Article Date: 5/1/2013

Coding Q & A
CODING Q&A

MPPR —The Latest Wrinkle in Diagnostic Testing Reimbursement

INFORMATION PROVIDED BY RIVA LEE ASBELL

One of the most frequent queries on the practice management listservs is how to be sure the payment for multiple diagnostic tests performed on the same day is correct. With the multiple changes in the fee schedules, coupled with the Medicare Administrative Contractor (MAC) difficulties in getting the correct fees posted, then sequestration, this has become a billing nightmare.

PROFESSIONAL AND TECHNICAL COMPONENTS OF DIAGNOSTIC TESTS

Most diagnostic tests have a global fee that incorporates both the professional and technical components, the exceptions in ophthalmology being extended ophthalmoscopy and gonioscopy that are considered physician services. The global fee is divided into a professional and technical component: the professional component is the Interpretation & Report, while the technical component is essentially the portion attributable to overhead.

Normally, you bill the global fee; however, on some occasions various reasons exist to bill them separately (performed on different dates of service; only one or the other is performed). Modifier 26 is placed after the diagnostic test code when you are billing for the professional component only and the TC modifier is used when only the technical component is billed.

MULTIPLE PROCEDURE PAYMENT REDUCTION

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.

Effective this year, Medicare instituted a new payment methodology when more than one diagnostic test was performed by a single physician. Instead of being paid the global fee for each diagnostic test, the physician receives the global fee for the first diagnostic test. However, the second and subsequent diagnostic tests are divided into their professional and technical components for payment purposes and are paid at 100% of the professional component but only at 80% of the technical component.

The examples shown in the MLN Matters1 article and the Medicare Change Request # 78482 are in the tables below. These are national fees and not specific to any MAC.

DATES OF SERVICE

Another issue concerns what date to use when the Interpretation & Report and the actual test itself are performed on different dates. Medicare gives the following instructions when this occurs:

The date of service submitted to Medicare for the professional component is the date the professional component is performed. When the technical and professional components of a radiology service are performed on different days, the services are not global and should be separated into their separate parts and each component should reflect the actual date performed …

BE CAREFUL!

For some unknown reason, some of the MACs have made calculation errors on the ophthalmology codes. It may be due to the fact that Medicare calculated cardiology and ophthalmology at the same time.

Sample Ophthalmology Payment Reduction

PC

CODE 92235

$46.00

CODE 92250

$23.00

TOTAL CURRENT PAYMENT

$69.00

TOTAL 2013 PAYMENT

$69.00

PAYMENT CALCULATION

no reduction

TC $92.00 $53.00 $145.00 $134.40 $92 + (.80 × $53)
Global $138.00 $76.00 $214.00 $203.40 $69 + $92 + (.80 × $53)


Ophthalmology Codes Subject to MPPR

DESCRIPTION

Ultrasound codes & pachymetry

CPT CODE(S)

76510, 76511, 76512, 76513, 76514, 76516, 76519

Corneal topography

92025

Orthoptic Evaluation/treatment

92060, 92065

Visual Field examinations

92081, 92082, 92083

Scanning Ophthalmic Diagnostic Imaging

92132, 92133, 92134

Ophthalmic biometry

92136

Remote retinal imaging

92228

Fluorescein Angiography & ICG

92235, 92240

Fundus Photos

92250

Electro-oculography

92270

Electroretinography

92275

Color Vision examination

92283

Dark Adaptation examination

92284

Ocular photography

92285

Specular microscopy

92286

Somewhat strangely, cardiology received a 25% reduction in the technical component, while ophthalmology received only 20%. Some of the MAC notices neglected to mention this. If your billing department finds errors, be sure to take them to the MAC. RP

CPT codes copyrighted 2012 by the American Medical Association.

REFERENCES

1. http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7848.pdf

2. CR LINK: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1149OTN.pdf



Retinal Physician, Volume: 10 , Issue: May 2013, page(s): 65 66