CurrentAnthemPolicy C-17005

Multiple Diagnostic Imaging - Facility, Commercial Reimbursement Policy

Defines Anthem's facility reimbursement rules when two or more diagnostic imaging procedures using the same modality are performed in the same imaging session on the same date of service; applies to UB-04 facility billers for commercial members.

Policy Summary

PayerAnthem

PolicyMultiple Diagnostic Imaging - Facility, Commercial Reimbursement Policy

Policy CodePolicy C-17005

Change TypeRelated coding and definitions updated

Effective DateJul 1, 2024

Next Review Date

Key ActionFollow authorization and medical necessity guidelines and submit claims using industry-standard compliant codes on UB-04.

SourceLink

POLICY UPDATE CHANGES

Updated Related Coding section to include modifiers; updated Definition section for clarity.

Previously removed TC modifier language was added earlier then removed again in prior revisions.

100% / 50%reimbursement: first vs subsequent imaging procedures

5listed imaging modalities governed

UB-04submitter type this policy applies to

Anthem commercialpayer / plan applicability

Multiple Diagnostic Imaging Reimbursement Criteria

Multiple diagnostic imaging facility reimbursement criteria

When two or more diagnostic imaging procedures are performed in the same facility, on the same member, using the same modality, during the same imaging session:

Reimburse 100% of the highest facility allowance for the first imaging procedure on the date of service

Reimburse 50% of the facility allowance for each subsequent imaging procedure on the same date of service

Applies to ultrasound, computed tomography (CT), computed tomographic angiography (CTA), magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA) procedures billed by UB-04 submitters

Rules are applied to the highest facility allowance among the diagnostic imaging procedures rendered on the same date of service and eligible for reimbursement

Policy Summary

PayerAnthem

PolicyMultiple Diagnostic Imaging - Facility, Commercial Reimbursement Policy

Policy CodePolicy C-17005

Change TypeRelated coding and definitions updated

Effective DateJul 1, 2024

Next Review Date

Key ActionFollow authorization and medical necessity guidelines and submit claims using industry-standard compliant codes on UB-04.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Related Coding and Reimbursement Details

Related modifiers and commentsModifier | CPT

LT	Left side modifier — when bilateral procedures with MPI of 4 are performed, report on two lines with LT and RT
RT	Right side modifier — when bilateral procedures with MPI of 4 are performed, report on two lines with LT and RT
TC	Technical component modifier — identifies technical component charges; reimbursement for subsequent procedures is based on 50% of the fee allowance (institutional context).

Reimbursement split (first vs subsequent procedures)

Reimbursement splitFirst imaging procedure on the date of service reimbursed at 100% of the highest facility allowance; each subsequent imaging procedure on the same date of service reimbursed at 50% of the facility allowance when performed in the same facility, on the same member, using the same modality during the same imaging session.

Applies toUB-04 facility billers submitting CPT and HCPCS Level II codes for diagnostic imaging procedures (ultrasound, CT, CTA, MRI, MRA).

Determination of highest allowanceRules applied to the highest facility allowance among the diagnostic imaging procedures eligible for reimbursement on that date of service.

Authorization and Billing Requirements

Note

Authorization, billing and documentation expectations for UB-04 facility claims

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, and to the member's state of residence. Follow proper billing and submission guidelines and use industry-standard, compliant codes (CPT, HCPCS, and/or revenue codes) on all claim submissions; charges must be fully supported in the medical record. Failure to follow appropriate coding/billing guidelines or current reimbursement policies may result in claim rejection or denial, and Anthem may recover and/or recoup claim payment. State, federal, or contract mandates take precedence over this reimbursement policy.

Obtain any required prior authorization and ensure medical necessity for the specific procedure and diagnosis per the member's state of residence.
Bill facility services on UB-04 using industry-standard CPT, HCPCS, and/or revenue codes; ensure documentation in the medical record supports billed services.
Be aware that Anthem may reject/deny claims or recover/recoup payments if coding/billing guidelines or reimbursement policies are not followed.
Follow state, federal, and contract language when it conflicts with this policy, as those mandates override the policy.

Key Definitions

Contiguous body areas

DefinitionContiguous body areas: In actual contact; touching along a boundary or at a point.

Policy application noteMultiple diagnostic imaging reimbursement rules are not limited to contiguous body areas (rules apply even if body areas are non-contiguous).

Source contextUsed to clarify scope of reimbursement rules for multiple diagnostic imaging procedures.

Modality

DefinitionModality: (An apparatus for applying) a usually physical therapeutic agency.

Policy usageReimbursement rules apply when two or more diagnostic imaging procedures use the same modality during the same imaging session.

Examples of modalities governedultrasound, CT, CTA, MRI, MRA (as listed in the policy).