Summary

There are four types of reductions for physical medicine:

1. “Always Therapy” Codes

2. Time based therapy codes

3. Therapy services furnished by a group

4. Multiple procedure value of “5” as well as selected codes

1. “Always Therapy” Codes

MPPR applies when more than one Medicare “Always Therapy” code is billed on the same day.

The list of "Always Therapy" codes can be found in the Update Table:

2. Time-based Therapy Codes

MPPR apply to time based codes which are billed with multiple units:

• Full payment is made on the procedure with the highest ‘practice expense’ (PE) RVU component.
• MPPR applies to subsequent codes.

3. Therapy Services Furnished by a Group

MPPR applies if other therapy services are provided by another practitioner within the same group practice: this includes physical therapy, occupational therapy, and speech-language pathology

4. Multiple Procedure Value of “5” + Selected Codes

MPPR also apply to procedures:

1. With a multiple procedure value of “5” on the National Physician Fee Schedule Relative Value File (RVU)

2. With codes 97810, 97811, 97813, 97814, 98940, 98941, 98942, and 98943

Update Table

National Physician Fee Schedule Relative Value File (RVU):

Reimbursement Caps Apply to Services Provided in a Single Visit

In addition to the MPPR, the following caps are presumed reasonable limitations on reimbursement for services provided at one visit.

• When billing for treatment consisting of physical medicine modalities only: no more than two codes on the same visit
• When billing for physical medicine modality, procedure, or acupuncture codes: no more than 60 minutes on the same visit
• Where modalities and procedures are billed: no more than 4 codes total on the same visit

Definitions:  

Modality: a service that is listed in the CPT Medicine section, Physical Medicine and Rehabilitation under the sub-heading of “Modalities”

Procedure: a service that is listed in the CPT Medicine section, Physical Medicine and Rehabilitation under the sub-headings “Therapeutic Procedures” and “Other Procedures” and the headings “Acupuncture” and “Chiropractic Manipulative Treatment”

These caps apply unless a pre-authorized and pre-negotiated fee agreement has been arranged and memorialized in writing.

California Code of Regulations (CCR)

§ 9789.15.4 Physical Medicine / Chiropractic / Acupuncture Multiple Procedure Payment Reduction; Pre-Authorization for Specified Procedure/Modality Services

Division of Workers’ Compensation Websites

Official Medical Fee Schedule

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