Description
CPT Codes with a Multiple Procedure Indicator of “6” are subject to a 25% reduction of the Technical Component (TC) when multiple procedures are billed on the same date of service, for the same patient, by the same physician, on the same claim. Claims incorrectly processed will be re-priced with the 25% reduction and the overpaid amount will be recovered. If the CPT code has a Multiple Procedure Indicator of ‘6’ then 75% of the TC portion (Codes with an Indicator of ‘1’) will be allowed and if the PC/TC Indicator is ‘3’ (Technical component only codes) 75% of the Full Fee Schedule for that code will be allowed.
Affected Code(s)
CPT/HCPCS Codes with a multiple procedure indicator of “6” (Diagnostic cardiovascular services subject to the MPPR methodology) per the Medicare Physician Fee Schedule (indicated under the “Multiple Procedure” column):
75600, 75605, 75625, 75630, 75705, 75710, 75716, 75726, 75731, 75733, 75736, 75741, 75743, 75746, 75756, 75809, 75820, 75822, 75825, 75827, 75831, 75833, 75840, 75842, 75860, 75870, 75872, 75880, 75885, 75887, 75889, 75891, 75893, 78428, 78445, 78451, 78452, 78453, 78454, 78456, 78457, 78458, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78494, 93000, 93005, 93015, 93017, 93024, 93025, 93040, 93041, 93050, 93224, 93225, 93226, 93229, 93241, 93242, 93243, 93245, 93246, 93247, 93260, 93261, 93268, 93270, 93271, 93278, 93279, 93280, 93281, 93282, 93283, 93284, 93285, 93286, 93287, 93288, 93289, 93290, 93291, 93292, 93303, 93304, 93306, 93307, 93308, 93312, 93314, 93318, 93350, 93351, 93701, 93702, 93724, 93784, 93786, 93788, 93880, 93882, 93886, 93888, 93890, 93892, 93893, 93895, 93922, 93923, 93924, 93925, 93926, 93930, 93931, 93970, 93971, 93975, 93976, 93978, 93979, 93980, 93981, 93985, 93986, 93990
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, §30.2 - MPFSDB Record Layout
Note: Beginning with the 2019 MPFSDB, and thereafter, the MPFSDB File Record Layout will no longer be revised annually in this section for the sole purpose of changing the calendar year, but will only be revised when there is a change to a field. Previous MPFSDB file layouts (for 2018 and prior) can be found on the CMS web site on the Physician Fee Schedule web page at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html.
8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
9. MPFS (Medicare Physician Fee Schedule) Relative Value Files- https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files
10. AMA CPT Codebook