About multiple-procedure payment reduction line item calculations

When modeling contracts, you can include multiple-procedure payment reduction calculations by percentage to handle contracts with multi-procedure payment reduction (MPR Multiple Procedure Payment Reduction. When providers report more than a single (non-evaluation and management) procedure during a single encounter, payers typically will reimburse only the highest-valued procedure at full fee schedule value, and will reduce payment for the second and subsequent procedures.) line items in excess of three reimbursement rates. This calculation handles dollar and percentage rates. The Line Item Code MPR calculation basis The calculation basis is one of the elements that defines how a claim pays on a clause or term. The calc basis is used in conjunction with the calculation type and measure to determine a specific reimbursement method. In normal contract building rules, the Calc Basis is used to determine if a claim qualifies for the clause or term. calculates claims that are reimbursed based on multiple rate tiers. This calculation basis is available in the Calc Basis menu for clauses and terms, as shown in the following example:

Line Item MPR uses translation tables similar to Line Item ASC Ambulatory Surgery Center. A facility service specializing in outpatient procedures.. Translation tables consist of columns of line item codes and their associated Group column. (Descriptions are not needed in the table because they are automatically populated based on the existing Line Item Code library entries.)

IMPORTANT: When adding translation tables and rates to a line item MPR clause, you must add the translation table file before you add the rates file, or else the rates will not load.

The Rates dialog for Line Item MPR has a ten-tier procedure reduction calculation consisting of nine rate columns and one sub rate column on the Category Assignment tab (see following image example) to handle procedure reduction logic in contracts. You do not need to specify all ten tiers, but at minimum you must specify one rate and the Subrate column. You can enter rates manually or upload translation and rates tables. For more information, see Import rates for a clause or term.

With Line Item MPR, rates may be either percentages (loaded as decimals) or dollars.

When loading rates using an Excel file, the subrate must be defined. The subrate is the last payable rate. Therefore, if a contract says all services are reimbursed at 100/50/25/25, then program 100% of the given rate in Rate 1, 50% of the given rate in Rate 2, and 25% of the given rate in the Subrate. This will calculate all services found in the translation table.

If reimbursement is limited to a set number of services, use the rate columns and subrate to limit reimbursement. For example, if only three services are payable, program Rate 1-3 with the appropriate value and subrate with $0. This prevents any services from calculating after the third procedure.

As with Line Item ASC, reimbursement order is determined by rate, assessing the services with the highest reimbursable amount, and paying those first.

NOTE: In the case of professional contracts with services that are always payable, you can ensure that these are calculated first regardless of highest reimbursable amount. For details, see Add an exclusion to a professional Line Item MPR calculation.

When a qualifying claim comes in and triggers the Line Item MPR clause, the system determines the group it belongs to based on the translation table. After all qualifying line items are grouped, the system assigns the rates to each group based on the Day of Service and rates set for the clause/term.

For more information, see the following:

• Add a clause to a provision
• Add a term to a clause
• Add a unit max limit to a Line Item MPR
• Modeling clauses and terms

Claim voucher reports display Line Item Code MPR calculation details

When reconciling an MPR calculation on a claim, you can use the voucher report to see which line items on the claim triggered Line Item Code MPR on a contract and were paid based on that calculation logic. You can use this detail to track down under or over payments and to justify proper payment from the payer.

In the following example, a claim voucher report displays the following details for a Line Item MPR calculation on a claim:

• The service codes on the claim that matched those on the Line Item MPR clause
• The service date detail, line item code with description, and the group, units, and qualified level
• Payment amount for each