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Incorrect Reimbursement: Misapplication of MPPR Billing Ground Rules
When an original bill is incorrectly denied or underpaid, DaisyBill advises filing a Second Review. Every request for Second Review submitted from DaisyBill is compliantly submitted using both a completed DWC Form SBR-1, as well as a compliant modified CMS 1500.
To store language for Request for Second Review reasons, use DaisyBill’s Second Review Reasons.
For more information on Multiple Procedure Payment Reductions (MPPR) of physical medicine codes, see DaisyBill’s Work Comp FAQ: § 9789.15.4 Physical Medicine / Chiropractic / Acupuncture Multiple Procedure Payment Reduction; Pre-Authorization for Specified Procedure / Modality Services.
Official Medical Fee Schedule
Physical Medicine / Chiropractic / Acupuncture Multiple Procedure Payment Reduction; Pre-Authorization for Specified Procedure / Modality Services
EOR Denial Reason
No separate payment was made because the value of the service is included within the value of another service performed on the same day.
Second Review Reason (SBR-1 Form)
Reason for Requesting Second Bill Review
§9789.15.4 Multiple Procedure Payment Reduction (MPPR) was incorrectly applied to this bill.
Per §9789.15.4 (a)(4) The MPPR applies to acupuncture codes and chiropractic manipulation codes and to the procedures listed in the “Separately Payable Always Therapy Services Subject to the Multiple Procedure Payment Reduction (MPPR)” file of the Medicare Physician Fee Schedule Final Rule. The listed procedures will also have a Multiple Procedure value of “5” on the National Physician Fee Schedule Relative Value File.
Per §9789.15.4 (a)(2)"Full payment is made for the unit or procedure with the highest PE payment. Full payment is made for the work and malpractice components and 50 percent payment is made for the PE for subsequent units and procedures, furnished to the same patient on the same day.”
Recommended Supporting Documents
- DaisyBill California Explanation of Fee Schedule (EOFS) - Download Instructions
- IBR Decision CB16-0000147
Other Second Review Topics
We hope that helps!