When Health care providers performing multiple procedures during one episode can be tricky. Educating yourself is key to maximising reimbursements, not all insurance companies have the same policies when it comes to MPPR’s. And although our team of experts at WWS know the ins and outs of how MPPR works, we want to make sure you to understand this insurance procedure, and why it occurs.
What it mean and how does it work?
In an age of increased regulations and reduced fee schedules, turning a profit in the outpatient rehab therapy industry is tougher than ever. And for the past five years going on six it’s been particularly tough for those therapists who treat a lot of Medicare patients. That’s because, under a policy called multiple procedure payment reduction (MPPR).
In other ways, when a physician performs multiple (two or more) related procedures during the same session, Medicare won’t necessarily pay 100% of the fee schedule amount. It allows 100% of the fee schedule amount for the first procedure reported, then 50% for the other procedures – but only up to five. Because of this, when completing physician billing, the highest value procedure should be listed first, followed by other procedures in order of value, with modifier 51 attached.
Mostly Medicare carriers do not require modifier 51 to be used for claims submitted. They will apply MPPR according to their RVU values for the procedures performed. Non-Medicare payors may have different rules when they apply MPPR.
For example, In some insurance companies they only pay 50% for the first additional procedure, and 25% for each additional procedure after two. They may also have different limits to the number of procedures that may be done in one session, for reimbursement.
Exclusion to MPPR:
There are some exclusion to MPPR. Medicare has a separate set of rules for endoscopy procedures. But MPPR does not apply to evaluation and management or physical medicine and rehabilitation services. It also cannot be used in order to reduce payment for supplies.
For Example, Modifier 51 should not be used for “add-on” codes, or procedures found in Appendix D of the CPT manual. Any code listed with a “+” preceding it is not subject to MPPR. There are also “modifier 51 exempt” procedures. Keep in mind, though, that MPPR does apply to office procedures like injections. Physician billing can get tricky when trying to report and calculate reimbursement for patients requiring injections in multiple sites, or injections and other treatments.
Educate yourself on Multiple Procedure Payment Reduction. If you need assistance or guidance, we’re happy to help. Contact us today or Schedule a live demo http://localhost/main-site-update/live-demo/