CurrentPremera BluecrossPolicy N/A

Multiple Diagnostic Imaging Reductions (Technical Component)

Defines how Premera identifies diagnostic imaging procedures subject to multiple procedure reductions (50% reduction of the technical component for second and subsequent procedures) and how to bill when multiple imaging procedures occur in the same or separate sessions; applies to Premera lines of business and affiliated products.

Policy Summary

PayerPremera Bluecross

PolicyMultiple Diagnostic Imaging Reductions (Technical Component)

Policy CodePolicy N/A

Change TypeAnnual reviewno material changes

Effective DateDec 1, 2013

Next Review DateSep 8, 2025

Key ActionWhen two or more imaging procedures subject to CMS multiple-procedure flag 4 occur in the same session by the same provider, reduce the technical component of the second and subsequent procedures by 50%; use XE modifier and documentation to indicate separate encounters to avoid reductions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

50%TC reduction for subsequent procedures

Flag 4CMS multiple-procedure flag

Premera & affiliatesLines of business covered

XEModifier to avoid reductions

Coverage and Billing Criteria

Coverage and billing criteria for multiple diagnostic imaging reductions

Rules for calculating allowed amounts when multiple diagnostic imaging procedures are performed:

If two or more diagnostic imaging procedures subject to the CMS multiple-procedure reduction (Multiple Procedure flag 4) are performed on the same patient by the same provider at the same session, the technical component (TC) of the second and each subsequent procedure will be reduced by 50%. The professional component (PC) will not be reduced.

For global codes subject to the multiple-procedure reduction, separate the allowed amount into technical and professional components based on RVU percentages; reduce the TC of the second and each subsequent global code by 50%, then recombine the reduced TC with the PC to determine the reduced global allowed amount.

When procedures subject to the reduction are billed on separate claims for the same session by the same provider, those separately billed services will be combined onto a single claim for claims processing and the TC reductions will be applied to the combined services.

Policy Summary

PayerPremera Bluecross

PolicyMultiple Diagnostic Imaging Reductions (Technical Component)

Policy CodePolicy N/A

Change TypeAnnual reviewno material changes

Effective DateDec 1, 2013

Next Review DateSep 8, 2025

SourceLink

On This Page

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Applicable Codes and Reduction Details

Applicable diagnostic imaging codesmixed

No codes listed

Multiple-procedure technical component reduction

Reduction amount50% reduction of the technical component (TC) for the second and each subsequent diagnostic imaging procedure when CMS Multiple Procedure flag = 4

Applies toDiagnostic imaging procedures identified with Multiple Procedure flag 4 in the CMS NPFS

Effect on professional componentNo reduction to the professional component (PC) for procedures subject to the multiple-procedure reduction

Global codesFor global codes subject to reduction, the allowed amount is split into TC and PC (by RVU); the TC of second/subsequent global codes is reduced 50% then recombined with the PC

When billed separately in same sessionServices billed on separate claims for the same session by the same provider will be combined and subject to the TC reduction

Provider Billing Expectations

Billing Rule

Bill TC at 50% for second+ imaging procedures; use XE and separate claims for distinct sessions

When two or more diagnostic imaging procedures subject to the CMS multiple-procedure reduction (Multiple Procedure flag 4) are performed in the same session by the same provider, the technical component (TC) of the second and each subsequent procedure will be reduced by 50%. Services billed on separate claims for the same session by the same provider will be combined for processing and are subject to the same TC reduction. To avoid reductions for procedures provided in separate and distinct sessions/encounters on the same date, bill on separate claims with the XE modifier and retain documentation that supports separate sessions.

50% reduction applies to the TC of the second and subsequent procedures when CMS Multiple Procedure flag = 4.
If procedures subject to reduction are billed on separate claims for the same session by the same provider, the claims will be combined and reductions applied.
For separate and distinct sessions on the same date, append XE (Separate Encounter) and submit separate claims; documentation must reflect separate sessions to avoid reductions.

Key Definitions

Multiple Procedure flag 4

DefinitionCMS NPFS Multiple Procedure flag 4 = identifies diagnostic imaging procedures subject to a 50% reduction of the technical component for the second and subsequent procedures

Source authorityIdentified on the current Centers for Medicare and Medicaid Services (CMS) National Physician Fee Schedule Relative Value File

ScopeApplies when two or more qualifying diagnostic imaging procedures are performed on the same patient by the same provider in the same session

Processing implicationUsed to determine which codes receive the technical component reduction during claims processing

XE modifier (Separate Encounter)

DefinitionXE (Separate Encounter) modifier = distinct procedural services modifier used to identify services provided in separate and distinct sessions/encounters on the same date of service

PurposeIndicates that multiple imaging reductions should not apply when qualifying procedures are rendered in separate sessions on the same date

Billing requirementServices rendered during separate and distinct sessions on the same date must be billed on two separate claims and appended with XE

DocumentationMember medical record/chart must reflect the multiple separate sessions/encounters to support use of XE