Wednesday, April 13, 2011

TC component - Multiple procedure reduction rule

Multiple Procedure Reduction on the TC of Certain Diagnostic Imaging Procedures

Effective January 1, 2006, a multiple procedure reduction of the TC of certain diagnostic imaging procedures applies. The reduction applies to TC-only services and the TC portion of global services for the procedures with a diagnostic imaging indicator as shown on the Medicare Fee Schedule. The reduction does not apply to Professional Component (PC) services. Full payment will be allowed for the highest-priced procedure and payment at 50 percent for each additional procedure when performed during the same session on the same day.

Note: Prior to July 1, 2010, the reduction was 25 percent for the additional procedures.

For dates of service prior to January 1, 2011, the reduction applies only to procedures to contiguous body areas (i.e., within a family of codes, not across families) that are provided in one session. For example, the reduction would not apply to an MRI of the brain (Procedure code 70552) in code family 5 when performed during the same (single) session, on the same day as an MRI of the neck and spine (Procedure code 72142) in code family 6.

The 11 families of imaging procedures are arranged by imaging modality:

* Ultrasound, Computed Tomography (CT) and Computed Tomographic Angiography (CTA).
* MRI and Magnetic Resonance Angiography (MRA).
* Contiguous area (for example: CT and CTA of Chest/Thorax/Abdomen/Pelvis).

To determine which family the imaging procedure belongs to, refer to the Diagnostic Imaging Indicator on the Medicare Fee Schedule on the TrailBlazer Health Enterprises® Web site.

CMS considers a single session to be one encounter where a patient could receive one or more radiological studies. If more than one of the imaging services in a single family is provided to the patient during one encounter, then this would constitute a single session and the lower-priced procedure(s) would be reduced.

There is no need to report the 51 modifier on your claim. Medicare will append the 51 modifier to the appropriate service during claims processing.

On the other hand, if a patient has a separate encounter on the same day for a medically necessary reason and receives a second imaging service from the same family, then CMS considers these multiple studies in the same family on the same day to be provided in separate sessions.

In the latter case, CMS has established that the physician should use modifier 59 to indicate multiple sessions, and that the multiple procedure reduction does not apply.

Effective January 1, 2011, per Change Request (CR) 6993, the 11 families of codes are being consolidated into a single family.

Currently, the multiple procedure reduction on diagnostic imaging services applies to contiguous body parts, i.e., within a family of codes, not across families. With the consolidation of the 11 families down to one family of codes, the reductions apply when two or more services on the list are furnished to the same patient in a single session. The complete list of codes is listed in the CR linked below.

Change Request:
http://www.cms.gov/transmittals/downloads/R738OTN.pdf

MLN Matters Article:
http://www.cms.gov/MLNMattersArticles/downloads/MM6993.pdf

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