As previously communicated in a
Partners in Health UpdateSM article, AmeriHealth New Jersey updated its multiple procedure payment reductions (MPPR) for certain diagnostic services in order to maintain consistency with the revised provisions issued by the Centers for Medicare & Medicaid Services (CMS) in 2017.
Claims status
As previously communicated, due to inadvertent system limitations and issues with the implementation of the original MPPR, which became effective in 2015, certain claims may not have been reimbursed correctly, resulting in overpayments to providers.
The system was corrected during the fourth quarter of 2018 and all changes have been fully coded. Claims are now being processed in accordance with the requirements of the updated reimbursement position and adjustments are being made consistent with the terms of your provider agreement with AmeriHealth New Jersey.
We are in the process of identifying claims with services paid on or after March 1, 2018, that resulted in overpayments and will begin sending letters to providers with affected claims in the coming weeks. The letters will contain further instructions on how to dispute those claims.
Refer to the policy below for more information and to view CPT® codes for multiple reduction diagnostic services.
MPPR reimbursement methodology
As a reminder,
for claims with a date of service on or after January 1, 2017, the following methodology is used to determine a provider’s reimbursement for certain diagnostic services that are billed together for certain CPT codes approved by CMS.
MPPR applies as follows when professional component (PC)-only services, technical component (TC)-only services, and when the PC and TC of global services are billed (refer to Group C of the policies mentioned in the Policy section below):
- The following MPPR percentages are applied to the PC:
- The PC with the highest allowance is eligible for reimbursement at 100 percent.
- The PC of each subsequent service is eligible for 95 percent of the provider’s allowance.
- The following MPPR percentages are applied to the TC:
- The TC with the highest allowance is eligible for reimbursement at 100 percent.
- The TC for each subsequent service is eligible for 50 percent of the provider's allowance.
Policy
For more information about how certain diagnostic services are reimbursed under the MPPR guidelines, refer to the AmeriHealth New Jersey Claim Payment Policy #00.01.60c: Multiple Procedure Payment Reduction on Certain Diagnostic Services.
Refer to Attachment A, Group C of this policy document to see the list of CPT codes for multiple reduction diagnostic services to which the updated methodology described above applies.
To view this policy, visit our
Medical Policy Portal.
More information
If you have questions after reviewing the above policy, please email us at
providercommunications@amerihealth.com.
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