New and Revised Policies on Multiple Procedures Effective August 1, 2017

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is committed to offering competitive options for affordable health care coverage in North Carolina. To do this over the long term, we must ensure our reimbursement policies are aligned appropriately with industry standards. We are introducing a new policy to address when multiple procedure payment reductions (MPPR) will apply for certain cardiovascular and ophthalmology services. We are also expanding our existing policy for the application of MPPR for certain diagnostic imaging services. 

The following policies become effective August 1, 2017: 

• New Policy, Effective August 1, 2017: Multiple Procedure Payment Reduction on the Technical Component (TC) of Diagnostic Cardiovascular and Ophthalmology Procedures 
• Revised Policy, Effective August 1, 2017: Radiology Services Reimbursement Policy notice 

These policies apply to applicable services provided Blue Cross NC members (listed below) for dates of service beginning on and after August 1, 2017: 

• Members enrolled in insured and administered products
• Members of the North Carolina State Health Plan
• Members in non-Medicare Advantage products accessed through the BlueCard^SM 

Neither the policy on Multiple Procedure Payment Reduction on the Technical Component (TC) of Diagnostic Cardiovascular and Ophthalmology Procedures, or the revised Radiology Services Reimbursement Policy are applicable to services provided to: 

• Members of Blue Cross NC’s Medicare Advantage products
• Members of the Federal Employees Program
• BlueCard members enrolled in other Blue Cross and Blue Shield-offered Medicare Advantage products 

However, similar policies may apply and should be reviewed when applicable, in advance of providing non-emergency services.   

Multiple Procedure Payment Reduction on the Technical Component (TC) of Diagnostic Cardiovascular and Ophthalmology Procedures 

A new policy on Multiple Procedure Payment Reduction on the Technical Component (TC) of Diagnostic Cardiovascular and Ophthalmology Procedures is available for reference on the Medical Policies and Coverage page of bluecrossnc.com. The policy describes when multiple procedure payment reductions (MPPR) are applied to multiple diagnostic cardiovascular and ophthalmology procedures. By implementing this policy, we better align Blue Cross NC with the Centers for Medicare and Medicaid Services (CMS), as well as other industry payers in the management of overlapping services.  

Effective for dates of service on or after August 1, 2017, when multiple diagnostic cardiovascular services are performed for the same commercially insured patient on the same day, during the same outpatient session, and by the same physician or multiple physicians in the same group practice reporting under the same federal tax identification, Blue Cross of NC will consider 100% of the allowance for the technical component of the primary procedure and apply MPPR to the policy defined, secondary components. The allowance for the technical component of the second and each subsequent imaging procedure will be considered at 75% of the allowed amount for each specific procedure.   

Effective for dates of service on or after August 1, 2017, when multiple diagnostic ophthalmology services are performed for the same commercially insured patient on the same day, during the same outpatient session, and by the same physician or multiple physicians in the same group practice reporting under the same federal tax identification, Blue Cross of NC will consider 100% of the allowance for the technical component of the primary procedure and apply MPPR to the policy defined, secondary components. The allowance for the technical component of the second and each subsequent imaging procedure will be considered at 80% of the allowed amount for each specific procedure.   

Please review the full text of the policy on Multiple Procedure Payment Reduction on the Technical Component (TC) of Diagnostic Cardiovascular and Ophthalmology Procedures for further information. 

Radiology Services Reimbursement Policy 

Blue Cross NC is revising its current Radiology Services Reimbursement Policy for our commercial products to apply additional multiple procedure payment reductions (MPPR) to the professional component of secondary and subsequent diagnostic imaging services. The policy becomes effective August 1, 2017, and upon that date it will replace the existing policy.         

Effective for dates of service on or after August 1, 2017, when multiple diagnostic imaging services are performed for the same commercially insured patient on the same day, during the same outpatient session, and by the same physician or multiple physicians in the same group practice reporting under the same federal tax identification, Blue Cross of NC will consider 100% of the allowance for the technical component of the primary procedure and apply MPPR to the policy defined, secondary components. The allowance for the technical component of the second and each subsequent imaging procedure will be considered at 50% of the allowed amount for each specific procedure.   

By implementing this policy, we better align Blue Cross NC with the Centers for Medicare and Medicaid Services (CMS), as well as other industry payers in the management of overlapping services. However, Blue Cross NC is not extending at this time MPPR to the professional component of diagnostic imaging services but reserves the right to do so in the future. 

Additionally, MPPR will not be applied when: 

• Second and subsequent technical components are billed as part of a global fee being charged by one provider or provider group. 
• Multiple diagnostic imaging procedures are reported using Current Procedural Terminology codes, appropriately appended with either modifier (59) or (XE), and in addition to a (TC) technical component modifier or (22) outpatient modifier. Modifiers (59) and (XE) can be appropriate to report when documentation supports that a procedure was performed on the same day but not during the same session.  

Codes applicable to this policy, as well as further information about this revised policy are available by reviewing the full text of the Radiology Services Reimbursement Policy notice.