CurrentColorado Rocky Mountain Health PlansPolicy 2026R9022A

Multiple Procedure Payment Reduction (MPPR) for outpatient therapy services billed on CMS 1500

Governs UnitedHealthcare Medicare Advantage reimbursement and payment methodology for Multiple Procedure Payment Reduction (MPPR) applied to the Practice Expense (PE) component of outpatient therapy services billed on CMS 1500 forms; affects providers billing Medicare Advantage plans through UnitedHealthcare.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyMultiple Procedure Payment Reduction (MPPR) for outpatient therapy services billed on CMS 1500

Policy CodePolicy 2026R9022A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders must submit accurate claims using CMS 1500 forms or electronic equivalent; policy does not include prior authorization notations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

50%PE payment applied to subsequent therapy services (office and facility)

2+ servicesMPPR trigger

Mar 1, 2012CMS RVU values in use since

Multiple Procedure Payment Reduction (MPPR) Criteria

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Trigger: Applies when TWO OR MORE services identified by Multiple Procedure value '5' are billed for the same beneficiary HIC and the same billing provider NPI (TIN) on the same date of service.

Scope: Reduction applies to HCPCS codes on the 'always therapy' list that are paid under the physician fee schedule; applies to services furnished in office and institutional settings and to services furnished by group practices or 'incident to' physician services across therapy disciplines.

Ranking: UnitedHealthcare retrieves non-facility PE RVUs from the Physician Fee Schedule Database and sorts services by highest non-facility PE RVU to determine rank.

ALL of the following

Tie-breaker: If two or more services share the highest non-facility PE RVU, those services are additionally sorted by highest total fee schedule (non-facility) amount; the highest fee-schedule amount (1 unit for timed codes) is ranked first.
Units handling: When the highest-ranked service is billed in multiple units and multiple units were reported, the first unit is considered the highest-ranked unit; MPPR applies to multiple units as well as multiple procedures.

ALL of the following

Payment for highest-ranked service: Full PE payment is made for the service ranked highest (reimbursed at the lower of billed or total fee schedule amount).
Payment for subsequent/lower-ranked services: Subsequent services are paid at 50% of the non-facility PE RVU; reimbursement for lower-ranked services is the lower of billed amount or the amount in field 31EE (Reduced Therapy Fee Schedule Amount).

Application mechanics: For professional claims, MPPR is applied to procedures with Multiple Procedure value '5' on the Medicare Fee Schedule Database; UnitedHealthcare uses fee schedule amounts when applying the 50% reduction in non-facility PE RVUs.

Claims review: Claims are reviewed and ranked as if reported on a single claim regardless of how/when they were submitted to ensure correct ranking and application of reductions.

Codes and Trigger Conditions

MPPR-targeted codesCPTCovered

multiple procedure value '5'	Procedures with Multiple Procedure value of '5' on Medicare Fee Schedule Database are subject to MPPR for professional claims
HCPCS 'always therapy' list	HCPCS codes on the 'always therapy' list paid under the physician fee schedule are subject to the reduction

Service count trigger — inv-03: MPPR

TriggerApplies when two or more services identified by multiple procedure value '5' are billed for the same beneficiary HIC and same billing provider NPI (TIN) on the same date of service

Identifiers usedMultiple procedure value '5', beneficiary HIC, billing provider NPI (TIN), and date of service

Counting ruleCounts reducible services (MPV=5) billed the same date for the same beneficiary and billing provider regardless of claim submission timing

Scope noteMPPR applies when 2 or more such services are present; subsequent ranking and reductions follow

Claims Submission and Provider Responsibilities

Documentation Required

Submit accurate claims on CMS 1500 (no prior‑auth exemption)

You are responsible for submission of accurate claims using CMS 1500 forms or the electronic equivalent; UnitedHealthcare Medicare Advantage reimbursement policies are based on CPT, CMS, and other coding guidelines and apply to all services billed on CMS 1500 forms. The policy text does not include any prior‑authorization requirements or notations relieving this claims‑submission responsibility.

Submit claims that accurately describe the services provided using CMS 1500 forms or electronic equivalents.
Follow CPT, CMS, and other coding guidelines referenced by this reimbursement policy when preparing claims.
This policy applies to all health care services billed on CMS 1500 forms and does not provide prior authorization exemptions.

Key Terms and Definitions

inv-05: Allowable Amount — definition entry

DefinitionAllowable Amount is the dollar amount eligible for reimbursement to the physician or other qualified health care professional on the claim (examples: contracted rate, reasonable charge, or billed charges)

Percent/discount contractsFor percent of charge or discount contracts, the Allowable Amount is determined as the billed amount less the discount

PurposeUsed as the basis for reimbursement determinations (lower of billed or fee schedule/allowable amounts per policy rules)

inv-06: PE RVU — definition

DefinitionPractice Expense Relative Value Units (PE RVU) are the portion of the Total RVU assigned to a CPT or HCPCS code for maintaining a practice, including rent, equipment, supplies and nonphysician staff costs.

Use in MPPRNon-facility PE RVUs are retrieved from the Physician Fee Schedule Database and used to rank services for MPPR application

Unit considerationPE RVUs for units billed in time and for non-time-based procedures are both considered in ranking; first unit ranked highest when multiple units billed

inv-07: Same Individual Physician or Other Qualified Health Care Professional — definition

DefinitionSame Individual Physician or Other Qualified Health Care Professional: the same individual rendering health care services reporting the same Federal Tax Identification number.

Implication for MPPRModifiers or reporting do not exempt codes from MPPR when reported by the same individual physician/TIN

Billing identifierDetermination uses the billing provider NPI and TIN to establish sameness for reduction rules

inv-08: Total Relative Value Units — definition

DefinitionTotal Relative Value Units (Total RVU) is the assigned unit value of a CPT or HCPCS code equal to the sum of Work RVUs, Practice Expense RVUs, and Malpractice RVUs.

Components usedIncludes Work RVU, PE RVU, and Malpractice RVU which together determine fee schedule amounts used in sorting and reimbursement

Role in sortingIf PE RVU ties occur, services are additionally sorted by highest total fee schedule non-facility amount (based on Total RVU-derived fee) for ranking