Commercial

Medical Policy

Notification

Multiple Procedure Payment Reduction Guidelines for Physical, Occupational, and Speech Therapy Services

Notification Issued Date: 8/29/2025 10:00 AM

This version of the policy will become effective 12/01/2025. Policy number 00.01.68c has been updated to communicate a change in the Company's reimbursement methodology to apply multiple procedure payment reduction (MPPR) for Always Therapy services to professional providers based on Centers for Medicare & Medicaid Services (CMS) Medicare Physician Fee Schedule Multiple Procedure Indicator "5". The reimbursement methodology for professional providers will apply MPPR to each subsequent unit or procedure code reported by the same provider, for the same individual, on the same date of service, at 75 percent of the provider's applicable contracted rate.

Title:

Multiple Procedure Payment Reduction Guidelines for Physical, Occupational, and Speech Therapy Services

Policy #:

00.01.68c

Policy

The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member's medical needs and condition.

This policy applies to professional providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, and outpatient facility providers billing on a CMS-1450 (UB-04) claim form or the electronic equivalent, 837i, for members enrolled in all Company products.

Multiple procedure payment reduction (MPPR) guidelines apply when multiple physical, occupational, and speech therapy services designated as Always Therapy are reported by the same provider, for the same individual, on the same date of service.

MPPR is applied when more than one unit or procedure code is provided, regardless of whether the services are within one therapy discipline or multiple disciplines (i.e., physical, occupational, or speech therapy).

PROFESSIONAL PROVIDERS

The hierarchy for MPPR guidelines is set forth below:

100 percent of the provider's applicable contracted rate of one unit of the procedure code with the highest total allowance is eligible for reimbursement consideration.
Each subsequent unit or procedure code is eligible for reimbursement at 75 percent of the provider's applicable contracted rate.

FACILITY PROVIDERS

The hierarchy for MPPR guidelines is set forth below:

100 percent of the provider's applicable contracted rate of one unit of the procedure code with the highest total allowance is eligible for reimbursement consideration.
Each subsequent unit or procedure code is eligible for reimbursement at 50 percent of the provider's applicable contracted rate.

MPPR guidelines for physical, occupational, and speech therapy services are not applied to services that are non-covered or not eligible for separate reimbursement consideration.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, the following: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

BILLING REQUIREMENTS

Always Therapy codes require a therapy modifier (GN, GO, GP) to indicate that the services are furnished under a physical, occupational, or speech therapy plan of care.

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

Guidelines

This claim payment rationale applies only to the procedure codes determined to be Always Therapy by Centers for Medicare & Medicaid Services (CMS) and does not apply to any other code and/or code and modifier combinations. Claims are processed according to the statements in this policy. When a medical policy on this topic also exists, the medical necessity criteria listed in the medical policy must be met.

Multiple procedure payment reduction (MPPR) guidelines for services that are designated as Always Therapy are based on the date of service regardless of the claim submission date or date received.

Description

The Centers for Medicare & Medicaid Services (CMS) applies a multiple procedure payment reduction (MPPR) to certain physical, occupational, and speech therapy services that are designated as Always Therapy.

Centers for Medicare & Medicaid Services (CMS) Annual Therapy disposition code "5" determines Always Therapy services for facility providers. The Medicare Physician Fee Schedule (MPFS) multiple procedure indicator "5" determines Always Therapy services for professional providers. These codes always represent therapy services when rendered by therapists or by practitioners who are not therapists in situations where the service provided is integral to an outpatient rehabilitation therapy plan of care.

In accordance with CMS, the Company has established claims processing guidelines to apply MPPR to CMS-designated Always Therapy services.

References

Centers for Medicare & Medicaid Services (CMS). MLN Matters Number MM8206. Effective April 1, 2013. [CMS Website]. Available at: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/MM8206.pdf. Accessed August 06, 2025.

Annual Therapy Update | CMS. Available at:
https://www.cms.gov/Medicare/Billing/TherapyServices/AnnualTherapyUpdate.html. Accessed August 06, 2025.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 5: Part B Outpatient Rehabilitation and CORF/OPT Services. Revised 11/22/2021. [CMS Website]. Available at:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c05.pdf. Accessed August 06, 2025.

Novitas Solutions. Multiple Procedure Payment Reduction. [

Novitas Solutions Web site]. Last modified: 05/13/2022. Available at: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?centerWidth=100%&contentId=00147106&leftWidth=0%&rightWid

th=0%&

showFooter=

false&showHeader=false&_

adf.ctrl-state=tl57mjwsj_4&_afrLoop=309444304661771#!. Accessed August 06, 2025.

Coding

CPT Procedure Code Number(s)

PROFESSIONAL PROVIDERS

Refer to the "MULT PROC" column of the Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule for procedure codes with Multiple Procedure Indicator 5: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html

Select the calendar year and RVU. The RVU is separated by quarters:
RVUA (January - March)
RVUB (April-June)
RVUC (July-September)
RVUD (October - December)

FACILITY PROVIDERS

Refer to Centers for Medicare & Medicaid Services (CMS) Annual Therapy List for procedure codes with Disposition Indicator 5. Annual Therapy Update | CMS

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

PROFESSIONAL PROVIDERS

FACILITY PROVIDERS

Refer to Centers for Medicare & Medicaid Services (CMS) Annual Therapy List for procedure codes with Disposition Indicator 5. Annual Therapy Update | CMS

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub
Modifiers

CO Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant

CQ Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant

GN Service delivered personally by a speech-language pathologist or under an outpatient speech-language pathology plan of care

GO Service delivered personally by an occupational therapist or under an outpatient occupational therapy plan of care

GP Service delivered personally by a physical therapist or under an outpatient physical therapy plan of care

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From 00.01.68c:

12/01/2025

Revisions From 00.01.68b:

07/01/2024

This version of the policy will become effective 07/01/2024. Policy number 00.01.68b has been updated to communicate the Company's reimbursement methodology.

The Company's reimbursement methodology has been revised from applying MPPR at the procedure code level only to include the procedure code or units of service.

The following CPT coding changes were made in accordance with the Centers for Medicare and Medicaid Services (CMS) Always Therapy CY 2024 code list:

Codes 97550 and 97552 have been deleted.
Codes 92605, 92606, 92618, and 97010 have been added.

Revisions From 00.01.68a:

01/02/2024

This policy has been identified and updated for the CPT/HCPCS code update effective 01/02/2024

Procedure codes 97550 and 97552 have been added to this policy.

Revisions From 00.01.68:

09/01/2019

This new policy becomes effective 09/01/2019 and applies to outpatient facility providers. Multiple procedure payment reduction guidelines for multiple therapies apply to physical, occupational, and speech therapy services designated as Always Therapy that are reported by the same provider, for the same individual, on the same date of service.

The procedure code with the highest total allowance is eligible for reimbursement at 100 percent of the provider's applicable contracted rate.
Each subsequent procedure code is eligible for reimbursement at 50 percent of the provider's applicable contracted rate.

Version Effective Date:

12/1/2025

Version Issued Date: