Effective Date: October 14, 2019

Purpose:
To provide guidelines for the application of Multiple Procedure Payment Reduction (MPPR) for Endoscopies when appropriately billed by professional providers.

Scope:
Products included:

• NJ FamilyCare/Medicaid Plan
• Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Definitions:

• Endoscopic Adjustment Rule: Allows the full Allowable Amount for the highest valued endoscopy code and allows any additional endoscopy codes (within the same family) at a reduced amount based on the value of the NPFS designated Endoscopic Base Code.

• Endoscopic Base Code: The most basic, least complex form of the endoscopic procedure being done.

• Relative Value Unit (RVU): The assigned unit value of a particular CPT or HCPCS code.

Policy:
Horizon NJ Health shall apply Multiple Procedure Payment Reduction (MPPR) adjustments to reimbursement when multiple endoscopic procedures from the same family (i.e., another endoscopy that has the same base procedure; Same Endoscopic Base Code) are reported on the same patient on the same date of service.

In addition, Horizon NJ Health will apply CMS multiple Endoscopic Adjustment Rules when related endoscopic procedures (within the same family) are performed on the same patient on the same date of service as other procedures that are subject to multiple procedure reduction, therefore endoscopy codes may be subject to both the endoscopic and multiple procedure reductions.

Appropriately billed claims for Assistant Surgeons, Co-Surgeons or Team Surgeon will be also subject to Multiple Procedure Payment Reduction. Surgeons billing from the same group practice shall be treated as the same provider.

Procedure:
Horizon NJ Health shall apply a payment reduction to multiple endoscopy procedures, reported within the same family on the same patient on the same date of service. The full allowable amount for the highest valued endoscopy code in the family will be allowed and any additional endoscopy codes in the same family will be allowed at a reduced amount based on the value of the National Physician Fee Schedule (NPFS) designated Endoscopic Base Code.

If more than one endoscopy family is reported and/or surgical procedures are reported, Horizon NJ Health shall apply the multiple surgery reductions to the appropriate endoscopy family or families and surgical procedures.

Horizon NJ Health shall use the CMS Facility Total Relative Value Units (RVUs) to determine the ranking of primary, secondary and subsequent procedures when those services are performed in an appropriate facility setting. Procedures performed in a place of service other than the facility setting will be ranked by the CMS Non-Facility RVUs.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

• Benefit Limitations
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

References:

Medicare Claims Processing Manual, Chapter 12 - Physicians/Nonphysician Practitioners cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

CMS National Physician Fee Schedule- Relative Value Files cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html