CurrentSelectHealthPolicy 59

Multiple procedure payment reduction for therapy services

This policy governs SelectHealth's application of payment reductions to the practice expense portion of multiple units or multiple therapy services billed for the same patient by the same provider on the same date of service for Commercial, Medicare Advantage, and Medicaid (Community Care/CHIP) plans.

Policy Summary

PayerSelectHealth

PolicyMultiple procedure payment reduction for therapy services

Policy CodePolicy 59

Change TypeNo material change

Effective DateJan 1, 2012

Next Review Date

Key ActionApply a payment reduction to the practice expense (PE) portion when multiple units or procedures are billed for the same patient by the same provider on the same date; pay full PE for the highest unit and 50% PE for subsequent units while paying full work and malpractice.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

50%practice expense payment applied to subsequent units/procedures

Fullwork and malpractice expenses for subsequent units/procedures

Listedcodes subject to reduction

Same patient/date/providerconditions for reduction

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Coverage stance and criteria for MPPR

Application of payment reduction across plans

Policy applies to Select Health Commercial and CHIP plans; Select Health Advantage (Medicare) and Select Health Community Care (Medicaid) follow the commercial plan policy.

When multiple units of therapy services and/or multiple procedures are billed for the same patient by the same provider on the same date of service, a payment reduction will be made to the practice expense (PE) portion.

Full payment will be made for the unit or procedure with the highest PE; subsequent units and procedures will receive full payment for work and malpractice expenses and 50% of the PE.

The reduction is applied regardless of the provider who supplies the services.

The reduction applies to the CPT/HCPCS therapy codes listed in this policy.

Applicable therapy codes and timing

Applicable therapy CPT/HCPCS codes listedmixedCovered

92507	Treatment of speech; language, voice, communication, and/or auditory processing disorder; individual
92508	Treatment of speech; language, voice, communication, and/or auditory processing disorder; group/other
97110	Therapeutic procedure, each 15 minutes; therapeutic exercises
97112	Neuromuscular reeducation, each 15 minutes
97116	Gait training, each 15 minutes
97140	Manual therapy techniques, each 15 minutes
97161	Physical therapy evaluation: low complexity
97530	Therapeutic activities, direct (one-on-one), each 15 minutes
G0283	Electrical stimulation (unattended), as part of a therapy plan of care

Typical face-to-face time for evaluations — times by CPT

97161Physical therapy evaluation: low complexity — typically ~20 minutes face-to-face

97162Physical therapy evaluation: moderate complexity — typically ~30 minutes face-to-face

97163Physical therapy evaluation: high complexity — typically ~45 minutes face-to-face

97164Physical therapy re-evaluation — typically ~20 minutes face-to-face

97165-97167Occupational therapy evaluations (low to high complexity) — typically 30–60 minutes depending on complexity

Billing and payment adjustments providers must follow

Billing Rule

Multiple Procedure Payment Reduction (MPPR) — PE reduced for subsequent units

When multiple units of therapy services and/or multiple procedures are billed for the same patient by the same provider on the same date of service, SelectHealth will reduce the practice expense (PE) portion: full payment is made for the unit/procedure with the highest PE; subsequent units/procedures receive full payment for work and malpractice and 50% of the PE. The reduction is applied regardless of the provider who supplies the services and applies to the listed therapy CPT/HCPCS codes in this policy.

Full payment for unit/procedure with highest PE
Subsequent units/procedures: 100% work and malpractice, 50% PE
Reduction applies regardless of which provider supplies the services
Applies when same patient, same date of service, same provider bills multiple units/procedures

Key terms

Practice Expense (PE) — definition of Practice Expense portion

DefinitionPractice Expense (PE) portion — the portion of payment representing practice-related costs (applies to time-based therapy services and is subject to reduction when multiple units/services are billed to the same patient by the same provider on the same date of service).

MPPR applicationWhen multiple units/procedures are billed for the same patient by the same provider on the same date, full payment is made for the unit/procedure with the highest PE; subsequent units/procedures receive full work and malpractice payment and 50% of PE.

ScopeReduction applies regardless of which provider supplies the services (applies across Commercial, Medicare Advantage, and Medicaid plans as described).