Someone is injured in a motor vehicle accident, and they are treated in a hospital emergency room. As part of the evaluation of the patient, an X-Ray of the patient’s lumbar spine (lower back area), an MRI of the brain, and a CAT-SCAN of the left leg are all performed. The PIP carrier pays the hospital 100% of one of the radiology codes, and 50% of the 2 subsequent codes. This is what is known as the Multiple Modality Reduction formula, or “MMR.” Application of MMR in this context is misplaced and the carrier is underpaying the hospital in applying it.
An understanding of the reason for the MMR formula is helpful to understanding why it should not apply to radiology treatment provided as part of a hospital emergency room encounter.
Simply stated, MMR applies to surgical services provided “in the same operative session.” The concept is simple. When a surgeon performs more than one procedure during the same operative session, certain actions performed initially do not have to be repeated for the subsequent procedures. When a patient undergoes a surgery, and as part of the operative session undergoes various procedures, a PIP carrier is permitted to reduce the total amount paid by paying half of the amount due for subsequent procedures performed in the same session, because certain steps are not repeated in each subsequent procedure. The principle is that it takes less time and resources to perform three procedures in the same session than if those same three procedures were performed separately in three independent operative sessions.
For example, a patient undergoes right shoulder arthroscopic surgery for rotator cuff tears. The surgery includes diagnostic arthroscopy, rotator cuff repair, extensive debridement, and manipulation procedures of that shoulder. PIP insurers must pay 100% of the amount due for the primary procedure, and then they may apply a 50% reduction pursuant to the MMR formula toward payment of the other procedures performed in the same operative session. The formula makes sense in that context. The patient is prepared for surgery and certain efficiencies are created for the subsequent procedures. (Please note there are some exceptions to the MMR application for physicians.)
These efficiencies, however, do not occur with radiological services. There is no time or resources saved by doing the X-Ray, the MRI and the Cat Scan in the same session as opposed to separate “radiological sessions.” Accordingly, to apply MMR to different radiology treatment provided as part of a hospital emergency room encounter is completely misplaced.
In sum, MMR makes sense if a patient undergoes surgery and multiple procedures are performed in the same operative session. It makes no sense, however, to apply this reduction to radiology treatment performed as part of a hospital Emergency Room encounter. We have been very successful arguing against the application of MMR in this context, and rightfully so.
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The Multiple Modality Reduction (MMR) Formula: When It Applies #Attorney, #Business, #Callagylaw, #LegalAdvice, #Seancallagy
