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

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 HMO^SM and Blue Advantage Plus^SM HMO
• Blue Choice PPO^SM
• Blue Essentials^SM and Blue Essentials Access^SM
• Blue Premier^SM and Blue Premier Access^SM
• 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

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

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:

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