CMS Pub. 100-04, ch. 5, § 10.7

Rehabilitation Services

(Rev. 3475, Issued: 03-04-16, Effective: 06-06-16, Implementation: 06-06-16)

Medicare applies a multiple procedure payment reduction (MPPR) to the practice

expense (PE) payment of select therapy services. The reduction applies to the HCPCS

codes contained on the list of “always therapy” services (see section 20), excluding A/B

MAC (B)-priced, bundled and add-on codes, regardless of the type of provider or

supplier that furnishes the services.

Medicare applies an MPPR to the PE payment when more than one unit or procedure is

provided to the same patient on the same day, i.e., the MPPR applies to multiple units as

well as multiple procedures. Many therapy services are time-based codes, i.e., multiple

units may be billed for a single procedure. The MPPR applies to all therapy services

furnished to a patient on the same day, regardless of whether the services are provided in

one therapy discipline or multiple disciplines, for example, physical therapy,

occupational therapy, or speech-language pathology.

Full payment is made for the unit or procedure with the highest PE payment.

For subsequent units and procedures with dates of service prior to April 1, 2013,

furnished to the same patient on the same day, full payment is made for work and

malpractice and 80 percent payment is made for the PE for services submitted on

professional claims (any claim submitted using the ASC X12 837 professional claim

format or the CMS-1500 paper claim form) and 75 percent payment is made for the PE

for services submitted on institutional claims (ASC X12 837 institutional claim format or

Form CMS-1450).

For subsequent units and procedures with dates of service on or after April 1, 2013,

furnished to the same patient on the same day, full payment is made for work and

malpractice and 50 percent payment is made for the PE for services submitted on either

professional or institutional claims.

To determine which services will receive the MPPR, contractors shall rank services

according to the applicable PE relative value units (RVU) and price the service with the

highest PE RVU at 100% and apply the appropriate MPPR to the remaining services.

When the highest PE RVU applies to more than one of the identified services, contractors

shall additionally sort and rank these services according to highest total fee schedule

amount, and price the service with the highest total fee schedule amount at 100% and

apply the appropriate MPPR to the remaining services.

The therapy payment amount that has been reduced by the MPPR is applied toward the

therapy caps described in section 10.2. As a result, the MPPR may increase the amount

of medically necessary therapy services a beneficiary may receive before exceeding the

caps. The reduced amount is also used to calculate the beneficiary’s coinsurance and

deductible amounts.

The contractor shall use the following remittance advice messages and associated codes

when adjusting payment under this policy. The CARC below is not included in the

CAQH CORE Business Scenarios.

Group Code: CO

CARC: 59

RARC: N/A

MSN: 30.1