Lost in the uproar over the blended payment amount for E/M services in the 2019 proposed physician fee schedule rule is a CMS proposal to apply the multiple procedure payment reduction (MPPR) when services are submitted with modifier 25. You don’t need to understand the inner workings of MPPR. The word reduction says it all.
CMS begins discussing this section of the proposed rule by describing their statutory authority to make this change. They note that they are concerned that when an evaluation and management service (E/M) is done on the same day as a procedure, particularly a procedure with 0 global days, there is overlap in payment for the work done for the procedure and the work done for the E/M service.
That is, they think they are paying twice for the same work.
Here are the exact words from their proposal:
“Using the surgical MPPR as a template, we are proposing that, as part of our proposal to make payment for the E/M levels 2 through 5 at a single PFS rate, we would reduce payment by 50 percent for the least expensive procedure or visit that the same physician (or a physician in the same group practice) furnishes on the same day as a separately identifiable E/M visit, currently identified on the claim by an appended modifier -25”.
Notice that they are not differentiating between new and established patient visits here.
Also, they say, “the least expensive procedure or visit”, not the least expensive procedure that has 0 or 10 global days. The 50% reduction could be on the E/M or the procedure. Although the concern they express is in relation to services with a 0 day global period, the proposal does not explicitly say that.
At a CMS Open Door Forum call a questioner asked if the 50% reduction would apply for a Medicare wellness visit and a problem oriented E/M service on the same calendar date. The representatives from CMS on the call said that there was no one available to answer that question at that time.
Since then, I’ve heard questions from fellow coders and clients about whether this would apply to medical procedures, not just surgical procedures in the 10000-69900 range. That is, will it apply to cardiovascular procedures, infusions, pulmonary function tests and services and ophthalmology services in the medicine section of the book?
Will it apply when a CPT code in the 90000 series is performed on the day and E/M service and modifier 25 is required?
I don’t know.
I don’t have a crystal ball to predict whether or not CMS will go forward with its wildly unpopular blended payment rate for office visits, with the new HCPCS codes for podiatry services, or if they will implement this proposal. However, when I read this section of the rule, CMS has calculated what it would save by implementing this payment reduction.
Since their proposals must be budget neutral, they propose to use the money from this savings to pay for the two new add-on codes for inherent complexity for primary care and certain other specialties.
Even without a crystal ball, I think this proposal will be implemented. How it will be implemented and whether it will include only CPT surgical services or whether it will include other services is the question I don’t know. We’ll see in November.
I don’t need a crystal ball to predict that if CMS does this, all other payers will follow.