Now that the Center for Medicare & Medicaid Services (CMS) has expanded the multiple procedural payment reduction (MPPR) for diagnostic imaging to include the professional component (PC), practices face a number of challenges, including defining what constitutes separate PC sessions and how to best comply with this policy change in day-to-day operations, according to Ezequiel Silva, III, MD, of the University of Texas Health Science Center at San Antonio.
“The PC MPPR expansion serves as another example of a misguided CMS policy, the practical ramifications of which were not thoroughly considered upon implementation,” wrote Silva in an article published in the May issue of the Journal of the American College of Radiology . “Now that the policy is in place, practices are faced with new challenges regarding the billing of multiple studies and the evaluation of the compliance risks involved.”
The first challenge for practices is simply figuring out the definition of a separate PC session, according to Silva. In certain cases, the -59 modifier can be used with the procedure code to indicate distinct services that occurred on the same date, but CMS guidance is a little murky on the criteria for differentiating when it would be appropriate to use the code. Silva explained that the guidelines do say that PC MPPR never applies when different radiologists each provide separate interpretations and that when interpretations are provided at the same time, the PC MPPR always applies.
“Therefore, the only instance in which interpretations performed by the same physician on the same date would be considered separate is when the interpretations occur at ‘widely different times,’” wrote Silva, who acknowledged that practices will have to establish some objective criteria to define separate sessions based on differences in interpretation time.
Next, practices will have to incorporate the determination of same versus different PC sessions into daily operations. Silva wrote that this could be done by the interpreting radiologist on the radiology report, or retrospectively by a coder. Since there are a number of complications with either approach—available data for coders, such as dictation time, may be misleading as to when interpretation actually occurred, for example—a hybrid approach featuring communication between radiologists and coders is most likely, according to Silva.
Finally, practices will have to determine how aggressively they will seek to identify different PC sessions. Simply accepting a 25 percent reduction on all affected multiple studies would not make much financial sense, as identifying even a single MPPR-exempt case in an hour of review time for a coder would compensate the extra effort. Being overly aggressive, however, and appending the -59 modifier to every case, or having different physicians provide interpretations in each case to bypass the PC MPPR, could lead to greater scrutiny, wrote Silva.
There may be some hope on the horizon in the form of the Diagnostic Imaging Services Access Protection Act, which would eliminate the PC MPPR if passed into law. “The [American College of Radiology] is working diligently to ensure that Congress recognizes the undue burden this flawed policy is having on radiologists,” said Silva in an email interview , though he said practices should not take it for granted that the PC MPPR will be discarded.
“I would advise practices to assume the PC MPPR will affect their billing operations indefinitely and plan accordingly,” he said.