§ 9789.15.4 Physical Medicine / Chiropractic / Acupuncture Multiple Procedure Payment Reduction; Pre-Authorization for Specified Procedure / Modality Services
There are four types of reductions for physical medicine:
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
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
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)
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