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Multiple Diagnostic Imaging Reduction (MPPR)

Policy ID: NDRP-RAD-001
Section: Radiology
Effective Date: July 01, 2018
Last Reviewed: March 30, 2020

Description

This policy addresses the reimbursement methodology for CMS-1500 Claims containing services subject to the multiple procedure payment reduction for certain diagnostic imaging procedures.

Definition:

Professional Component – Represents the physician or qualified health professional (QHP) expense for the reading, interpretation and report of the service.

Technical Component – Represents the practice expense (PE) for clinical staff (non-physician/QHP staff), supplies, and equipment.

Policy:

The Centers for Medicare & Medicaid Services (CMS) established a reimbursement methodology for certain multiple diagnostic imaging services performed on the same patient, on the same day, during the same imaging session, by the same physician or physician/group practice submitted on a CMS-1500 Claim Form. The reimbursement methodology is separated into three groups based on the three diagnostic imaging families which are

  • Diagnostic Imaging Services
  • Diagnostic Cardiovascular Imaging Services
  • Diagnostic Ophthalmology Imaging Services

The multiple reduction reimbursement methodology applies independently to the specific diagnostic imaging families when multiple imaging services within the same family are performed for the same patient during the same imaging session on the same date of service by the same physician or physician/Group practice.

Modifier 59
When multiple diagnostic imaging services within the same diagnostic imaging family are performed on the same day for the same patient, but at different imaging sessions, modifier -59 must be reported for the subsequent session(s) to allow separate reimbursement. Modifier -59 should not be appended when all imaging services are rendered during the same imaging session.

Multiple Diagnostic Imaging Reduction (MDIR) Methodology
Diagnostic services subject to the MDIR methodology can be identified in the CMS National Physician Fee Schedule Relative Value Unit (NPFSRVU) File under the column MULT PROC with indicator “4”. This MDIR applies to both professional and technical services when these diagnostic imaging services are performed for the same patient during the same imaging session on the same date of service by the same physician or physician/Group practice.

Professional Component Reduction - Payment will be made at 100% for the professional component of the imaging procedure with the highest allowance. Payment for additional imaging services with a CMS NPFSRVU File indicator of “4” will be made at 95% of the allowance for the professional component.

Technical Component Reduction - Payment will be made at 100% for the imaging procedure with the highest allowance. Payment for additional imaging services with a CMS NPFSRVU File indicator of “4” will be made at 50% of the allowance for the technical component.

Diagnostic Cardiovascular Imaging Reduction (DCIR) Methodology
Diagnostic cardiovascular services subject to the DCIR methodology can be identified in the CMS National Physician Fee Schedule Relative Value Unit (NPFSRVU) File under the column MULT PROC with indicator “6”. The DCIR applies to the technical services and the technical portion of the global services when these diagnostic cardiovascular imaging services are performed for the same patient during the same imaging session on the same date of service by the same physician or physician/Group practice. The DCIR does not apply to the professional component of these services.

Technical Component Reduction - Payment will be made at 100% for the cardiovascular imaging procedure with the highest allowance. Payment for additional imaging services with a CMS NPFSRVU File indicator of “6” will be made at 75% of the allowance for the technical component.

Diagnostic Ophthalmology Imaging Reduction (DOIR) Methodology
Diagnostic ophthalmology services subject to the DOIR methodology can be identified in the CMS National Physician Fee Schedule Relative Value Unit (NPFSRVU) File under the column MULT PROC with indicator “7”. The DOIR applies to the technical services and the technical portion of the global services when these diagnostic ophthalmology imaging services are performed for the same patient during the same imaging session on the same date of service by the same physician or physician/Group practice. The DOIR does not apply to the professional component of these services.

Technical Component Reduction - Payment will be made at 100% for the ophthalmology imaging procedure with the highest allowance. Payment for additional imaging services with a CMS NPFSRVU File indicator of “7” will be made at 80% of the allowance for the technical component.

Limitations and Exclusions

While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

Cross Reference

Revision Date

History

03/30/2020

·         Moved information about modifier 59 into a separate section for better visibility.