It’s January 2013 already. Twelve months and counting until major provisions of the Affordable Care Act (ACA) go into place. To many, January 2014 seems like it’s far away.
Well, guess what? It’s virtually here. There are so many initiatives that are critical to the average practitioner, I can’t even list them all here. Suffice it to say that it is the purview of this column and opinion of this author that the average OD’s knowledge and preparation for this event is woefully inadequate.
Be aware that many aspects of the ACA will be implemented over time before the first day of 2014. So, let’s discuss an example that hits us this month, January 2013—the MPPR, or the Multiple Procedure Payment Reduction.1
What is the MPPR? It’s a new Medicare payment reduction that applies when multiple services are furnished to the same patient on the same day.
The Affordable Care Act specifies that Health and Human Services shall identify potentially misvalued codes. To do so, HHS will look at multiple codes that are frequently billed in conjunction with furnishing a single service. As a further step in implementing this provision, Medicare is expanding the MPPR policy by applying MPPRs to the Technical Component (TC) of diagnostic ophthalmology procedures.
The MPPRs on diagnostic ophthalmology procedures apply when multiple services are furnished to the same patient on the same day. The MPPRs apply to TC-only services and to the TC of global services. (The MPPRs do not apply to professional component services.)
In short, CMS will make a full payment for the TC of the highest priced procedure, but will pay 80% of the TC for subsequent services provided by the same physician (or by multiple physicians in the same group practice) to the same patient on the same day.
Here’s an example: Let’s say that a patient came in for a glaucoma work-up and the tests that you want to do on this date of service are visual fields, fundus photography and pachymetry. Below is what your reimbursement would look like both before and after the ACA MPPR is put in place. (Note: the Reimbursement Values are based on 2012 CMS National Averages.2)
As you can see, the reduction affects all procedures performed after the one with the highest payment. (A list of all procedures subject to the MPPR is at
www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1149OTN.pdf.) When these payments are reduced, they will be reflected on your Explanation of Benefits with a Claim Adjustment Reason Code of 59.
It may be T minus 12 and counting until full implementation of the Affordable Care Act; however, it’s clear that no one at the government level is waiting until 2014 to put these changes into place. Certainly, we’re just beginning to see the far-reaching impact of this law. It will impact our practices now and will continue to do so in the future. So, it is important for all to be prepared and aware how it will affect the delivery of care to our patients.
1. Centers for Medicare & Medicaid Services. Multiple Procedure Payment Reduction (MPPR) on the Technical Component (TC) of Diagnostic Cardiovascular and Ophthalmology Procedures. Available at:
www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1149OTN.pdf. Accessed December 22, 2012.
2. Centers for Medicare & Medicaid Services. Physician Fee Schedule. Available at: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html. Accessed December 22, 2012.
Reimbursement Before and After MPPR
Professional Component (-26)
$60.25 Technical Component (-TC)
$169.04 Total reduction in this example 6% *Red indicates the two technical components subject to reduction.