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Multiple Procedure Payment Reduction (MPPR) for Endoscopies

Reimbursement Policy:
Multiple Procedure Payment Reduction (MPPR) for Endoscopies

Effective Date:
February 25, 2019

Purpose:
To provide guidelines for the application of Multiple Procedure Payment Reduction (MPPR) for Endoscopies when appropriately billed by professional providers.

Scope:
All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap)
  • COB
  • ITS Home In-Network
  • FEP
  • SHBP non MA

All Insured Individual, Commercial medical plans, and Medicare Advantage Plans, are included.

ASO accounts will be included as an Opt-In option for additional claims editing on an account-by-account basis

Policy:
In accordance with CMS guidelines, Horizon BCBSNJ shall apply MPPR adjustments to reimbursement when multiple endoscopic procedures from the same family (i.e., another endoscopy that has the same base procedure; Same Endoscopic Base Code) are reported on the same patient on the same date of service.

In addition, Horizon BCBSNJ will apply CMS multiple Endoscopic Adjustment Rules when related endoscopic procedures (within the same family) are performed on the same patient on the same date of service as other procedures that are subject to multiple procedure reduction, therefore endoscopy codes may be subject to both the endoscopic and multiple procedure reductions.

Appropriately billed claims for Assistant Surgeons, Co-Surgeons or Team Surgeon will be also subject to Multiple Procedure Payment Reduction. Surgeons billing from the same group practice shall be treated as the same provider.

Procedure:
Horizon BCBSNJ shall apply a payment reduction to multiple endoscopy procedures, reported within the same family on the same patient on the same date of service. The full allowable amount for the highest valued endoscopy code in the family will be allowed and any additional endoscopy codes in the same family will be allowed at a reduced amount based on the value of the NPFS designated Endoscopic Base Code.

If more than one endoscopy family is reported and/or surgical procedures are reported, Horizon BCBSNJ shall apply the multiple surgery reductions to the appropriate endoscopy family or families and surgical procedures.

Horizon BCBSNJ shall use the CMS Facility Total RVUs to determine the ranking of primary, secondary and subsequent procedures when those services are performed in an appropriate facility setting.

Procedures performed in a place of service other than the facility setting will be ranked by the CMS Non-Facility RVUs.

No additional reimbursement shall be made if the provider is capitated or the reimbursement structure for that provider is a global fee.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply. Providers may not bill for difference due to reduced payment.

In instances where the provider is not participating, member liability shall be up to the provider’s charge.

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.

History:
01/22/2018: Policy approved

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

Policy 120_v1.0_01222018