The UnitedHealthcare Policy is based on the Centers for Medicare and Medicaid Services (CMS) Multiple Procedure Payment Reduction (MPPR) Policy. UnitedHealthcare has adopted CMS guidelines that when multiple Diagnostic Cardiovascular Procedures or Diagnostic Ophthalmology Procedures are performed on the same day, most of the clinical labor activities are not performed or furnished twice. Specifically, UnitedHealthcare considers that the following clinical labor activities, among others, are not duplicated for subsequent procedures:
Greeting the patient. Positioning and escorting the patient. Providing education and obtaining consent. Retrieving prior exams. Setting up the IV. Preparing and cleaning the room.
Payment at 100% for secondary and subsequent procedures would represent reimbursement for duplicative components of the primary procedure.
CMS assigns Multiple Procedure Indicators (MPI) on the National Physician Fee Schedule (NPFS) to procedures that are subject to the MPPR Policy.
The codes with the following CMS multiple procedure indicators are addressed within this reimbursement policy:
Aligning with CMS, UnitedHealthcare independently ranks and applies reductions to the secondary and subsequent Technical Component(s) (TC) of multiple Diagnostic Ophthalmology Procedures as described in the Reimbursement Guidelines section below.
Also aligning with CMS, UnitedHealthcare independently ranks and applies reductions to the secondary and subsequent Technical Component(s) (TC) of multiple Diagnostic Cardiovascular Procedures as described in the Reimbursement Guidelines section below.
Find your specific codes below.
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Q: Does UnitedHealthcare apply a multiple diagnostic cardiovascular reduction or multiple diagnostic ophthalmology reduction based on the place of service in which services are rendered?
A: This policy will apply to all claims reported on a CMS-1500 claim form, regardless of place of service. However, it should be noted that procedures reported for the TC portion are additionally subject to UnitedHealthcare's Professional/Technical Component Policy which does not allow reimbursement for the TC portion in a facility setting.
Q: How will the Same Group Physician and/or Other Health Care Professional, who are contracted at percent of charge rates, be reimbursed when reporting the Global Procedure Code for multiple diagnostic cardiovascular or ophthalmology procedures which are subject to reduction?
A: The charges for the Global Procedure Code(s) will be divided into the PC and TC portions using UnitedHealthcare's standard Professional/Technical splits. The MDCR or MDOR is applied to the Allowable Amount for the TC portion of the second and each subsequent procedure within the respective category of Diagnostic Cardiovascular Procedures or Diagnostic Ophthalmology Procedures.
Q: If the provider bills Global Test Only Codes 93040 and 93268 (which are PC/TC Indicator 4), how is the TC portion obtained in order to rank and apply MDCR to these Diagnostic Cardiovascular Procedures?
A: In order to obtain the TC portion of a Global Test Only Code, first refer to the Cardiovascular Parent Child Table which lists the TC and PC codes associated with each Global Test Only Code. Next, refer to the NPFS for the values of each TC code. If a Global Test Only Code has multiple TC codes, all TC code values would be added together for ranking purposes as shown in the example below.
Q: Are there any modifiers that will override MDCR or MDOR?
A: No, in accordance with CMS MPPR Policy, both MDCR and MDOR apply when multiple procedures are performed on the same day regardless if they were performed at the same or separate sessions.
Q: If the provider bills Global Procedure Codes 75600 and 75726 and Technical Component Only Codes 93225 and 93702, how is the TC portion obtained in order to rank and apply MDCR to these Diagnostic Cardiovascular Procedures?
A: When a provider bills globally for two or more procedures subject to MDCR, the charge for the Global Procedure Code will be divided into the PC and TC (indicated by modifiers 26 and TC) using UnitedHealthcare's standard Professional/Technical percentage splits included in the Professional/Technical Component Policy. Ranking is based on the TC Non-Facility Total RVU of each code and can be found in the Attachments section of the policy.