Payment Adjustment Rules for Multiple Procedures and CCI Edits

July 9th, 2020 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
Categories:   CPT® Coding   Modifiers   Billing   Denials & Denial Management   Practice Management  

Surgical and medical services often include work that is required to be done prior to a procedure and post-procedure. When there are multiple procedures done by the same physician, group, or another qualified healthcare professional on the same day, the pre and post work is only required once. Therefore, CMS and other payers take a reduction in reimbursement for the secondary and subsequent procedures applied to the Practice Expense (PE). This is called a Multiple Procedure Payment Reduction (MPPR). 

Using a CCI validator or claim scrubber can be helpful and will often give errors and warnings if a set of codes require a modifier. However, this is not always the case. Other validators such as Find-A-Code's Scrub-A-Claim not only use government edits, but also private payer edits. Therefore, you may see different results.    

It is vital to have access to current information, coding rules, and guidelines. Refer to the NCCI policy manual if you have questions, or are expecting to see an edit that is not there with the NCCI validator.  Understanding the description of modifier 51 - multiple procedures, sounds simple enough, but is it? How is it used by government and private payers? When reporting multiple procedures, it is often misunderstood. 

51 - Multiple Procedures

When multiple procedures, other than E/M services, physical medicine, and rehabilitation services, or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s).


Note: This modifier should not be appended to designated "add-on" codes (see Appendix D)


CMS - NCCI Edit Rules

Take a look at the use of modifier 51 with the NCCI edits. For example, "Why are there no errors or warnings with the CCI edits stating the following codes should require the use of modifier 51? I am reporting multiple procedures using the following codes: 51741 and 51784."  

First of all, remember the CCI editor is using CMS rules. Therefore, we must understand how CMS applies the standard payment adjustment rules for multiple procedures as well as the use of modifier 51. For example, CMS has assigned the #2 payment indicator, telling us the standard payment adjustment rules for multiple procedures apply to both CPT codes, 51741 and 51784.

Some Payers Align with CMS

Here is an example of a UnitedHealthcare (UHC) policy using the same processing rules as CMS on Multiple Procedures Payment Reduction (MPPR) for medical and Surgical Services.

The UHC surgery policy states; "The use of modifier 51 appended to a code is not a factor that determines which codes are considered subject to multiple procedure reductions; the determining factor is the standard payment adjustment rules."

Medicare Physician Fee Schedule (MPFS) Indicators

CMS assigns the standard payment adjustment rules, assigning indicator codes to CPT codes using Medicare Physician Fee Schedule (MPFS) Indicators. These are assigned to codes applicable to the multiple procedure reduction using the status #2 indicator. Status indicators can be found on the CPT code information page under the Additional Information tab when using Find-A-Code. 

The #2 indicator description states "Standard payment adjustment rules for multiple procedures apply." The payment adjustment rules for the #2 indicator is below. 

Payment Adjustment Rules for #2 Status Indicator

According to CMS, "Standard payment adjustment rules for multiple procedures apply for a procedure reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100%, 50%, 50%, 50%, 50% and by report). Base the payment on the lower of (a) the actual charge or (b) the fee schedule amount reduced by the appropriate percentage." 

Therapy, Time Based - Multiple Units

For selected therapy codes, the rules may be different. For example, according to CMS MLN MM8206 Multiple Procedure Payment Reduction (MPPR) for Selected Therapy Services, the MPPR is applied to units when the code is a time-based code and multiple units are billed to the same patient on the same day. This reduction applies to Healthcare Common Procedure Coding System (HCPCS) codes that are considered "Always therapy". Therefore, the first unit is paid in full and the remaining are paid with the payment reduction rule.  

RVU's Determine Ranking

RVU's assigned by CMS are used to determine the ranking of services. The highest RVU will be paid at 100%, and the subsequent services will each be paid at 50%.

RVUs are generally higher in a physician's office due to the practice expense. For example, the practice expense (PE) for a facility with CPT code 11044 is 1.68, but in an office setting the practice expense is 3.895. Any place of service not listed as a facility will be ranked as a Non-Facility. 

Facility Place of Service (POS) 19, 21, 22, 23, 24, 26, 31, 34, 41, 42, 51, 52, 53, 56 and 61.

Emergency Room (POS 23) Facility

11044 RVU 6.408 Secondary reduction of 50%
14301 RVU 24.168 Primary -0- Reduction paid 100%

Office (POS 11) Non-Facility

11044 RVU 8.624 Secondary reduction of 50%
14301 RVU 29.568 Primary -0- Reduction paid 100%

Other Factors to Consider

  • If only one code is subject to payment reduction there will be no reduction in payment.
  • If one code is subject to payment reduction and submitted with 3 units, the payment reduction would apply to the second and third Units. 
  • Payment adjustment rules do not apply for add-on codes are assigned 0,  No payment adjustment rules for multiple procedures apply.
  • The only modifier that will override the MPPR if appropriately reported, is modifier 78.

Denials

If your claim is denied for Multiple Procedure Payment Reduction (MPPR) you will get a denial reason code of 45 (Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement) and a Group Code of Contractual Obligation (CO), according to the  CMS Pub-100 Claims Processing Manual - Search "Standard Payment" in the Pub-100.

Be sure to contact your payer or carrier to determine their payment processing rules. 

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Artificial Intelligence in Healthcare - A Medical Coder's Perspective
December 26th, 2023 - Aimee Wilcox
We constantly hear how AI is creeping into every aspect of healthcare but what does that mean for medical coders and how can we better understand the language used in the codeset? Will AI take my place or will I learn with it and become an integral part of the process that uses AI to enhance my abilities? 
Specialization: Your Advantage as a Medical Coding Contractor
December 22nd, 2023 - Find-A-Code
Medical coding contractors offer a valuable service to healthcare providers who would rather outsource coding and billing rather than handling things in-house. Some contractors are better than others, but there is one thing they all have in common: the need to present some sort of value proposition in order to land new clients. As a contractor, your value proposition is the advantage you offer. And that advantage is specialization.
ICD-10-CM Coding of Chronic Obstructive Pulmonary Disease (COPD)
December 19th, 2023 - Aimee Wilcox
Chronic respiratory disease is on the top 10 chronic disease list published by the National Institutes of Health (NIH). Although it is a chronic condition, it may be stable for some time and then suddenly become exacerbated and even impacted by another acute respiratory illness, such as bronchitis, RSV, or COVID-19. Understanding the nuances associated with the condition and how to properly assign ICD-10-CM codes is beneficial.
Changes to COVID-19 Vaccines Strike Again
December 12th, 2023 - Aimee Wilcox
According to the FDA, CDC, and other alphabet soup entities, the old COVID-19 vaccines are no longer able to treat the variants experienced today so new vaccines have been given the emergency use authorization to take the place of the old vaccines. No sooner was the updated 2024 CPT codebook published when 50 of the codes in it were deleted, some of which were being newly added for 2024.
Updated ICD-10-CM Codes for Appendicitis
November 14th, 2023 - Aimee Wilcox
With approximately 250,000 cases of acute appendicitis diagnosed annually in the United States, coding updates were made to ensure high-specificity coding could be achieved when reporting these diagnoses. While appendicitis almost equally affects both men and women, the type of appendicitis varies, as dose the risk of infection, sepsis, and perforation.
COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli
COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.
Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli
2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....



Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2024 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association