Multiple Procedure Payment Reduction (MPPR) on Diagnostic ... - AAPC

Reimbursement Policy

Multiple Procedure Payment Reduction (MPPR) on Diagnostic

Cardiovascular and Ophthalmology Procedures

Policy

Number

MPCO02132013RP

Approved

By

UnitedHealthcare Medicare

Reimbursement Policy Committee

Current

Approval Date

01/22/2014

IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY

This policy is applicable to UnitedHealthcare Medicare Advantage Plans offered by UnitedHealthcare and its

affiliates.

You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that

you are reimbursed based on the code or codes that correctly describe the health care services provided.

UnitedHealthcare reimbursement policies use Current Procedural Terminology (CPT?*), Centers for Medicare

and Medicaid Services (CMS), or other coding guidelines. References to CPT or other sources are for

definitional purposes only and do not imply any right to reimbursement.

This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when specified, to

those billed on UB04 forms (CMS 1450). Coding methodology, industry-standard reimbursement logic,

regulatory requirements, benefits design and other factors are considered in developing reimbursement policy.

This information is intended to serve only as a general resource regarding UnitedHealthcare¡¯s reimbursement

policy for the services described and is not intended to address every aspect of a reimbursement situation.

Accordingly, UnitedHealthcare may use reasonable discretion in interpreting and applying this policy to health

care services provided in a particular case. Further, the policy does not address all issues related to

reimbursement for health care services provided to UnitedHealthcare enrollees. Other factors affecting

reimbursement may supplement, modify or, in some cases, supersede this policy. These factors may include,

but are not limited to: legislative mandates, the physician or other provider contracts, and/or the enrollee¡¯s

benefit coverage documents. Finally, this policy may not be implemented exactly the same way on the

different electronic claims processing systems used by UnitedHealthcare due to programming or other

constraints; however, UnitedHealthcare strives to minimize these variations.

UnitedHealthcare may modify this reimbursement policy at any time by publishing a new version of the policy

on this Website. However, the information presented in this policy is accurate and current as of the date of

publication.

*CPT copyright 2010 (or such other date of publication of CPT) American Medical Association. All rights

reserved. CPT is a registered trademark of the American Medical Association.

Proprietary information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc.

Table of Contents

Application ......................................................................................................................................1

Summary .........................................................................................................................................2

Overview........................................................................................................................................2

Reimbursement Guidelines ...............................................................................................................2

CPT/HCPCS Codes: Diagnostic Cardiovascular Services Subject to the MPPR ..................................3

CPT/HCPCS Codes: Diagnostic Ophthalmology Services Subject to the MPPR .................................9

References Included (but not limited to): .......................................................................................10

CMS Transmittals ............................................................................................................................10

UnitedHealthcare Reimbursement Policies ..........................................................................................10

MLN Matters ...................................................................................................................................10

History ............................................................................................................................................10

Application

This reimbursement policy applies to services reported using the Health Insurance Claim Form CMS-1500 or its

electronic equivalent or its successor form, and services reported using facility claim form CMS-1450 or its

electronic equivalent or its successor form. This policy applies to all products, all network and non-network

physicians, and other health care professionals.

The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take

precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code

combinations prior to billing UnitedHealthcare. It is not enough to link the procedure code to a correct, payable

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Reimbursement Policy

Multiple Procedure Payment Reduction (MPPR) on Diagnostic

Cardiovascular and Ophthalmology Procedures

ICD-9-CM diagnosis code. The diagnosis must be present for the procedure to be paid. Compliance with the

provisions in this policy is subject to monitoring by pre-payment review and/or post-payment data analysis

and subsequent medical review. The effective date of changes/additions/deletions to this policy is the

committee meeting date unless otherwise indicated. CPT codes and descriptions are copyright 2010 American

Medical Association (or such other date of publication of CPT). All rights reserved. CPT is a registered

trademark of the American Medical Association. Applicable FARS/DFARS restrictions apply to Government use.

Fee schedules, relative value units, conversion factors, and/or related components are not assigned by the

AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly

practice medicine or dispense medical services. The AMA assumes no liability for data contained or not

contained herein. Current Dental Terminology (CDT), including procedure codes, nomenclature, descriptors,

and other data contained therein, is copyright by the American Dental Association, 2002, 2004. All rights

reserved. CDT is a registered trademark of the American Dental Association. Applicable FARS/DFARS apply.

Summary

Overview

Section 3134 of the Affordable Care Act (ACA) added section 1848(c)(2)(K) of the Social Security Act which

specifies that the Secretary shall identify potentially misvalued codes by examining multiple codes that are

frequently billed in conjunction with furnishing a single service. As a further step in implementing this

provision, Medicare is expanding the MPPR policy by applying MPPRs to the TC of diagnostic cardiovascular and

ophthalmology procedures.

Reimbursement Guidelines

The MPPRs on diagnostic cardiovascular and ophthalmology procedures apply when multiple services are

furnished to the same patient on the same day. The MPPRs apply independently to cardiovascular and

ophthalmology services. The MPPRs apply to TC-only services, and to the TC of global services.

For cardiovascular services, full payment is made for the TC service with the highest payment under the

Medicare Physician Fee Schedule (MPFS). Payment is made at 75 percent for subsequent TC services furnished

by the same physician (or by multiple physicians in the same group practice) to the same patient on the same

day.

For ophthalmology services, full payment is made for the TC service with the highest payment under the

Medicare Physician Fee Schedule (MPFS). Payment is made at 80 percent for subsequent TC services furnished

by the same physician (or by multiple physicians in the same group practice) to the same patient on the same

day.

The MPPRs do not apply to professional component (PC) services. The current and proposed payments are

summarized below in the following examples:

The complete lists of codes subject to the MPPRs on diagnostic cardiovascular and ophthalmology procedures

are provided in the codes section below.

To accommodate implementation of this new proposal, CMS has modified the 2013 Medicare Physician Fee

Schedule to include the following changes:

1. A new Multiple Procedure (Field 21) value of ¡®6¡¯ will denote diagnostic cardiovascular services subject to the

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Reimbursement Policy

Multiple Procedure Payment Reduction (MPPR) on Diagnostic

Cardiovascular and Ophthalmology Procedures

MPPR methodology.

2. A new Multiple Procedure (Field 21) value of ¡®7¡¯ will denote diagnostic ophthalmology services subject to

the MPPR methodology.

UnitedHealthcare Medicare Advantage will align with CMS and implement the new Multiple Procedure Payment

Reduction (MPPR) for Diagnostic Cardiovascular and Ophthalmology Services Policy, effective with claims

reported with a date of service on and after May 1, 2014.

CPT/HCPCS Codes: Diagnostic Cardiovascular Services Subject to the MPPR

Code

Description

75600

Aortography, thoracic, without serialography, radiological supervision and interpretation

75605

Aortography, thoracic, by serialography, radiological supervision and interpretation

75625

Aortography, abdominal, by serialography, radiological supervision and interpretation

75630

Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography,

radiological supervision and interpretation

75658

Angiography, brachial, retrograde, radiological supervision and interpretation

75705

Angiography, spinal, selective, radiological supervision and interpretation

75710

Angiography, extremity, unilateral, radiological supervision and interpretation

75716

Angiography, extremity, bilateral, radiological supervision and interpretation

75726

Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological

supervision and interpretation

75731

Angiography, adrenal, unilateral, selective, radiological supervision and interpretation

75733

Angiography, adrenal, bilateral, selective, radiological supervision and interpretation

75736

Angiography, pelvic, selective or supraselective, radiological supervision and interpretation

75741

Angiography, pulmonary, unilateral, selective, radiological supervision and interpretation

75743

Angiography, pulmonary, bilateral, selective, radiological supervision and interpretation

75746

Angiography, pulmonary, by nonselective catheter or venous injection, radiological supervision

and interpretation

75756

Angiography, internal mammary, radiological supervision and interpretation

75791

Angiography, arteriovenous shunt (e.g., dialysis patient fistula/graft), complete evaluation of

dialysis access, including fluoroscopy, image documentation and report (includes injections of

contrast and all necessary imaging from the arterial anastomosis and adjacent artery through

entire venous outflow including the inferior or superior vena cava), radiological supervision and

interpretation

75809

Shuntogram for investigation of previously placed indwelling nonvascular shunt (e.g., LeVeen

shunt, ventriculoperitoneal shunt, indwelling infusion pump), radiological supervision and

interpretation

75820

Venography, extremity, unilateral, radiological supervision and interpretation

75822

Venography, extremity, bilateral, radiological supervision and interpretation

75825

Venography, caval, inferior, with serialography, radiological supervision and interpretation

75827

Venography, caval, superior, with serialography, radiological supervision and interpretation

75831

Venography, renal, unilateral, selective, radiological supervision and interpretation

75833

Venography, renal, bilateral, selective, radiological supervision and interpretation

75840

Venography, adrenal, unilateral, selective, radiological supervision and interpretation

75842

Venography, adrenal, bilateral, selective, radiological supervision and interpretation

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Reimbursement Policy

Multiple Procedure Payment Reduction (MPPR) on Diagnostic

Cardiovascular and Ophthalmology Procedures

75860

Venography, venous sinus (e.g., petrosal and inferior sagittal) or jugular, catheter, radiological

supervision and interpretation

75870

Venography, superior sagittal sinus, radiological supervision and interpretation

75872

Venography, epidural, radiological supervision and interpretation

75880

Venography, orbital, radiological supervision and interpretation

75885

Percutaneous transhepatic portography with hemodynamic evaluation, radiological supervision

and interpretation

75887

Percutaneous transhepatic portography without hemodynamic evaluation, radiological

supervision and interpretation

75889

Hepatic venography, wedged or free, with hemodynamic evaluation, radiological supervision

and interpretation

75891

Hepatic venography, wedged or free, without hemodynamic evaluation, radiological supervision

and interpretation

75893

Venous sampling through catheter, with or without angiography (e.g., for parathyroid hormone,

renin), radiological supervision and interpretation

78428

Cardiac shunt detection

78445

Non-cardiac vascular flow imaging (ie, angiography, venography)

78451

Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction,

qualitative or quantitative wall motion, ejection fraction by first pass or gated technique,

additional quantification, when performed); single study, at rest or stress (exercise or

pharmacologic)

78452

Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction,

qualitative or quantitative wall motion, ejection fraction by first pass or gated technique,

additional quantification, when performed); multiple studies, at rest and/or stress (exercise or

pharmacologic) and/or redistribution and/or rest reinjection

78453

Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection

fraction by first pass or gated technique, additional quantification, when performed); single

study, at rest or stress (exercise or pharmacologic)

78454

Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection

fraction by first pass or gated technique, additional quantification, when performed); multiple

studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest

reinjection

78456

Acute venous thrombosis imaging, peptide

78457

Venous thrombosis imaging, venogram; unilateral

78458

Venous thrombosis imaging, venogram; bilateral

78466

Myocardial imaging, infarct avid, planar; qualitative or quantitative

78468

Myocardial imaging, infarct avid, planar; with ejection fraction by first pass technique

78469

Myocardial imaging, infarct avid, planar; tomographic SPECT with or without quantification

78472

Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (exercise

and/or pharmacologic), wall motion study plus ejection fraction, with or without additional

quantitative processing

78473

Cardiac blood pool imaging, gated equilibrium; multiple studies, wall motion study plus ejection

fraction, at rest and stress (exercise and/or pharmacologic), with or without additional

quantification

78481

Cardiac blood pool imaging (planar), first pass technique; single study, at rest or with stress

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Reimbursement Policy

Multiple Procedure Payment Reduction (MPPR) on Diagnostic

Cardiovascular and Ophthalmology Procedures

(exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without

quantification

78483

Cardiac blood pool imaging (planar), first pass technique; multiple studies, at rest and with

stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or

without quantification

78494

Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection

fraction, with or without quantitative processing

93000

Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report

93005

Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and

report

93015

Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise,

continuous electrocardiographic monitoring, and/or pharmacological stress; with supervision,

interpretation and report

93017

Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise,

continuous electrocardiographic monitoring, and/or pharmacological stress; tracing only,

without interpretation and report

93024

Ergonovine provocation test

93025

Microvolt T-wave alternans for assessment of ventricular arrhythmias

93040

Rhythm ECG, 1-3 leads; with interpretation and report

93041

Rhythm ECG, 1-3 leads; tracing only without interpretation and report

93224

External electrocardiographic recording up to 48 hours by continuous rhythm recording and

storage; includes recording, scanning analysis with report, review and interpretation by a

physician or other qualified health care professional

93225

External electrocardiographic recording up to 48 hours by continuous rhythm recording and

storage; recording (includes connection, recording, and disconnection)

93226

External electrocardiographic recording up to 48 hours by continuous rhythm recording and

storage; scanning analysis with report

93229

External mobile cardiovascular telemetry with electrocardiographic recording, concurrent

computerized real time data analysis and greater than 24 hours of accessible ECG data storage

(retrievable with query) with ECG triggered and patient selected events transmitted to a

remote attended surveillance center for up to 30 days; technical support for connection and

patient instructions for use, attended surveillance, analysis and transmission of daily and

emergent data reports as prescribed by a physician or other qualified health care professional

93268

External patient and, when performed, auto activated electrocardiographic rhythm derived

event recording with symptom-related memory loop with remote download capability up to 30

days, 24-hour attended monitoring; includes transmission, review and interpretation by a

physician or other qualified health care professional

93270

External patient and, when performed, auto activated electrocardiographic rhythm derived

event recording with symptom-related memory loop with remote download capability up to 30

days, 24-hour attended monitoring; recording (includes connection, recording, and

disconnection)

93271

External patient and, when performed, auto activated electrocardiographic rhythm derived

event recording with symptom-related memory loop with remote download capability up to 30

days, 24-hour attended monitoring; transmission and analysis

93278

Signal-averaged electrocardiography (SAECG), with or without ECG

93279

Programming device evaluation (in person) with iterative adjustment of the implantable device

to test the function of the device and select optimal permanent programmed values with

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