There are some physical medicine and rehabilitation therapy proceduresthat are frequently reported together on the same date of service. Some of the elements that comprise these services, referred to as Practice Expense (PE) by the Centers for Medicare and Medicaid Services (CMS), are duplicative. These duplicated PE elements include cleaning the room and equipment; education, instruction, counseling and coordinating home care; greeting the patient and providing the gown; obtaining measurements (e.g., range of motion); post-therapy patient assistance; the multispecialty visit pack.
This policy describes how UnitedHealthcare aligns with CMS and reduces reimbursement for the PE portions of certain therapy procedures that share these components when those services are the secondary or subsequent procedures provided on a single date of service by the Same Group Physician and/or Other Qualified Health Care Professional.
UnitedHealthcare aligns with CMS in determining which procedures are subject to the multiple therapy reduction and the primary or secondary ranking of these procedures based on Practice Expense Relative Value Units(PE RVU).
For the purposes of this policy, Same Group Physician and/or Other Qualified Health Care Professional refers to all physicians and health care professionals who report under the same Federal Tax Identification number (TIN).
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Q: How is the PEportion of a service determined?
A: The PE portion of a service is determined by calculating the ratio of PE RVU to Total RVU. This ratio is applied to the Allowable Amount of each charge to determine the PE portion in dollars.
Q: If a provider group includes several specialty providers (physical, occupational, speech-language therapists), how will their services provided to a single patient on a single date of service be reduced?
A: All Multiple Therapy ReducibleCodes reported for a single patient on a single date of service by all providers sharing the sameTINare considered reported by the Same Group Physicianand/or Other Qualified Health Care Professionalandwill be viewed together for ranking and reduction purposes. The single code with the highest PE RVU will be ranked primary and will not be reduced. All remaining codessubject to this policyfrom all otherprovidersin the same group, regardless of specialty,will be ranked as secondary, tertiary and so on and the PEportion of those services will be reduced bythe appropriate percentage, depending on the date theservicewas performed. See the Reimbursement section for information about reduction percentages.
Q: Other Physical Medicine & Rehabilitation policies allow the reporting of timed codes with modifiers GO, GN or GP to distinguish the type of specialty provider who is performing services. Should these modifiers still be reported when they apply?
A: Yes. Continue to report modifiers that are appropriate and that communicate information that may be used in policies other than this one. The use of these distinguishing modifiers will not exempt reducible codes from multiple therapy reduction when reported bythe Same Group Physician and/or Other Qualified Health Care Professional for thesame member on the same day. However, claims are edited against all applicable policies, so the modifiers should be reported when appropriate to ensure accurate reimbursement under policies other than Multiple Therapy Reduction.
Q: If a single provider group withthe same TIN reports several Multiple Therapy Reducible Codesona single date of serviceon separate claimsat different times, how will these codes be reimbursed?
A: The claims editing system reviews all codes for a single date of service as if they were reported on a single claim, regardless of when they are reported. When codes for services provided to a single patient on a single date of service that are subject to multiple therapy reduction are submitted on different claims at different times, adjustments will be made to ensure that the code with the highest PE RVUis considered primary (that is,not subject to reduction) and that the remaining codes are correctly ranked and reduced.
Q: If several Multiple Therapy Reducible Codesthat share the same PE RVU are reported on the same date of service, how are they ranked?
A: When Multiple Therapy Reducible Codesfor the same date of service share the same PE value, the system then utilizes Total RVUs for those codes in order to rank them.
Q: Will all services providedon the same date as Multiple TherapyReducible Codesbe reduced?
A: No. The only services that are subject to this policy are those on the Multiple Therapy Reducible Codes list. However, all codes reported on the same date of service, bothreducible and non-reducible,will be subject to all other reimbursement policies that apply.