Why Am I Not Getting Paid?
By Melody W. Mulaik, MSHS, CPC, CPC-H, RCC, PCS, FCS
In our ever changing world of radiology
coding and reimbursement there is
always a new challenge to address and
conquer. Sometimes we have to revisit
existing issues to ensure that we understand the what, where, and how of a
given situation. Payment reductions are
one such issue.
In addition to coding guidelines and
payor bundling edits, Medicare applies a
payment discount when certain combinations of procedures are reported by
the same provider on the same day.
These reductions are “Multiple Procedure Payment Reductions” (MPPR).
These reductions do not apply to hospitals or other entities reimbursed through
the Outpatient Prospective Payment
System (OPPS). Rather, these reductions
apply to the technical and/or professional
component (TC/PC) of services that
are paid under the Medicare Physician
Fee Schedule (MPFS). All radiology
professionals need to understand the
definitions and financial implications of
these reductions given our ever changing
There are several different MPPRs that
apply to different types of services. These
All radiology professionals need to understand the definitions
and financial implications of these reductions given
our ever changing healthcare landscape.
When multiple surgical codes are
reported together, Medicare pays 100%
of the allowable for the highest valued
procedure and discounts the other procedures by 50%. For example, if a physician
performs image guided percutaneous
biopsy (19102) of two lesions in the
patient’s right breast, Medicare will pay
the first unit of code 19102 at 100% and
the second unit at 50%. Add on codes are
generally exempt from the discount.
reduction on claims that included whole
body planar bone scan code 78306 followed by SPECT bone scan code 78320.
However, these technical problems have
been corrected and, effective January 1,
2013, the nuclear medicine MPPR will be
applied to any combination of the designated codes.
Advanced Imaging Services
Nuclear Medicine MPPR
• Surgical MPPR
• Nuclear medicine MPPR
• Advanced imaging service MPPR—TC
• Advanced imaging service MPPR—PC
• Cardiovascular service TC MPPR
Since 1995, CMS has applied a payment
discount whenever specific nuclear medi-
cine codes are billed together. These
include certain codes for bone scans
(78306, 78320), tumor localization
(78802, 78803), and abscess localization
(78806, 78807). The discount applies to
both the TC and the PC. The highest val-
ued procedure is paid at 100% and any
other procedures are discounted by 50%.