Add a unit max limit to a Line Item MPR

Use these instructions to add a Unit Max limit on a contract clause or term that uses the Line Item 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. calculation basis. Setting a unit max limit puts a cap on how many units are paid. The unit max acts as a counter; when the limit is reached, additional claims for that item that are eligible are not reimbursed (they are paid at $0).

NOTE: The Unit Max limit used on an MPR calculation applies to professional claims A claim billed from a physician's office as opposed to a hospital or institution. only.

To add a unit max limit to a Line Item MPR calculation:

  1. Navigate to the clause or term that has the Line Item MPR calculation method.

    NOTE: Be sure you have added translation tables and rates to the clause before setting a limit.

  2. In the Limits column of the clause/term row, click the Limit icon ().
  3. On the Limits page, click the Maximum check box.

  4. From the Description drop-down, select a description.

  5. From the Calc Basis drop-down, select Unit Max.

    Notice that you cannot change the selected Calc Type.

  6. From the Calc Measure drop-down, select whether the max should be applied per claim, per date, or per line item.

    NOTE: When creating a unit max limit, you cannot change the default Calc Type or Calc Measure after selecting Unit Max as the Calc Basis.

  7. In the Rates field, enter the unit limit. For example, if the unit is the number of therapy sessions and the contract stops paying after the 6th visit, enter 6.

  8. Click Save.

    The voucher report for claims that are run against this limit will display the limits and a payment of 0 once the rate cap is met.

See also