Here’s detailed information about our Multiple Therapy Procedure Reduction policy

In the October 2024 Record, we let you know that we were planning to implement the Multiple Therapy Procedure Reduction, or MTPR, policy in 2025. The policy will apply to claims with dates of service on and after April 1, 2025.

Health care providers are responsible for submitting accurate claims. This policy is designed to ensure reimbursement aligns with correct coding and industry standards. The Blue Cross Blue Shield of Michigan reimbursement policies incorporate guidelines from the Current Procedural Terminology, or CPT^®, the Centers for Medicare & Medicaid Services and other relevant coding frameworks.

This policy applies to claims billed on CMS-1500 and UB-04 forms. It reflects CMS methodology, regulatory requirements, contract terms, benefit design and medical policies. Blue Cross reserves the right to modify this policy at any time by publishing updates on its website.

Overview

Certain physical medicine and rehabilitation therapy procedures frequently reported together on the same date of service include overlapping practice expense components, such as:

• Equipment and room preparation
• Patient education and home care coordination
• Obtaining patient measurements (for example, range of motion)
• Post-therapy patient assistance

To align with CMS guidelines, Blue Cross applies a multiple therapy procedure reduction to the practice expense portion of secondary and subsequent therapy procedures provided on the same date by the same physician, facility or other qualified health care professional.

Reimbursement guidelines

Ranking and reduction of procedures

Blue Cross follows CMS guidelines for determining which procedures are subject to the reduction and how they are ranked:

1. Primary procedure — The procedure with the highest practice expense relative value unit, or PE RVU, is reimbursed at 100%.
2. Secondary and subsequent procedures — The practice expense portion of all additional procedures is reduced by 50%.

This reduction applies when one or both of the following happens:

• Multiple procedures from the CMS Multiple Therapy Reducible Codes list (Multiple Procedure Payment Reduction, or MPPR, indicator “5” in the CMS National Physician Fee Schedule) are performed on the same date.
• Multiple units of the same procedure code are billed.

The reduction doesn’t apply to therapy services for behavioral health conditions (ICD-10 codes beginning with an F).

Procedure ranking methodology

The CMS non-facility PE RVU is used to determine the primary procedure:

• The procedure with the highest PE RVU isn’t reduced.
• For all additional therapy codes on the same date of service, the practice expense portion of each charge is reduced by 50%.
• If multiple procedures share the same PE RVU, the total RVU is used as the tiebreaker.

Example calculation

Frequently asked questions

Question: How is the PE portion of a service determined?

Answer: The practice expense portion is calculated by taking the PE RVU/total RVU ratio and applying it to the allowed amount.

Q: If multiple therapy specialists (physical, occupational, speech-language pathology) provide services on the same day, will the reduction apply?

A: Yes, if all services are billed under the same physician or other qualified health care professional, reductions will apply according to CMS guidelines.

Q: How are codes ranked if they share the same PE RVU?

A: If two or more codes have identical PE RVUs, the total RVU is used to rank them.

Documentation requirements

Providers must submit accurate and complete claims following industry coding standards, including:

• CPT^®, HCPCS, ICD-10 and DRG coding guidelines
• CMS National Correct Coding Initiative, or NCCI, Policy Manual
• HIPAA-approved code sets

Claims are subject to coding audits, benefit coverage reviews and medical policy assessments.