Medicare applies a multiple procedure payment reduction (MPPR) to the practice expense (PE) payment of select therapy services. The reduction applies to the HCPCS codes contained on the list of “always therapy” services, regardless of the type of provider or supplier that furnishes the services.
The MPPR is applied to the PE payment when more than one unit or procedure is provided to the same patient on the same day, i.e., the MPPR applies to multiple units as well as multiple procedures.
Many therapy services are time-based codes, i.e., multiple units may be billed for a single procedure. The MPPR applies to all therapy services furnished to a patient on the same day, regardless of whether the services are provided in one therapy discipline or multiple disciplines such as, physical therapy, occupational therapy, or speech-language pathology.
Full payment is made for the unit or procedure with the highest PE payment.
For subsequent units and procedures furnished to the same patient on the same day, full payment is made for work and malpractice and 50% payment is made for the PE for services submitted on either professional or institutional claims.
To determine which services receive the MPPR, we rank the services according to the applicable PE relative value units (RVU) and price the service with the highest PE RVU at 100% and apply the appropriate MPPR to the remaining services.
When the highest PE RVU applies to more than one of the identified services, we sort and rank these services according to highest total fee schedule amount and price the service with the highest total fee schedule amount at 100% and apply the appropriate MPPR to the remaining services.
Example below is based on the 75% reduction for institutional settings as referenced in CR7050-Multiple procedure payment reduction (MPPR) for selected therapy services.
| |
Procedure 1 unit 1 |
Procedure 1 unit 2 |
Procedure 2 |
Current total payment |
Proposed total payment |
Proposed payment calculation |
Work |
$7.00 |
$7.00 |
$11.00 |
$25.00 |
$25.00 |
no reduction |
PE |
$10.00 |
$10.00 |
$8.00 |
$28.00 |
$23.50 |
$10 + (.75 x $10) + (.75 x $8) |
Malpractice |
$1.00 |
$1.00 |
$1.00 |
$3.00 |
$3.00 |
no reduction |
Total |
$18.00 |
$18.00 |
$20.00 |
$56.00 |
$51.50 |
$18 + ($18-$10) + (.75 x $10) +($20-$8) + (.75 x $8) |
The therapy payment amount that has been reduced by the MPPR is applied toward the therapy caps. As a result, the MPPR may increase the amount of medically necessary therapy services a beneficiary may receive before exceeding the caps.
The reduced amount is also used to calculate the beneficiary’s coinsurance and deductible amounts.
Note: Section 50202 of the Bipartisan Budget Act of 2018 repeals application of the Medicare outpatient therapy caps, but retains the former cap amounts as a threshold above which claims must include the KX modifier as confirmation that services are medically necessary, as justified by appropriate documentation in the medical record; and retains the targeted medical review process, but at a lower threshold amount. Continue to submit the KX modifier on claims in excess of the prior therapy cap amount for claims with dates of service on and after Jan. 1, 2018.
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