California Code of Regulations
Title 8 - Industrial Relations
Division 1 - Department of Industrial Relations
Chapter 4.5 - Division of Workers' Compensation
Subchapter 1 - Administrative Director-Administrative Rules
Article 5.3 - Official Medical Fee Schedule
Section 9789.15.4 - Physical Medicine/Chiropractic/Acupuncture Multiple Procedure Payment Reduction; Pre-Authorization for Specified Procedure/Modality Services

Universal Citation: 8 CA Code of Regs 9789.15.4

Current through Register 2024 Notice Reg. No. 38, September 20, 2024

(a)

(1) The Medicare Multiple Procedure Payment Reduction ("MPPR") for "Always Therapy" Codes shall be applied when more than one of the following codes is billed on the same day: codes on the Medicare "Always Therapy" list, acupuncture codes, chiropractic manipulation codes.

(2) Many therapy services are time-based codes, i.e., multiple units may be billed for a single procedure. The MPPR applies to the Practice Expense ("PE") payment when more than one unit or procedure is provided to the same patient on the same day, i.e., the MPPR applies to multiple units as well as multiple procedures. Full payment is made for the unit or procedure with the highest PE payment. Full payment is made for the work and malpractice components and 50 percent payment is made for the PE for subsequent units and procedures, furnished to the same patient on the same day.

(3) For therapy services furnished by a group practice or "incident to" a physician's service, the MPPR applies to all services furnished to a patient on the same day, regardless of whether the services are provided in one therapy discipline or multiple disciplines, for example, physical therapy, occupational therapy, or speech-language pathology.

(4) The MPPR applies to acupuncture codes and chiropractic manipulation codes and to the procedures listed in the "Separately Payable Always Therapy Services Subject to the Multiple Procedure Payment Reduction (MPPR)" file of the Medicare Physician Fee Schedule Final Rule. The listed procedures will also have a Multiple Procedure value of "5" on the National Physician Fee Schedule Relative Value File.

(5) See section 9789.19 for the location of the list of codes on the Medicare "Always Therapy" code list, by date of service.

(b) In addition to the MPPR, the following caps are presumed reasonable limitations on reimbursement for services provided at one visit unless pre-authorization and a pre-negotiated fee arrangement has been obtained. The pre-authorization must be provided by an authorized agent of the claims administrator to the physician or qualified non-physician practitioner. The fee agreement and pre-authorization must be memorialized in writing prior to performing the medical services.

(1) When billing for treatment consisting of physical medicine modalities only: no more than two codes on the same visit;

(2) When billing for physical medicine modality, procedure, or acupuncture codes, no more than 60 minutes on the same visit;

(3) Where modalities and procedures are billed: no more than 4 codes total on the same visit.

For the purpose of this subdivision "modality" means a service that is listed in the CPT Medicine section, Physical Medicine and Rehabilitation under the sub-heading of "Modalities". For the purpose of this subdivision "procedure" means a service that is listed in the CPT Medicine section, Physical Medicine and Rehabilitation under the sub-headings "Therapeutic Procedures," "Other Procedures," and under the headings "Acupuncture" and "Chiropractic Manipulative Treatment."

1. New section filed 9-24-2013; operative 1-1-2014. Submitted to OAL as a file and print only pursuant to Government Code section 11340.9(g) (Register 2013, No. 39).
2. Amendment of subsection (a)(4) filed 3-23-2016; operative 1-1-2016 pursuant to Labor Code section 5307.1(g)(2). Submitted to OAL for filing and printing only pursuant to Labor Code section 5307.1(g)(2) (Register 2016, No. 13).

Note: Authority: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference: Sections 4600, 5307.1 and 5307.11, Labor Code.

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