- Email: [email protected]
The PC MPPR: Implications for Practices
REIMBURSEMENT ROUNDS
EZEQUIEL SILVA III, MD
The PC MPPR: Implications for Practices INTRODUCTION
The multiple procedural payment reduction (MPPR) for diagnostic imaging applies when multiple services are furnished by the same physician on the same patient in the same session on the same date. In other words, same radiologist, same patient, same session, same day. CMS has expanded the MPPR to now include the professional component (PC) of radiologic services. Under this policy, the second and subsequent interpretations performed by the same physician have their payments reduced by 25%. The reduction does not apply when different physicians, even in the same group practice, provide the interpretations. CMS does not apply the reduction to PC services provided in different sessions on the same date of service. The MPPR policy creates 3 unique challenges for practices that I discuss in this column: (1) What is the definition of separate PC sessions? (2) Once defined, how does a practice identify the same vs a different PC session in its day-to-day operations? and (3) What are the compliance implications of this policy? THE DEFINITION OF A SEPARATE PC SESSION
CMS has acknowledged that separate PC sessions may occur on the same date, such that the PC MPPR does not apply, and recommends appending the ⫺59 modifier to the code. By convention, the ⫺59 modifier is used to indicate a “distinct procedural service.” CMS also recognizes that identifying instances exempt from the PC MPPR will pose a challenge for providers. In the Medicare Physician Fee Schedule final rule, CMS [1] states, In cases where the physician demonstrates the medical necessity of furnishing interpretations in separate sessions, use of the ⫺59 modifier would be appropriate. We recognize that it may not always be a simple matter to determine whether a service was furnished in the “same” session, particularly in the case of the PC.
CMS has provided little specific guidance on the criteria for differentiating the same vs different sessions but has indicated that “for the purposes of the MPPR on the PC, scans interpreted at widely different times. . .would constitute separate sessions, even though the scans themselves were conducted in the same session.” On the basis of the limited guidance provided, the following statements are true: (1) The PC MPPR never applies when different radiologists each provide a separate interpretation, and (2) 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.” So what is the definition of widely different times? One appropriate example of different sessions would be an ultrasound study interpreted at 8 AM with a CT study interpreted 8 hours later. Studies with shorter time intervals between interpretations may be less clear regarding the distinction between the same and different sessions, and the determination may be affected by other factors besides time. For example, what if different modalities are interpreted at different times? Or what if different clinical indications or anatomic areas lead to the different studies’ being performed at different times? The ACR [2] has provided some guidance: Possible examples of when a ⫺59 modifier might be used include examinations interpreted at different times during the day, examinations acquired using different modalities and interpreted at different times during the day, and examinations of different anatomic areas performed for disparate clinical reasons that are interpreted at different times during the day.
As with CMS’s guidance, all of the ACR’s suggestions require that the
© 2012 American College of Radiology 0091-2182/12/$36.00 ● DOI 10.1016/j.jacr.2012.02.003
interpretations occur at different times of the day to be considered separate [2]. In the end, practices will be required to establish some objective criteria for the definition of separate sessions. OPERATIONALIZE IT
Once the criteria for the same vs separate sessions have been defined, the next challenge is ensuring that the information necessary for this determination is available at the time of billing. The determination of the same vs different PC sessions could be made prospectively by the interpreting radiologist and documented in the radiology report. It could also be made retrospectively by a coder based on the available data, such as time of interpretation. The ACR [2] has recommended the following: Documenting that these were indeed separate sessions will be necessary and would be best done in the reports of the subsequent examinations. However, the ACR recognizes this will be problematic for physicians and often impossible for coders to know that the prior examination on the same patient had been reported in the same day.
A key data point is obviously the exact time of interpretation, which is presumably related to the time of dictation. However, even with the dictation time indicated, determining the exact interpretation time may not be entirely clear. For example, the indicated time of dictation may be the moment the radiologist hits the “end” button; however, what if the radiologist started the dictation considerably earlier and performed other activities between the start and finish of the dictation? Which time would be used—the start or end of the dictation time? What if the interpretive information was communicated to the referring physician much earlier than the actual dictation, such as when radiologists batch their dictations? 311
312 Reimbursement Rounds
What about when a radiologist purposefully waits to dictate an earlier study pending the results of a much later follow-up study? In this scenario, the interpretation and communication technically occurred at different times, although the time of dictation was the same. For comparison studies performed at the same time, the ACR has stated that if “the initial study and comparison study are interpreted by the same physician during the same session, the MPPR would be applied” [3]. The clinical decision tree would also seem to be a consideration, such as when one study leads to another, and the coder may not be as well versed in such clinical judgments. The most likely approach will be a combination of prospective and retrospective considerations, with some dialogue occurring between radiologists and coders. COMPLIANCE CONSIDERATIONS
Practice leaders may decide to ignore the potential for different PC sessions and accept an across-the-board 25% reduction on all affected multiple studies. This would be shortsighted because 25% of a $100 Medicare PC payment for an advanced imaging study is $25. An experienced coder can review 20 or more cases in an hour, so identifying even 1 MPPR-exempt case among those 20 compensates for the extra collection expense. At the other extreme, practices may append the ⫺59 modifier to every instance of multiple interpretations, taking the position that efficiencies never occur with multiple interpretations. I do not recommend either of these extremes because there are important compliance considerations. In general, the ⫺59 modifier should be used carefully because CMS has indicated that “the physician will need to exercise judgment to determine when it is appropriate to use the ⫺59
modifier indicating separate sessions. We do not expect use of the modifier to be a frequent occurrence.” Indeed, CMS does not even mention the use of ⫺59 in its transmittals to Medicare intermediaries or the Medicare Learning Network article on the topic [4]. The frequent use of the ⫺59 modifier may lead to greater scrutiny from recovery audit contractors. In particular, care should be taken when studies obtained in the same technical component session are interpreted by the same physician in different sessions, because CMS has stated that “as a general policy. . .when multiple scans are conducted on a patient in the same session, we would generally consider the interpretations of those scans to be furnished in the same session. . .the physician will need to exercise judgment.” Practices may consider directing different studies on the same patient to different physicians to bypass the PC MPPR. The ACR [2] has communicated to CMS its assertion that “anytime different physicians interpret examinations it is by definition a separate session.” CMS, however, has not acknowledged its acceptance of this ACR assertion as the reason for not expanding the PC MPPR to multiple physicians in the same practice. Rather, CMS indicates that “operational considerations” precluded the expansion. Thus, although different physicians interpreting studies bypasses the MPPR, purposefully operationalizing changes in workflow for this purpose would be a noncompliant act. In fact, CMS describes the “review of [calendar year] 2010 claims data” in describing the fact that 97% of MPPR-affected studies would involve the same modality. With such a broad review, it is likely that CMS also has a broad range of radiologist-specific baseline data and any shift in these numbers could lead to unwanted scrutiny [1].
CONCLUSIONS
The PC MPPR expansion serves as another example of a misguided CMS policy, the practical ramifications of which were not thoroughly considered upon implementation. 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. As I have shown, the differentiation of the same vs different PC sessions will be especially challenging to define and subsequently apply to a group’s billing operations. Indeed, the MPPR may be expanded in the future, and CMS notes that it will be “aggressively looking for efficiencies in other sets of codes during the coming years” and as examples mentions applying the MPPR to the technical component and PC of “all imaging services” and even to the technical component of “all diagnostic tests” [1]. Practices will find it in their best interest to fully understand the PC MPPR and its implications and look to the ACR and other resources for clarification of the details and implications of the MPPR. REFERENCES 1. Center for Medicare and Medicaid Services. Medicare program; payment policies under the Physician Fee Schedule and other revisions to part B for CY 2012; final rule. Fed Reg 2011;76:73071-80. 2. American College of Radiology. MPPR policy applied to professional component in 2012. Available at: http://www.acr.org/HomePage Categories/News/ACRNewsCenter/MPPRPolicy-Applied-to-Professional-Componentin-2012.aspx. Accessed January 30, 2012. 3. American College of Radiology. Medicare’s MPPR Policy and Professional Component Reporting. ACR Radiology Coding Source. Jan-Feb 2012. Available at: http://www.acr.org/Hidden/ Economics/FeaturedCategories/Pubs/coding_ source/archives/JanFeb2012/MPPR.aspx. Accessed March 26, 2012. 4. Centers for Medicare and Medicaid Services. Multiple procedure payment reduction (MPPR) on certain diagnostic imaging procedures. Available at: https://www.cms.gov/ MLNMattersArticles/downloads/MM7442. pdf. Accessed January 30, 2012.
Ezequiel Silva III, MD, South Texas Radiology Group, 8401 Datapoint, Suite 600, San Antonio, TX 78229; University of Texas Health Science Center at San Antonio, Department of Radiology, MC 7800, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900; e-mail: [email protected].
EZEQUIEL SILVA III, MD
The PC MPPR: Implications for Practices INTRODUCTION
The multiple procedural payment reduction (MPPR) for diagnostic imaging applies when multiple services are furnished by the same physician on the same patient in the same session on the same date. In other words, same radiologist, same patient, same session, same day. CMS has expanded the MPPR to now include the professional component (PC) of radiologic services. Under this policy, the second and subsequent interpretations performed by the same physician have their payments reduced by 25%. The reduction does not apply when different physicians, even in the same group practice, provide the interpretations. CMS does not apply the reduction to PC services provided in different sessions on the same date of service. The MPPR policy creates 3 unique challenges for practices that I discuss in this column: (1) What is the definition of separate PC sessions? (2) Once defined, how does a practice identify the same vs a different PC session in its day-to-day operations? and (3) What are the compliance implications of this policy? THE DEFINITION OF A SEPARATE PC SESSION
CMS has acknowledged that separate PC sessions may occur on the same date, such that the PC MPPR does not apply, and recommends appending the ⫺59 modifier to the code. By convention, the ⫺59 modifier is used to indicate a “distinct procedural service.” CMS also recognizes that identifying instances exempt from the PC MPPR will pose a challenge for providers. In the Medicare Physician Fee Schedule final rule, CMS [1] states, In cases where the physician demonstrates the medical necessity of furnishing interpretations in separate sessions, use of the ⫺59 modifier would be appropriate. We recognize that it may not always be a simple matter to determine whether a service was furnished in the “same” session, particularly in the case of the PC.
CMS has provided little specific guidance on the criteria for differentiating the same vs different sessions but has indicated that “for the purposes of the MPPR on the PC, scans interpreted at widely different times. . .would constitute separate sessions, even though the scans themselves were conducted in the same session.” On the basis of the limited guidance provided, the following statements are true: (1) The PC MPPR never applies when different radiologists each provide a separate interpretation, and (2) 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.” So what is the definition of widely different times? One appropriate example of different sessions would be an ultrasound study interpreted at 8 AM with a CT study interpreted 8 hours later. Studies with shorter time intervals between interpretations may be less clear regarding the distinction between the same and different sessions, and the determination may be affected by other factors besides time. For example, what if different modalities are interpreted at different times? Or what if different clinical indications or anatomic areas lead to the different studies’ being performed at different times? The ACR [2] has provided some guidance: Possible examples of when a ⫺59 modifier might be used include examinations interpreted at different times during the day, examinations acquired using different modalities and interpreted at different times during the day, and examinations of different anatomic areas performed for disparate clinical reasons that are interpreted at different times during the day.
As with CMS’s guidance, all of the ACR’s suggestions require that the
© 2012 American College of Radiology 0091-2182/12/$36.00 ● DOI 10.1016/j.jacr.2012.02.003
interpretations occur at different times of the day to be considered separate [2]. In the end, practices will be required to establish some objective criteria for the definition of separate sessions. OPERATIONALIZE IT
Once the criteria for the same vs separate sessions have been defined, the next challenge is ensuring that the information necessary for this determination is available at the time of billing. The determination of the same vs different PC sessions could be made prospectively by the interpreting radiologist and documented in the radiology report. It could also be made retrospectively by a coder based on the available data, such as time of interpretation. The ACR [2] has recommended the following: Documenting that these were indeed separate sessions will be necessary and would be best done in the reports of the subsequent examinations. However, the ACR recognizes this will be problematic for physicians and often impossible for coders to know that the prior examination on the same patient had been reported in the same day.
A key data point is obviously the exact time of interpretation, which is presumably related to the time of dictation. However, even with the dictation time indicated, determining the exact interpretation time may not be entirely clear. For example, the indicated time of dictation may be the moment the radiologist hits the “end” button; however, what if the radiologist started the dictation considerably earlier and performed other activities between the start and finish of the dictation? Which time would be used—the start or end of the dictation time? What if the interpretive information was communicated to the referring physician much earlier than the actual dictation, such as when radiologists batch their dictations? 311
312 Reimbursement Rounds
What about when a radiologist purposefully waits to dictate an earlier study pending the results of a much later follow-up study? In this scenario, the interpretation and communication technically occurred at different times, although the time of dictation was the same. For comparison studies performed at the same time, the ACR has stated that if “the initial study and comparison study are interpreted by the same physician during the same session, the MPPR would be applied” [3]. The clinical decision tree would also seem to be a consideration, such as when one study leads to another, and the coder may not be as well versed in such clinical judgments. The most likely approach will be a combination of prospective and retrospective considerations, with some dialogue occurring between radiologists and coders. COMPLIANCE CONSIDERATIONS
Practice leaders may decide to ignore the potential for different PC sessions and accept an across-the-board 25% reduction on all affected multiple studies. This would be shortsighted because 25% of a $100 Medicare PC payment for an advanced imaging study is $25. An experienced coder can review 20 or more cases in an hour, so identifying even 1 MPPR-exempt case among those 20 compensates for the extra collection expense. At the other extreme, practices may append the ⫺59 modifier to every instance of multiple interpretations, taking the position that efficiencies never occur with multiple interpretations. I do not recommend either of these extremes because there are important compliance considerations. In general, the ⫺59 modifier should be used carefully because CMS has indicated that “the physician will need to exercise judgment to determine when it is appropriate to use the ⫺59
modifier indicating separate sessions. We do not expect use of the modifier to be a frequent occurrence.” Indeed, CMS does not even mention the use of ⫺59 in its transmittals to Medicare intermediaries or the Medicare Learning Network article on the topic [4]. The frequent use of the ⫺59 modifier may lead to greater scrutiny from recovery audit contractors. In particular, care should be taken when studies obtained in the same technical component session are interpreted by the same physician in different sessions, because CMS has stated that “as a general policy. . .when multiple scans are conducted on a patient in the same session, we would generally consider the interpretations of those scans to be furnished in the same session. . .the physician will need to exercise judgment.” Practices may consider directing different studies on the same patient to different physicians to bypass the PC MPPR. The ACR [2] has communicated to CMS its assertion that “anytime different physicians interpret examinations it is by definition a separate session.” CMS, however, has not acknowledged its acceptance of this ACR assertion as the reason for not expanding the PC MPPR to multiple physicians in the same practice. Rather, CMS indicates that “operational considerations” precluded the expansion. Thus, although different physicians interpreting studies bypasses the MPPR, purposefully operationalizing changes in workflow for this purpose would be a noncompliant act. In fact, CMS describes the “review of [calendar year] 2010 claims data” in describing the fact that 97% of MPPR-affected studies would involve the same modality. With such a broad review, it is likely that CMS also has a broad range of radiologist-specific baseline data and any shift in these numbers could lead to unwanted scrutiny [1].
CONCLUSIONS
The PC MPPR expansion serves as another example of a misguided CMS policy, the practical ramifications of which were not thoroughly considered upon implementation. 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. As I have shown, the differentiation of the same vs different PC sessions will be especially challenging to define and subsequently apply to a group’s billing operations. Indeed, the MPPR may be expanded in the future, and CMS notes that it will be “aggressively looking for efficiencies in other sets of codes during the coming years” and as examples mentions applying the MPPR to the technical component and PC of “all imaging services” and even to the technical component of “all diagnostic tests” [1]. Practices will find it in their best interest to fully understand the PC MPPR and its implications and look to the ACR and other resources for clarification of the details and implications of the MPPR. REFERENCES 1. Center for Medicare and Medicaid Services. Medicare program; payment policies under the Physician Fee Schedule and other revisions to part B for CY 2012; final rule. Fed Reg 2011;76:73071-80. 2. American College of Radiology. MPPR policy applied to professional component in 2012. Available at: http://www.acr.org/HomePage Categories/News/ACRNewsCenter/MPPRPolicy-Applied-to-Professional-Componentin-2012.aspx. Accessed January 30, 2012. 3. American College of Radiology. Medicare’s MPPR Policy and Professional Component Reporting. ACR Radiology Coding Source. Jan-Feb 2012. Available at: http://www.acr.org/Hidden/ Economics/FeaturedCategories/Pubs/coding_ source/archives/JanFeb2012/MPPR.aspx. Accessed March 26, 2012. 4. Centers for Medicare and Medicaid Services. Multiple procedure payment reduction (MPPR) on certain diagnostic imaging procedures. Available at: https://www.cms.gov/ MLNMattersArticles/downloads/MM7442. pdf. Accessed January 30, 2012.
Ezequiel Silva III, MD, South Texas Radiology Group, 8401 Datapoint, Suite 600, San Antonio, TX 78229; University of Texas Health Science Center at San Antonio, Department of Radiology, MC 7800, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900; e-mail: [email protected].