The Centers for Medicare and Medicaid Services (CMS) will begin applying its Multiple Procedure Payment Reduction (MPPR) policy to the professional component (PC) of certain diagnostic imaging services (computed tomography, magnetic resonance imaging, and ultrasound). The policy, effective January 1, 2012, applies to all sites of service including physician offices, independent diagnostic testing facilities, and hospital-based practices (see MLN Matters® Number: MM7442 and click here for a listing of procedure codes subject to the MPPR policy). This means that when the same physician interprets two or more studies using these modalities in the same session for the same patient, Medicare will make a full PC payment for the procedure with the highest payment under the Medicare Physician Fee Schedule (PFS), and then pay 75 percent for the second and subsequent PC services for those services subject to the MPPR policy. As with the technical component (TC) MPPR, CMS will apply this payment across multiple modalities. The PC MPPR only applies when the same physician interprets the examinations and, unlike the TC MPPR, will not be applied to group practices due to “operational considerations.” The technical component MPPR policy remains unchanged and continues to be applied to group practices. The technical component is paid at 100 percent for the highest payment procedure under the PFS and at 50 percent for second and subsequent studies.
 
The final CMS policy represents a departure from what CMS originally proposed. In response to ACR comments and meetings with Medicare officials during the past six months, CMS reduced the magnitude of the payment reduction from 50 to 25 percent and agreed not to apply the policy more broadly across group practices. However, the ACR continues to disagree with the magnitude of the reduction, and we believe CMS should acknowledge that interpretations by different physicians by definition constitute separate sessions. Please see the ACR comment letter on the 2012 MPFS Final Rule for a full discussion of the MPPR policy applied to the PC and the ACR’s concerns with the implementation of this policy.
 
While it is the ACR's opinion that anytime different physicians interpret examinations it is by definition a separate session, CMS has not acknowledged this was the reason for not applying the MPPR regulation to group practices; therefore, we caution members against changing their practice patterns. However, instances that clearly constitute separate sessions are when different sub-specialists interpret examinations in different body areas (e.g., thorax and abdomen) or when different modalities are used and interpreted by different physicians. Additionally, multiple physicians might be required to interpret multiple examinations on the same patient from the Emergency Department to expedite patient care, and this scenario would also constitute separate sessions. There is no reason to apply a -59 modifier when examinations are interpreted by different physicians.
 
Some of these same scenarios may constitute separate sessions even when the same physician interprets examinations on the same patient during the course of the day. These scenarios can and should be coded using the -59 modifier (distinct procedural service) at the discretion of the interpreting physician.  As noted on p. 73079 of the Federal Register, Col. 76, No. 228, Monday, November 28, 2011, Rules and Regulations,
 
“In cases where the physician demonstrates the medical necessity of furnishing interpretations in separate sessions, use of the -59 modifier would be appropriate.”
 
Possible examples of when a -59 modifier might be used include examinations interpreted at different times during the day, examinations acquired using different modalities and interpreted at different times during the day, and examinations of different anatomic areas performed for disparate clinical reasons that are interpreted at different times during the day - if the interpreting physician deems the second and subsequent interpretations are distinct and separate sessions. In the Final Rule, CMS further states that:
 
“For purposes of the MPPR on the PC, scans interpreted at widely different times…would constitute separate sessions, even though the scans themselves were conducted in the same session and the MPPR on the TC would apply.  We further recognize that in some cases, imaging tests utilizing different modalities may be conducted in separate sessions for the TC service, such as when the patient must be moved to another floor of the hospital; however, the PC services in such cases may, or may not, be furnished in separate sessions….As a general policy, however, when multiple scans are conducted on a patient in the same session, we would generally consider the interpretations of those scans to be furnished in the same session…the physician will need to exercise judgment.”
 
The ACR is concerned about the logistics of using the -59 modifier and cautions against its indiscriminate use. The increasing use of the -59 modifier could subject practices to Recovery Audit Contractor (RAC) audits of these services. Documenting that these were indeed separate sessions will be necessary and would be best done in the reports of the subsequent examinations. However, the ACR recognizes this will be problematic for physicians and often impossible for coders to know that the prior examination on the same patient had been reported in the same day. The ACR's Economics Committee on Coding and Nomenclature is working to develop guidelines that will better define the appropriate use of the -59 modifier. We will work with the AMA and CMS to assure the guidelines we offer to members follow the intent of the MPPR regulation. At the same time, we hope that adherence to these guidelines will keep practices in compliance with CMS regulation and prevent unnecessary practice audits.