CMS Transmittal 1104

CMS recently issued Transmittal 1104, effective January 1, 2013 (with an implementation date of January 7, 2013) dealing with the application of the Multiple Procedure Payment Reduction (“MPPR”) on the Professional Component (“PC”) and Technical Component (“TC”) of Certain Diagnostic Imaging Procedures to physicians in the same group practice.

Prior to this transmittal, the MPPR was applicable only when the same physician (not physicians in the same group practice) furnished multiple services to the same patient on the same day (in the same session). Now it applies to the physicians in the group practice in the same manner.

The transmittal states the policy as follows:

The MPPR on diagnostic imaging applies when multiple services are furnished by the same physician to the same patient in the same session on the same day.  The MPPR on certain diagnostic imaging services applies to PC and TC services.  It applies to both PC-only services, TC-only services, and to the PC and TC of global services.  Full payment is made for each PC and TC service with the highest payment under the MPFS.  Payment is made at 75 percent for subsequent PC services furnished by the same physician to the same patient in the same session on the same day.  Payment is made at 50 percent for subsequent TC services furnished by the same physician to the same patient in the same session on the same day.  The individual PC and TC services with the highest payments under the MPFS of globally billed services must be determined in order to calculate the reduction.

As stated, previously the MPPR applied only when an individual physician furnished multiple services to the same patient, in the same session, on the same day.  CMS therefore expanded the MPPR on the PC and TC of imaging services by applying it to physicians in the same group practice (same Group National Provider Identifier (NPI)) who furnish multiple services to the same patient, in the same session, on the same day.

The complete list of codes subject to the MPPR on diagnostic imaging is in the attachment to the transmittal. CMS will assume procedures furnished on the same date of service were furnished in the same session unless a modifieris used to indicate multiple sessions; in that case, the reduction will not apply.

Physicians and physician practices had fought hard in Congress and with CMS to prevent the foregoing from happening-arguingthat, unlike the TC, the PC of diagnostic services was differenteven if multiple services were provided to the same patient in the same session (i.e., there are no economies of scale in professional services). They argued further that such was even truer with respect to different physicians in the same practice as different skills/ intellectual activities were being performed by the different physicians, even to the same patient in the same session.

These arguments were to no avail, as imaging had a bull’s eye on its back again, and CMS found another way to cut reimbursement –this time with physician groups.