Multiple Diagnostic Imaging Reduction (MPPR)

Policy ID: NDRP-RAD-001
Section: Radiology
Effective Date: July 01, 2018
Revised Date: May 28, 2020
Last Reviewed: May 28, 2020

Description:

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

Definition:

Global Service

A global service includes both a professional and technical component.

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. 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.

The technical component of radiology services furnished to hospital patients is included in the hospital claim and should not be billed on a professional claim.

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. This includes all outpatient institutional radiology claims and ambulatory surgical center (ASC) claims billed on the UB-04 Claim Form as well as physician/allied provider claims billed on the CMS-1500 Claim Form.

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.

Note: Services billed on the UB-04 Claim Form are always considered Technical Component only services and apply to the technical component reduction.  Institutional services require the appropriate revenue code for the service and a line-item date of service. 

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 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 for claims billed on the CMS-1500 Claim Form.  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 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 for claims billed on the CMS-1500 Claim Form. 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.

Limitation 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:

History:

Date

Updates

3/30/20

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

5/28/20

Made edits to show when this policy applies to claims billed on the CMS-1500 and/or UB-04 claim forms. 

Disclaimer

Reimbursement policies are intended only to establish general guidelines for reimbursement under BCBSND plans. BCBSND retains the right to review and update its reimbursement policy guidelines at its sole discretion.