The MPPR and the –59 Modifier: Buyer, Beware

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Radiology practices took a blow when CMS invoked the Multiple Procedure Payment Reduction (MPPR) for professional-component services provided to the same patient in the same session by the same physician on the same day, beginning in January 2012. The specialty narrowly avoided an even greater indignity—that the MPPR be applied to such studies read by any member of the practice—primarily because of the administrative difficulties of enforcement, not because the efficiencies that CMS cited as justification for applying the 25% reduction for second and subsequent studies read by any practice member were a figment of someone’s imagination.

As recently described by Silva, ¹ the MPPR policy has saddled practices with three administrative challenges: defining a separate professional-component session; distinguishing, for purposes of billing, between the same professional-component session and a different professional-component session; and handling the compliance issues associated with the policy.

Silva reports that CMS has acknowledged that separate professional-component sessions can occur on the same day for a single patient, in which case using the –59 modifier in coding is recommended to indicate a distinct procedural service. CMS, however, has not provided clear guidance on when a service is distinct.

Silva has drawn two main truths from the scant guidance that has been provided: First, the professional-component MPPR is never applied when two different radiologists provide separate interpretations; second, when two interpretations are provided at the same time, the professional-component MPPR is always applied. He writes, “Therefore, the only instance in which interpretations performed by the same physician on the same date would be considered separate is when the interpretations occur at ‘widely different times.’”

Whether the studies are acquired using different modalities or on different anatomic areas for disparate reasons, time between interpretations is a common characteristic of guidance from both CMS and the ACR® on the subject. Silva suggests that an interval of eight hours between interpretations would be an appropriate example of separate services, but shorter time intervals might not. “In the end,” he writes, “practices will be required to establish some objective criteria for the definition of separate sessions.”

After a separate session has been defined, the practice then will be challenged to identify those sessions that warrant the –59 modifier at the time of billing. The options are prospective identification—by the radiologist, at the time of reporting—or retrospective identification by a coder. The ACR acknowledges that both of these options are likely to be insufficient, both because many radiologists would rather not take the time to identify the relevant sessions and because coders will not always know that another same-day exam exists.

Silva proposes a series of what-if scenarios that underscore the difficulty of identifying time of interpretation: Is it when the radiologist begins dictation or finalizes it (for those radiologists who do batch dictation)? What if the interpretation was communicated to the referring physician much earlier than the actual dictation took place? he asks, suggesting that the probable approach will be a combination of the two identification options.

Keeping Compliant

Lest a practice be tempted to forfeit 25% of all second and subsequent studies due to the difficulty of identifying separate sessions in same-patient, same-day, same-physician encounters, Silva suggests that they consider that 25% of a $100 Medicare professional-component payment for advanced imaging is, after all, $25. Another option that would probably pay for itself (as cumbersome as it sounds) would be to hire a coder to catch all exams to which the –59 modifier could be appended.

Neither of these extremes are recommended because of compliance considerations. It has been documented that CMS does not expect use of the –59 modifier to be a frequent occurrence, and its frequent use could attract increased scrutiny on the part of recovery contractors.

Nor does Silva recommend that practices direct same-day, same-patient studies to different radiologists (for an end run around the professional-component MPPR). Silva writes, “. . . although different physicians interpreting studies bypasses the MPPR, purposefully operationalizing changes in workflow for this purpose would be a noncompliant