CurrentPremera BluecrossPolicy CP.PP.402.v1.5

Multiple Diagnostic Ophthalmology Services Reductions

Defines how Premera identifies diagnostic ophthalmologic procedures subject to multiple procedure technical-component reductions and how reductions are applied; applies to professional claims submitted on CMS-1500/837P across Premera and affiliated plans.

Policy Summary

PayerPremera Bluecross

PolicyMultiple Diagnostic Ophthalmology Services Reductions

Policy CodePolicy CP.PP.402.v1.5

Change TypeNon‑material edits and clarifications

Effective Date

Next Review Date

Key ActionWhen multiple diagnostic ophthalmologic procedures are rendered during separate and distinct sessions on the same date, bill with modifier XE and document separate encounters to avoid technical-component reductions.

SourceLink

POLICY UPDATE CHANGES

Clarified the Purpose statement to indicate that the policy pertains to Professional services billed on a CMS-1500 or 837P claim forms.

Added link to the National Physician Fee Schedule Relative Value file.

Added a bullet to the Exceptions section indicating the policy does not apply to ASCs paid on APC payment methodology.

Removed statement that Blue Card Home/Host and FEP claims will not be subject to this policy.

20%TC reduction

Flag 7NPFS flag

Payment Integrity Oversight CommitteePolicy owner

10/03/24Last review

Multiple Diagnostic Ophthalmologic Reductions

Multiple diagnostic ophthalmologic reductions criteria

Application of multiple diagnostic ophthalmologic reductions for the technical component

ALL of the following

For a technical component only procedure submitted with modifier TC, reduce the allowed amount of the second and each subsequent procedure by 20%.
For a professional component only procedure submitted with modifier 26, do not apply multiple ophthalmologic reductions.
For a global submission of a diagnostic ophthalmologic service, separate the allowed amount into technical and professional components based on RVU percentages; reduce the technical component of the second and subsequent global codes by 20% and then recombine with the professional component to determine the reduced global allowed amount.

When services that would be subject to the multiple diagnostic ophthalmologic reduction are billed on separate claims for the same session, the services will be combined during claims processing and then subject to the TC reductions.

Policy Summary

PayerPremera Bluecross

PolicyMultiple Diagnostic Ophthalmology Services Reductions

Policy CodePolicy CP.PP.402.v1.5

Change TypeNon‑material edits and clarifications

Effective Date

Next Review Date

SourceLink

On This Page

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Coding Identifiers, Modifiers and Reduction Amounts

NPFS multiple procedure identificationmixed

Multiple Procedure Flag 7

NPFS flag indicating subject to 20% TC reduction for second and subsequent diagnostic ophthalmologic procedures

Relevant modifiers and their effectModifier

TC	Technical component modifier; TC-only submissions have 20% reduction applied to second and subsequent procedures
26	Professional component modifier; no reductions applied to PC-only submissions
XE	Distinct procedural services - Separate Encounter; prevents multiple procedure reduction when appropriately used and documented

TC reduction percentage

TC reduction percentage20% reduction applied to the technical component of the second and each subsequent diagnostic ophthalmologic procedure

Applies to TC-only submissionsModifier TC submissions — allowed amount of second and subsequent procedures reduced by 20%

Applies to global submissionsGlobal codes are split into TC and PC by RVU; TC of second and subsequent global codes reduced by 20% then recombined

Billing and Claim Submission Guidance

Billing Rule

Use XE modifier for separate encounters

When multiple diagnostic ophthalmologic procedures subject to the multiple diagnostic ophthalmologic reduction are rendered to the same patient on the same date of service at multiple separate and distinct sessions/encounters (for example, morning and later in the day), bill the services on separate claims and append modifier XE (Separate Encounter). The use of modifier XE indicates that multiple ophthalmologic reductions should not apply; documentation in the member's medical record/chart must reflect the multiple separate sessions/encounters to support XE.

Bill services from separate sessions on separate claims with modifier XE.
Ensure member medical record/chart documents the separate and distinct encounters to support XE.
XE signals reductions should not be applied to those services.

Denial Risk

Claim combination during processing

When two or more diagnostic ophthalmologic procedures are performed on the same patient by the same provider at the same session, services billed on separate claims will be combined during claims processing and then subject to multiple diagnostic ophthalmologic technical-component reductions.

Services billed on separate claims for the same-session procedures will be combined during processing.
Combined services are subject to multiple diagnostic ophthalmologic TC reductions.

Terms and Flags

Multiple Procedure Flag 7

NPFS identificationMultiple Procedure Flag 7 — Subject to 20% reduction of the second highest and subsequent procedures to the TC of diagnostic ophthalmology services

Effect on PC-only submissionsModifier 26 (professional component only) — no multiple procedure TC reductions applied

Combination during processingWhen multiple diagnostic ophthalmologic procedures are performed in the same session they are subject to the Flag 7 reduction rules

Separate and distinct sessions/encounters

Billing to avoid reductionServices provided at multiple distinct sessions/encounters on the same date must be billed on separate claims with modifier XE and documentation supporting separate encounters to avoid TC reduction

Claim combination riskWhen services from the same session are billed on separate claims they will be combined during claims processing and then subject to TC reductions

Definition of separate and distinct sessionsExamples include procedures performed in the morning and later in the day as separate encounters; documentation must support the separation