CurrentUnitedHealthcarePolicy 2025R9022A

Multiple Procedure Payment Reduction (MPPR) for therapy services on CMS 1500

Defines UnitedHealthcare Medicare Advantage reimbursement methodology for applying the Multiple Procedure Payment Reduction (MPPR) to practice expense (PE) payments for outpatient therapy services billed on CMS 1500 forms; applies to network physicians and other qualified health care professionals serving UnitedHealthcare Medicare Advantage enrollees.

Policy Summary

PayerUnitedHealthcare

PolicyMultiple Procedure Payment Reduction (MPPR) for therapy services on CMS 1500

Policy CodePolicy 2025R9022A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionIdentify claims subject to MPPR by using Multiple Procedure value '5', beneficiary HIC, billing provider NPI/TIN, and date of service; sort services by non-facility PE RVU and apply the 50% PE reduction to subsequent services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

50%PE payment reduction applied to subsequent therapy units/procedures

Mar 1, 2012Date of service baseline for using current CMS RVU values

QuarterlyFrequency for reviewing/updating CMS RVU values

Value 5Indicator used on MFSDB to identify reducible therapy procedures

CMS 1500

Policy Summary

PayerUnitedHealthcare

PolicyMultiple Procedure Payment Reduction (MPPR) for therapy services on CMS 1500

Policy CodePolicy 2025R9022A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

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When MPPR Applies

MPPR application criteria

MPPR applies when two or more identified therapy services are billed for the same beneficiary on the same date by the same billing provider; ranking and payment rules follow CMS methodology.

Services must be on the 'always therapy' reducible list and carry a Multiple Procedure value of '5' on the Medicare Fee Schedule Database (MFSDB).

Claims must share the same beneficiary HIC, the same billing provider NPI (TIN), and the same date of service to be considered together for MPPR.

When two or more reducible services meet the identification criteria, sort and rank services by highest non-facility Practice Expense (PE) Relative Value Unit (RVU).

If the highest non-facility PE RVU is tied between two or more services, additionally sort those tied services by highest total fee schedule non‑facility amount (use the single‑unit fee schedule amount for time‑based codes).

Payment application: the highest‑ranked service (after sorting) is paid at 100% of the non‑facility PE RVU (reimbursed at the lower of billed or applicable fee schedule amount). Subsequent services are paid at 50% of the non‑facility PE RVU (reimbursed at the lower of billed or the amount in field 31EE when applicable).

When the highest‑ranked service is billed in multiple units, treat the first unit as the highest‑ranked unit; additional units and other procedures are subject to MPPR reductions.

MPPR applies to multiple units as well as multiple procedures furnished to the same patient on the same day and applies across office and institutional settings and across therapy disciplines (PT, OT, SLP).

For professional claims, MPPR applies to procedures with Multiple Procedure value of '5' on MFSDB and UnitedHealthcare will use non‑facility PE RVUs from the physician fee schedule database to perform ranking and pricing.

Use current CMS RVU values for dates of service on or after March 1, 2012; these RVU values are reviewed and updated quarterly.

Claims submitted at different times: the system will review codes for a single date as if reported on one claim to ensure correct ranking and reduction; adjustments will be made when reducible codes are submitted on separate claims for the same date, beneficiary HIC and billing provider NPI (TIN).

Limitations: Only services on the Multiple Therapy Reducible Codes list (Multiple Procedure value '5') are subject to MPPR; other services provided the same day that are not on that list are not reduced.

Modifiers (e.g., GO, GN, GP) should be reported when appropriate; modifiers do not generally exempt a code from MPPR though they may affect other policy determinations.

Codes and Payment Rules

MPPR-identifying codesmixed

Multiple Procedure value '5'

Indicator on Medicare Fee Schedule Database for procedures subject to MPPR

Payment reduction threshold

Payment reduction appliedApply 50% reduction to the Practice Expense (PE) component for all subsequent units/procedures after the highest‑ranked service on the same day

ScopeApplies to multiple units and multiple procedures furnished to the same patient on the same day (office and institutional settings)

Highest‑ranked service paymentFull payment made for the unit or procedure with the highest PE payment

Professional claims identificationFor professional claims, MPPR applies to procedures with Multiple Procedure value of '5' on the Medicare Fee Schedule Database (MFSDB)

Claims Identification & Billing Actions

Billing Rule

Identify and sort claims for MPPR using multiple procedure value '5' and PE RVUs

Identify therapy claims subject to MPPR by selecting services with multiple procedure value '5' that share the same beneficiary HIC, the same billing provider NPI/TIN, and the same date of service; then sort those services by highest non-facility Practice Expense (PE) RVU (ties broken by highest total fee schedule non‑facility amount using a single unit for time‑based codes) so that the highest‑ranked service is paid in full and subsequent services are reduced.

Use multiple procedure value '5', beneficiary HIC, billing provider NPI (TIN), and date of service to identify claims subject to MPPR.
Sort identified services by highest non‑facility PE RVU; include both time‑based unit PE RVUs and non‑time‑based service PE RVUs in the ranking.
If PE RVUs tie, sort the tied services by highest total fee schedule non‑facility amount (use one unit amount for time‑based services).
When the highest‑ranked service is billed in multiple units, treat the first unit as the highest‑ranked unit.

Key Terms

Practice Expense Relative Value Units (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.

Role in paymentPE RVUs represent the practice expense component used to calculate reimbursement under the Physician Fee Schedule when combined with other RVU components (Work RVU, Malpractice RVU).

Use in MPPRMPPR reduces payment to the PE component (measured by PE RVUs) for subsequent same‑day units/procedures; fee schedule amounts are used when applying the reduction.

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).