CurrentUnitedHealthcarePolicy 2025R9022A

Multiple Procedure Payment Reduction (MPPR) for outpatient therapy services

Defines UnitedHealthcare Medicare Advantage reimbursement methodology for applying the MPPR to the Practice Expense (PE) component of outpatient therapy services billed on CMS 1500 forms; affects network physicians and other qualified health care professionals submitting Medicare Advantage claims.

Policy Summary

PayerUnitedHealthcare

PolicyMultiple Procedure Payment Reduction (MPPR) for outpatient therapy services

Policy CodePolicy 2025R9022A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit accurate CMS 1500 claims and ensure services are billed with the correct billing provider NPI/TIN and beneficiary HIC for MPPR determinations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

50%PE payment reduction applied to subsequent ranked therapy services

Mar 1, 2012Effective date for current CMS RVU values

MP value 5Codes subject to MPPR

Same DOS & NPI/TINClaim grouping criteria

MPPR Application and Payment Rules

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MPPR application criteria and payment rules

MPPR applies to outpatient therapy services paid under Part B that are identified as "always" therapy and have Multiple Procedure value "5" on the Medicare Fee Schedule Database. Apply when multiple services/units are furnished to the same beneficiary on the same date of service by the same billing provider.

Services are outpatient therapy services paid under Part B identified as 'always' therapy (per ACA/MPPR provision).

The procedure(s) billed have a Multiple Procedure value of '5' on the Medicare Fee Schedule Database.

Grouping criteria: services are for the same beneficiary (HIC), billed by the same billing provider (same NPI/TIN), and on the same date of service.

MPPR applies to multiple units of a time‑based therapy code as well as to multiple different therapy procedure codes furnished the same date.

ALL of the following

Rank services by non‑facility PE RVU in descending order.
If two or more services share the highest non‑facility PE RVU, additionally sort those services by highest total fee schedule (non‑facility) amount; the highest is ranked first.
For services billed in multiple units, use the PE RVU for units and consider the first unit as the highest‑ranked unit when multiple units are reported.

ALL of the following

Pay the highest‑ranked service at 100% of the non‑facility PE RVU (reimbursed at the lesser of billed or fee schedule amount).
Pay remaining ranked services at 50% of the non‑facility PE RVU (reimbursed at the lesser of billed or the Reduced Therapy Fee Schedule Amount in field 31EE for those lower‑ranked services).

ALL of the following

Retrieve current non‑facility PE RVUs from the CMS physician fee schedule database to perform ranking; values effective for claims with DOS on or after March 1, 2012 and reviewed quarterly for updates.
Identify MPPR‑eligible services using Multiple Procedure value = 5, beneficiary HIC, billing provider NPI/TIN, and date of service for claims processing and system adjustments.

Codes Subject to MPPR and Ranking Rules

MPPR-eligible codesmixedCovered

Multiple Procedure value = 5

HCPCS/CPT codes flagged with Multiple Procedure value of '5' on the Medicare Fee Schedule are subject to MPPR

Ranking/Reduction threshold

Ranking methodServices are ranked by non-facility PE RVU (highest to lowest); if tied, rank by highest fee schedule amount; for services billed in units, the first unit is considered highest.

Primary service paymentThe highest-ranked service is paid at 100% of the non-facility PE RVU (reimbursement is the lesser of billed or fee schedule amount).

Subsequent services paymentAll remaining ranked services are paid at 50% of the non-facility PE RVU (reimbursed as the lesser of billed or the Reduced Therapy Fee Schedule Amount where applicable).

Units handlingWhen a highest-ranked service is billed in multiple units, the first unit is ranked as the highest for payment purposes.

RVU source and updatesUse current CMS non-facility PE RVU values from the Physician Fee Schedule database and review/update quarterly to align with CMS.

Claims Submission and Billing Requirements

Documentation Required

Claims submission requirements for MPPR

Submit accurate CMS 1500 claims and ensure each service is billed with the correct billing provider NPI/TIN and the beneficiary's HIC so MPPR grouping and determinations are applied correctly.

Use CMS 1500 (or electronic equivalent) for all Medicare Advantage outpatient therapy submissions.
Include the billing provider National Provider Identifier (NPI) and tax identification number (TIN) on claims.
Include the beneficiary's Health Insurance Claim number (HIC) on claims to allow grouping for MPPR.
Claims for two or more services with Multiple Procedure value '5' will be evaluated together when they share the same beneficiary HIC, same billing provider NPI/TIN, and same date of service.

Key Terms

Allowable Amount

DefinitionAllowable Amount — 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 as applicable).

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

Determination examplesAllowable Amount may be the contracted rate, reasonable charge, or billed charges depending on the terms applicable to the claim.

PE RVU

DefinitionPractice Expense Relative Value Units (PE RVU) — the portion of the Total Relative Value Units 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.

Relation to Total RVUPE RVU is one component of Total RVU (which also includes Work RVU and Malpractice RVU).

Same Individual Physician

DefinitionSame Individual Physician or Other Qualified Health Care Professional — the same individual rendering health care services who reports the same Federal Tax Identification number (TIN).

Claims groupingMPPR applies when services are for the same beneficiary HIC, from the same billing provider NPI (TIN), and on the same date of service.

Application noteServices billed on separate claims/dates but meeting the same beneficiary HIC, billing provider NPI (TIN) and date of service will be processed as subject to MPPR methodology.

MPPR (Multiple Procedure Payment Reduction)

DefinitionMultiple Procedure Payment Reduction (MPPR) — Medicare provision that reduces the Practice Expense (PE) payment for second and subsequent therapy services identified as 'always' therapy when furnished to the same beneficiary on the same date of service.

ScopeApplies to outpatient therapy services paid under Part B that are identified as 'always' therapy and flagged with Multiple Procedure value of '5' on the Medicare Fee Schedule database.

Payment mechanicsHighest-ranked service (by non-facility PE RVU) paid at 100% of non-facility PE RVU; remaining ranked services paid at 50% of non-facility PE RVU; reimbursements limited to the lesser of billed or applicable fee schedule/reduced therapy amount.

Ranking inputsRanking uses non-facility PE RVUs; ties are broken by highest fee schedule amount; for multi-unit services, first unit is ranked highest.

Policy Summary

PayerUnitedHealthcare

PolicyMultiple Procedure Payment Reduction (MPPR) for outpatient therapy services

Policy CodePolicy 2025R9022A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit accurate CMS 1500 claims and ensure services are billed with the correct billing provider NPI/TIN and beneficiary HIC for MPPR determinations.

SourceLink

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