Multiple Procedure Payment Reduction Effective July 1, 2018 For Certain Diagnostic Cardiovascular and Ophthalmology Procedures

March 29, 2018

Effective July 1, 2018, Blue Cross and Blue Shield of Texas (BCBSTX) will implement a multiple procedure payment reduction (MPPR) to the technical component (TC) modifier of certain diagnostic cardiovascular and ophthalmology procedures billed by physicians and providers on a CMS-1500 claim form.

MPPR applies to the following plans:

  • Blue Advantage HMOSM and Blue Advantage PlusSM HMO
  • Blue Choice PPOSM
  • Blue EssentialsSM and Blue Essentials AccessSM
  • Blue PremierSM and Blue Premier AccessSM
  • PAR Plan

The MPPRs for multiple diagnostic cardiovascular or ophthalmology services will be applied when more than one of the services is billed for the same patient on the same day. It will apply to modifier TC-only services and to the technical component portion of global services. The MPPRs do not apply to professional component (modifier 26) services. A list of cardiovascular and ophthalmology services subject to MPPRs is included in this notice.

BCBSTX provides general reimbursement information policies, fee schedule request forms and fee schedule information on the BCBSTX provider website. To view this information, visit the “General Reimbursement Information” section under the Standards and Requirements tab. Under the All Product News section, MPPR changes and updates will be posted under “Multiple Procedure Payment Reductions”.

Cardiovascular Services

For cardiovascular services, full payment is applied to the technical component service with the highest allowable under the BCBSTX fee schedule. Payment is made at 75% of the technical component allowable for the identified subsequent services when performed by the same provider for the same patient on the same day.

The following is an example of how the MPPR applies to cardiovascular services:

Sample Cardiovascular Payment Reduction

Modifier Code #1 Allowed Code #2 Allowed Total Allowed prior to 7/1/18 Total Allowed 7/1/18 or after Payment Calculation
26 $77.00 $65.00 $142.00 $142.00 no reduction
TC $427.00 $148.00 $575.00 $538.00 $427.00 + (.75 X $148.00)
Global $504.00 $213.00 $717.00 $680.00 $504.00 + $65.00 + (.75 X $148.00)

Ophthalmology Services

For ophthalmology services, full payment is applied to the technical component service with the highest allowable under the BCBSTX fee schedule. Payment is made at 80% of the technical component allowable for the identified subsequent services when performed by the same physician for the same patient on the same day.

The following is an example of how the MPPR applies for ophthalmology services:

Sample Ophthalmology Payment Reduction

Modifier Code #1 Allowed Code #2 Allowed Total Allowed prior to 7/1/18 Total Allowed 7/1/18 or after Payment Calculation
26 $46.00 $23.00 $69.00 $69.00 no reduction
TC $92.00 $53.00 $145.00 $134.40 $92.00 + (.80 X $53.00)
Global $138.00 $76.00 $214.00 $203.00 $138.00 + $23.00 + (.80X $53.00)

Please be advised that the reimbursement information being disclosed within this notice contains confidential information proprietary to BCBSTX. The use and disclosure of this information is restricted under Texas Insurance Code Section 1301.136(b), Texas Insurance Code Section 843.321(b) and the terms of your BCBSTX agreements.

We value your participation as a contracted provider. If you have any questions or if you need additional information, please contact your BCBSTX Network Management Representative.

BCBSTX Cardiovascular Services Subject to Multiple Procedure Payment Reduction are listed below:

CODE DESCRIPTION CODE DESCRIPTION
75600 Contrast exam thoracic aorta 75891 Vein x-ray liver
75605 Contrast exam thoracic aorta 75893 Venous sampling by catheter
75625 Contrast exam abdominal aorta 78428 Cardiac shunt imaging
75630 X-ray aorta leg arteries 78445 Vascular flow imaging
75705 Artery x-rays spine 78451 Ht muscle image spect sing
75710 Artery x-rays arm/leg 78452 Ht muscle image spect mult
75716 Artery x-rays arms/legs 78453 Ht muscle image planar sing
75726 Artery x-rays abdomen 78454 Ht musc image planar mult
75731 Artery x-rays adrenal gland 78456 Acute venous thrombus image
75733 Artery x-rays adrenals 78457 Venous thrombosis imaging
75736 Artery x-rays pelvis 78458 Ven thrombosis images bilat
75741 Artery x-rays lung 78466 Heart infarct image
75743 Artery x-rays lungs 78468 Heart infarct image (ef)
75746 Artery x-rays lung 78469 Heart infarct image (ef)
75756 Artery x-rays chest 78472 Gated heart planar single
75809 Nonvascular shunt x-ray 78473 Gated heart multiple
75820 Vein x-ray arm/leg 78481 Heart first pass single
75822 Vein x-ray arms/legs 78483 Heart first pass multiple
75825 Vein x-ray trunk 78494 Heart image spect
75827 Vein x-ray chest 93024 Cardiac drug stress test
75831 Vein x-ray kidney 93025 Microvolt t-wave assess
75833 Vein x-ray kidneys 93050 Art pressure waveform analysis
75840 Vein x-ray adrenal gland 93260 Prgrmg dev eval impltbl sys
75842 Vein x-ray adrenal glands 93261 Interrogate subq defib
75860 Vein x-ray neck 93278 Ecg/signal-averaged
75870 Vein x-ray skull 93279 Pm device progr eval sngl
75872 Vein x-ray skull epidural 93280 Pm device progr eval dual
75880 Vein x-ray eye socket 93281 Pm device progr eval multi
75885 Vein x-ray liver w/hemodynam 93282 Prgrmg eval implantable dfb
75887 Vein x-ray liver w/o hemodyn 93283 Prgrmg eval implantable dfb
75889 Vein x-ray liver w/hemodynam 93284 Prgrmg eval implantable dfb
93285 Ilr device eval progr 93888 Intracranial limited study
93286 Peri-px pacemaker device evl 93890 Tcd vasoreactivity study
93287 Peri-px device eval & prgr 93892 Tcd emboli detect w/o inj
93288 Pm device eval in person 93893 Tcd emboli detect w/inj
93289 Interrog device eval heart 93895 Carotid intima atheroma eval
93290 Icm device eval 93922 Upr/l xtremity art 2 levels
93291 Ilr device interrogate 93923 Upr/lxtr art stdy 3+ lvls
93292 Wcd device interrogate 93924 Lwr xtr vasc stdy bilat
93303 Echo transthoracic 93925 Lower extremity study
93304 Echo transthoracic 93926 Lower extremity study
93306 Tte w/doppler complete 93930 Upper extremity study
93307 Tte w/o doppler complete 93931 Upper extremity study
93308 Tte f-up or lmtd 93970 Extremity study
93312 Echo transesophageal 93971 Extremity study
93314 Contrast exam thoracic aorta 93975 Vascular study
93318 Echo transesophageal intraop 93976 Vascular study
93350 Stress tte only 93978 Vascular study
93351 Stress tte complete 93979 Vascular study
93724 Analyze pacemaker system 93980 Penile vascular study
93880 Extracranial bilat study 93981 Penile vascular study
93882 Extracranial uni/ltd study 93990 Doppler flow testing
93886 Intracranial complete study    

BCBSTX Ophthalmology Services Subject to Multiple Procedure Payment Reduction are listed below:

CODE DESCRIPTION CODE DESCRIPTION
76510 Ophth us b & quant a 92136 Ophthalmic biometry
76511 Ophth us quant a only 92145 Corneal hysteresis deter
76512 Ophth us b w/non-quant a 92228 Remote retinal imaging mgmt
76513 Echo exam of eye water bath 92235 Fluorescein angrph uni/bi
76514 Echo exam of eye thickness 92240 Icg angiography uni/bi
76516 Analyze pacemaker system 93980 Penile vascular study
76519 Echo exam of eye 92250 Eye exam with photos
92025 Corneal topography 92265 Eye muscle evaluation
92060 Special eye evaluation 92270 Electro-oculography
92081 Visual field examination(s) 92275 Electroretinography
92082 Visual field examination(s)   Color vision examination
92083 Visual field examination(s) 92284 Dark adaptation eye exam
92132 Cmptr ophth dx img ant segmt 92285 Eye photography
92133 Cmptr ophth img optic nerve 92286 Internal eye photography
92134 Cptr ophth dx img post segmt