This year, CMS announced a multiple procedure payment reduction (MPPR) that impacts 27 ophthalmic testing codes. It affects payment for those codes’ technical component (–TC), which represents performance of the test, equipment used, and cost of supplies.
How does the MPPR work? When multiple tests from the list of affected codes (see "27 Testing Codes Affected") are performed on the same patient on the same date of service, the test with the highest –TC value is reimbursed in full, but payment for the –TC of the second and subsequent tests is reduced by 20 percent. The reduction is calculated automatically, regardless of whether you appended the –TC and –26 modifiers.
What’s the Payment?
Use these six scenarios to test your awareness of MPPR’s impact on your practice. When the following services are performed on the same day on the same patient, do you know which would be reimbursed in full and which would be hit by the 20 percent reduction to –TC reimbursement?
Q1. Exam and visual field (VF).
a) 100 percent for exam and VF.
b) 100 percent for exam; –TC reduction for VF.
Q2. Exam, OCT, and subsequent ophthalmoscopy (SO) on the right eye.
a) 100 percent for exam and SO; –TC reduction for OCT.
b) 100 percent for exam, OCT, and SO.
Q3. Exam, SCODI, VF, and pachymetry.
a) 100 percent for exam, VF, and SCODI; –TC reduction for pachymetry.
b) 100 percent for exam and VF; –TC reduction for SCODI and pachymetry.
Q4. Exam, fluorescein angiography (FA), and fundus photography. Pathology is in both eyes.
a) 100 percent for exam and FA of one eye; –TC reduction for FA of second eye and fundus photography.
b) 100 percent for exam and FA of both eyes; –TC reduction for fundus photography.
Q5. VF (92083) and fundus photography.
a) 100 percent for fundus photography; –TC reduction for VF.
b) 100 percent for VF; –TC reduction for fundus photography.
Q6. Exam, VF (92081), and external ocular photography.
a) 100 percent for exam and VF; –TC reduction for ocular photography.
b) 100 percent for exam and ocular photography; –TC reduction for VF.
Answers: Q1—a; Q2—b; Q3—b; Q4—a; Q5—a; Q6—a or b same –TC for VF and photo.
27 Testing Codes Affected
The MPPR applies to 27 ophthalmic testing codes:
76511 Ultrasound, A-scan only
76512 Ultrasound, diagnostic; B-scan
76513 Anterior segment ultrasound
92060 Sensorimotor exam
92081 Visual field
92082 Visual field, intermediate examination
92083 Visual field, extended examination
92132 Anterior segment SCODI
92228 Remote imaging
92235 Fluorescein angiography
92250 Fundus photo
92265 Needle oculoelectromyography
92283 Color vision
92284 Dark adaptation
92285 External ocular photography
92286 Special anterior segment photography