Defines Humana's payment adjustments (MPPR) applied when the same provider performs multiple procedures or multiple units of a procedure for the same patient on the same day across Medicare Advantage and Commercial products.
Policy Summary
PayerHumana
PolicyMultiple Procedure Payment Reduction (MPPR)
Policy CodePolicy CP2016011
Change TypeNo material change
Effective DateMar 1, 2017
Next Review Date
Key ActionClaims payments remain subject to medical necessity, reasonableness, and any referral or authorization requirements of the member's plan.
No material clinical or coverage changes in this revision.
25%TC reduction for diagnostic cardiovascular services
50%TC reduction for diagnostic imaging and therapy PE
5%PC reduction for diagnostic imaging (>= Jan 1, 2017)
25%PC reduction for diagnostic imaging (before Jan 1, 2017)
20%TC reduction for diagnostic ophthalmology services
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50% / 75%
Commercial multiple surgery reductions
Multiple Procedure Payment Reduction (MPPR) — Application by Service Type
inv-01: Diagnostic Cardiovascular Services (TC)
Humana applies MPPR to same-day diagnostic cardiovascular technical component (TC) services rendered by the same provider. Covered when ALL of the following are met:
ALL of the following
Identify services: Same-day services with MPFS Relative Value File multiple procedure indicator 6 for TC reimbursement are identified.
Rank services: Rank identified services by the portion of the per‑unit contracted rate or base maximum amount payable under the member's plan that is attributable to TC, from highest to lowest.
Eliminate highest: Eliminate from MPPR review the single highest‑ranked unit (if multiple units tie for highest, eliminate one of those units).
Apply reduction: Apply a 25% reduction to the TC portion of reimbursement for each remaining unit where MPPR applies.
TC portion attribution: For codes billed with both TC and PC, the portion attributable to TC = contracted/base amount x (MPFS local TC amount / MPFS local global amount). For TC‑only reimbursement, 100% of the amount is attributable to TC.
inv-02: Diagnostic Imaging Services (TC and PC)
Humana applies MPPR to same-day diagnostic imaging services. When both TC and PC MPPRs may apply, rankings and calculations are performed separately for each component. Covered when ALL of the following are met:
ALL of the following
Identify services: Identify same‑day services with MPFS Relative Value File multiple procedure indicator 4 for TC and PC reimbursement.
Separate rankings: Rank services separately for TC and PC by the portion of the per‑unit contracted rate or base maximum amount attributable to each component; TC and PC rankings are independent.
Eliminate highest: Eliminate the highest‑ranked unit for each component (no reduction); apply MPPR to the other units for that component.
TC reduction:
inv-03: Diagnostic Ophthalmology Services (TC)
Humana applies MPPR to same-day diagnostic ophthalmology technical component (TC) services rendered by the same provider. Covered when ALL of the following are met:
ALL of the following
Identify services: Identify same‑day services with MPFS Relative Value File multiple procedure indicator 7 for TC reimbursement.
Rank services: Rank identified services by the portion of the per‑unit contracted rate or base maximum amount attributable to TC, from highest to lowest.
Eliminate highest: Eliminate from review the highest‑ranked unit (if multiple units tie for highest, eliminate one of those units); apply MPPR to all other allowed units.
Apply reduction:
inv-04: Always Therapy Services (PE)
Humana applies MPPR to same-day 'always therapy' services for the practice expense (PE) portion when rendered by the same provider. Covered when ALL of the following are met:
ALL of the following
Identify services: Identify same‑day services with MPFS Relative Value File multiple procedure indicator 5 for PE reimbursement.
Calculate PE portion: Portion attributable to PE = contracted/base amount x (MPFS local PE amount / MPFS local global amount). MPFS local PE amount = (PE RVU x PE GPCI) x CF.
Rank services: Rank identified services by the portion attributable to PE from highest to lowest per‑unit amount.
Eliminate highest:
inv-05: Multiple Endoscopic Procedures
Humana applies MPPR to same‑family endoscopic procedures (MPFS indicator 3). Covered when ALL of the following are met:
ALL of the following
Identify endoscopy codes: Identify, for the date of service, all MPFS Relative Value File multiple procedure indicator 3 endoscopy codes and determine each service's base endoscopy code.
Group families: Group services that share the same endoscopy base code into an endoscopic family.
Base code handling: If multiple procedure codes for a family include the family's base code, Humana denies separate reimbursement for the base code; reimbursement for the base code is included in the highest‑ranked procedure in that endoscopic family.
Rank within family:
inv-06: MPPR and multiple surgery application rules
Rules for applying MPPR and multiple surgery reductions. These steps and rules are applied in sequence to determine final reimbursements when multiple procedures occur same day.
ALL of the following
Identify all MPFS Relative Value File multiple procedure indicator 3 endoscopy codes for the date of service and determine each service's base endoscopy code.
Group services by the same endoscopy base code — each group is an endoscopic family.
If multiple procedure codes for an endoscopic family include the family's base code, Humana denies separate reimbursement for the base code; reimbursement for the base code is included in the highest‑ranked procedure in that family.
Within each endoscopic family, rank reimbursable services by contracted rate or base maximum amount payable under the member's plan; the highest‑ranked procedure is not reduced for the family.
Code Lists, Indicators, and Reduction Calculations
Used to identify same-day always therapy services for PE MPPR application.
MPFS multiple procedure indicator 3 (Endoscopy - referenced for family grouping)mixed
MPFS indicator 3
Used to identify endoscopic services and determine each service's base endoscopy code for endoscopic family grouping.
Endoscopy code groupingmixed
MPFS indicator 3 endoscopy codes
Endoscopy codes identified in the MPFS Relative Value File with multiple procedure indicator 3; used to determine base endoscopy codes and group services into endoscopic families. When a family's base code is present among multiple procedures, Humana denies separate reimbursement for the base code and includes its payment in the highest-ranked procedure in the family.
inv-09: Diagnostic imaging PC reduction date threshold
PC reduction (on or after Jan 1, 2017)5% reduction to the portion attributable to the Professional Component (PC)
PC reduction (before Jan 1, 2017)25% reduction to the portion attributable to the Professional Component (PC)
Identification for applicationHumana first identifies same-day services with MPFS multiple procedure indicator 4 for PC before applying the reduction
inv-10: CMS-derived reduction ratio
CMS-derived reduction ratio (formula)When a contracted rate lacks an amount allowed for a base code, Humana computes reduction amount = contracted rate × (CMS fee schedule amount for base code ÷ CMS fee schedule amount for the procedure)
Claims Processing and Billing Guidance
Documentation Required
General claims processing requirements
Claims payments remain subject to medical necessity, reasonableness, and any applicable referral or authorization requirements of the member's plan.
Billing Rule
Endoscopic family identification and ranking
Identify all MPFS Relative Value File multiple procedure indicator 3 endoscopy codes for the date of service; group services that share the same endoscopy base code into an endoscopic family and rank reimbursable services in each family by contracted rate or the base maximum amount payable under the member's plan.
Determine each service's base endoscopy code from the MPFS indicator 3 list (identify all indicator 3 codes for the date of service).
Group services with the same base code — each group is one endoscopic family.
Terms and Definitions
inv-13: MPPR
DefinitionMultiple Procedure Payment Reduction (MPPR): an adjustment that reduces reimbursement to offset duplication of inputs when the same provider renders multiple services or multiple units of the same service to the same patient on the same day.
PurposeOffsets duplicated payment for inputs such as patient greeting, room/equipment prep, education and consent
Application contextApplies across various service categories (e.g., diagnostic imaging TC/PC, cardiovascular TC, ophthalmology TC, therapy PE, endoscopy families)
inv-14: Practice Expense (PE)
PE portion calculationPortion attributable to Practice Expense (PE) = contracted/base amount × (MPFS local PE amount ÷ MPFS local global amount); MPFS local PE amount = (PE RVU × PE GPCI) × CF
When applied
Policy Summary
PayerHumana
PolicyMultiple Procedure Payment Reduction (MPPR)
Policy CodePolicy CP2016011
Change TypeNo material change
Effective DateMar 1, 2017
Next Review Date
Key ActionClaims payments remain subject to medical necessity, reasonableness, and any referral or authorization requirements of the member's plan.
When TC MPPR applies to a unit, apply a 50% reduction to the TC portion of reimbursement.
PC reduction: When PC MPPR applies to a unit, apply a 5% reduction to the PC portion of reimbursement for dates of service on or after January 1, 2017; apply a 25% reduction for dates of service before January 1, 2017.
TC/PC attribution: For codes billed with both TC and PC, the portion attributable to each component = contracted/base amount x (MPFS local TC or PC amount / MPFS local global amount). For component‑only reimbursement, 100% of the amount is attributable to that component.
Apply a 20% reduction to the TC portion of reimbursement for each unit where MPPR applies.
TC portion attribution: For codes billed with both TC and PC, the portion attributable to TC = contracted/base amount x (MPFS local TC amount / MPFS local global amount). For TC‑only reimbursement, 100% of the amount is attributable to TC.
Eliminate from review the highest‑ranked unit (if multiple units tie for highest, eliminate one of those units); apply MPPR to other units.
Apply reduction: Apply a 50% reduction to the PE portion of reimbursement for each unit where MPPR applies.
Example calculation: MPFS local PE amount is computed as (PE RVU x PE GPCI) x CF and used in the ratio above to determine the portion attributable to PE.
Rank reimbursable services within each endoscopic family by the procedure's contracted rate or base maximum amount payable under the member's plan to determine the highest‑ranked procedure (that procedure is not reduced for the family).
Apply reduction: Reduce reimbursement for each procedure in the endoscopic family except the family's highest‑ranked procedure by the amount allowed for the procedure's base code (if contracted rate lacks an amount allowed for the base code, Humana will compute a reduction amount using CMS amounts and apply that reduction to the contracted rate).
When a contracted rate does not include an amount allowed for a base code, Humana applies a CMS‑derived ratio (using CMS amounts) to create the reduction amount to apply to the contracted rate.
Reduce reimbursement for each procedure in the endoscopic family except the family's highest‑ranked procedure by the amount allowed for the procedure's base code; if the contracted rate lacks a base‑code amount, apply a CMS‑derived ratio to compute the reduction amount.
After applying any multiple endoscopy reductions, treat all endoscopic services in the same endoscopic family as a single service for multiple surgery ranking purposes.
Apply multiple surgery reduction when any of the following occur: same provider performs >1 same‑day MPFS indicator 2 service; or performs endoscopic procedures in >1 endoscopic family on the same day; or performs at least one MPFS indicator 2 service and at least one endoscopic procedure on the same day.
Humana Medicare Advantage plans: the highest procedure is not reduced; all other procedures are reduced by 50%.
Humana commercial plans: the highest procedure is not reduced; the second‑highest procedure is reduced by 50%; all other procedures are reduced by 75%.
Notes: Multiple endoscopy reduction is always determined before multiple surgery reduction. Other payment rules (e.g., bilateral adjustments) may apply and are applied before multiple surgery reduction. Multiple surgery reduction applies regardless of submission of modifiers 51, 59 or X{EPSU}. In unique circumstances Humana may treat or not treat certain services as surgeries for multiple surgery reduction purposes.
When contracted rates lack base‑code amounts, Humana will compute reduction amounts using a CMS‑derived ratio based on CMS fee schedule amounts to create the reduction applied to the contracted rate.
Use of CMS amounts
Humana uses CMS fee schedule amounts to create the reduction amount which is then applied to the contracted rate
Example calculationIf contracted rate = $1,000, CMS amount for procedure = $850, CMS amount for base code = $400 → ratio = 400/850 = 47.06%; reduction = $1,000 × 47.06% = $470.60
If an endoscopic family's base code is present among multiple procedures, deny separate reimbursement for the base code; its payment is included in the highest-ranked procedure in that family.
Rank reimbursable services within the family by contracted rate or base maximum amount payable; the highest-ranked procedure is not reduced.
Humana applies PE MPPR to same-day 'Always Therapy' services identified by MPFS multiple procedure indicator 5
Example inputsExample: PE RVU 0.25, PE GPCI 2.0, CF $32 → MPFS local PE amount = (0.25×2.0)×$32 = $16
inv-15: TC / PC attribution
Attribution methodTC or PC portion = contracted/base amount × (MPFS local TC or PC amount ÷ MPFS local global amount)
All-TC or All-PC casesIf only TC (or only PC) is reimbursed, 100% of the contracted/base amount is attributable to that component
Identification for MPPRHumana identifies same-day services by MPFS multiple procedure indicators specific to component (e.g., indicator 6 for cardiovascular TC, 4 for imaging TC/PC, 7 for ophthalmology TC, 5 for therapy PE)
inv-16: Base maximum amount payable under the member's plan
Base maximum amount payableThe maximum amount of reimbursement for a unit of a covered expense as determined by the member's plan (may be the plan's maximum allowable fee, Medicare fee schedule rate, or another payment model)
Plan adjustment noteActual plan reimbursement may be less than the base maximum amount because of applicable adjustments
Use in MPPRHumana applies MPPR to the portion of the base maximum amount attributable to TC, PC or PE for out-of-network services
inv-17: MPFS Relative Value File
File contentsMedicare Physician Fee Schedule (MPFS) Relative Value File includes multiple procedure indicators, RVUs and conversion factors used to identify indicators and amounts for MPPR application
Elements referencedElements referenced in this policy include CF (conversion factor), PE GPCI, PE RVU and multiple procedure indicators
PurposeUsed to determine TC/PC/PE attributable portions and to identify service indicators (e.g., indicators 3,4,5,6,7)
X modifiers detailX{EPSU} expands to XE (Separate encounter), XP (Separate practitioner), XS (Separate structure), XU (Unusual non-overlapping service)
Use noteMultiple surgery reduction applies regardless of submission of modifiers 51, 59 or X{EPSU}; presence of modifiers does not prevent reduction
inv-19: Same Provider
DefinitionSame Provider: a single qualified practitioner or multiple practitioners within the same group practice
ApplicationMPPR and multiple surgery reductions apply when the same provider performs multiple same-day services or multiple units of the same service for the same patient
In-network vs out-of-networkFor out-of-network practitioners, reductions are applied to the base maximum amount payable under the member's plan rather than an in-network contracted rate