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Reimbursement Policy Update: Pay Percent for Multiple Services

Effective February 12, 2018, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider and reimburse claims for certain multiple services (i.e., diagnostic cardiovascular services, diagnostic ophthalmology services and outpatient therapy services1) when rendered by the same provider on the same date of service.

Per the Pay Percent Multiple Cardiology Rule, Pay Percent Multiple Ophthalmology Rule and Pay Percent Multiple Therapy Rule subsections of our ClaimsXten Editing Rules reimbursement policy guidelines, Horizon BCBSNJ will process professional claims submitted for the following services rendered on and after February 12, 2018 based on Centers for Medicare & Medicaid Services (CMS) guidelines for Multiple Procedure Payment Reduction (MPPR).

  • Multiple Diagnostic Cardiovascular Services

    The MPPR on diagnostic cardiovascular procedures applies when a physician (or the same group practice) provides multiple services to the same patient in the same session on the same day. The MPPR on these procedures applies to Technical Component (TC)-only services, and to the TC of global services.

    Horizon BCBSNJ will consider the TC service with the highest payment under the Medicare Physician Fee Schedule (MPFS) at 100 percent of the appropriate allowance. Subsequent TC services will be considered at 75 percent of the appropriate allowance.

    Diagnostic cardiovascular procedures subject to MPPR may be reviewed within the MPFS. A Multiple Procedure (Field 21) value of “6” denotes a diagnostic cardiovascular service subject to the MPPR methodology.

  • Multiple Diagnostic Ophthalmology Services

    The MPPR on diagnostic ophthalmology procedures applies when a physician (or the same group practice) to provides multiple services to the same patient in the same session on the same day. The MPPR on these procedures applies to Technical Component (TC)-only services, and to the TC of global services.

    Horizon BCBSNJ will consider the TC service with the highest payment under the MPFS at 100 percent of the appropriate allowance. Subsequent TC services will be considered at 80 percent of the appropriate allowance.

    Diagnostic ophthalmology procedures subject to MPPR may be reviewed within the MPFS. A Multiple Procedure (Field 21) value of “7” denotes a diagnostic ophthalmology procedure subject to MPPR methodology.

  • Multiple Therapy Services1

    Horizon BCBSNJ only applies MPPR guidelines to therapy services rendered by nonparticipating practitioners. MPPR guidelines on therapy services will NOT apply to therapy services rendered by participating practitioners.

    The MPPR on therapy services applies when a physician (or the same group practice) provides multiple services to the same patient in the same session on the same date of service.

    When multiple outpatient therapy procedures are performed, the primary procedure will be considered at 100 percent of the appropriate allowance. The non-facility Practice Expense RVU of all secondary and subsequent procedures will be reduced by 50 percent.

    Therapy procedures subject to MPPR may be reviewed within the MPFS. A Multiple Procedure (Field 21) value of “5” denotes a therapy service subject to MPPR methodology.

Review our ClaimsXten Editing Rules policy here.

Unless Horizon BCBSNJ gives written notice that all or part of the above-noted changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after February 12, 2018.

1 Horizon BCBSNJ only applies Multiple Procedure Payment Reduction (MPPR) guidelines to therapy services rendered by nonparticipating practitioners. MPPR guidelines on therapy services will NOT apply to therapy services rendered by participating practitioners.

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

Published on: November 14, 2017, 11:20 a.m. ET
Last updated on: November 14, 2017, 11:26 a.m. ET