CurrentAnthemPolicy G-12002

Multiple Radiology Payment Reduction

Defines Anthem's reimbursement reductions when multiple diagnostic imaging procedures (MPI=4) are performed by the same provider or provider group on the same date of service during the same encounter in California Medicare Advantage products.

Policy Summary

PayerAnthem

PolicyMultiple Radiology Payment Reduction

Policy CodePolicy G-12002

Change TypeMaterial updates (MPI=4 addedCT exclusion removed)

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionEnsure appropriate authorization and medical necessity and use modifier 59 or X{EPSU} to indicate distinct services to avoid MPPR when applicable.

SourceLink

POLICY UPDATE CHANGES

Language of MPI 4 was added to the policy body.

Language stating CT scan services are not subject to a multiple procedure payment reduction was removed.

95%professional component subsequent

50%technical component subsequent

100%highest allowance reimbursed

MPI = 4MPI subject to MPPR

Californiajurisdiction

Multiple Procedure Payment Reduction (MPPR) Reimbursement Criteria

MPPR reimbursement criteria

Covered when ALL of the following are met:

When multiple diagnostic imaging procedures with the CMS National Physician Fee Schedule (NPFS) multiple procedure indicator (MPI) of 4 are performed by the same care provider or provider group on the same date of service during the same member encounter, MPPR applies.

The global procedure, professional component, or technical component with the highest allowance will reimburse at 100% of the contracted/negotiated rate.

ALL of the following

Professional component: reimbursed at 95% for the second and subsequent procedures.
Technical component: reimbursed at 50% for the second and subsequent procedures.

Policy Summary

PayerAnthem

PolicyMultiple Radiology Payment Reduction

Policy CodePolicy G-12002

Change TypeMaterial updates (MPI=4 addedCT exclusion removed)

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionEnsure appropriate authorization and medical necessity and use modifier 59 or X{EPSU} to indicate distinct services to avoid MPPR when applicable.

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.

Coding and Procedure Indicators

Multiple procedure indicatormixed

MPI=4

CMS National Physician Fee Schedule multiple procedure indicator of 4 — subject to MPPR

Professional component reduction

Professional component reimbursement for subsequent procedures95% of the professional component for the second and subsequent diagnostic imaging procedures

Highest professional allowanceThe professional component with the highest allowance reimburses at 100% of the contracted/negotiated rate

ApplicabilityApplies when multiple diagnostic imaging procedures with CMS MPI=4 are performed by the same provider or provider group on the same date of service during the same encounter

Technical component reduction

Technical component reimbursement for subsequent procedures50% of the technical component for the second and subsequent diagnostic imaging procedures

Highest technical allowanceThe technical component with the highest allowance reimburses at 100% of the contracted/negotiated rate

ApplicabilityApplies when multiple diagnostic imaging procedures with CMS MPI=4 are performed by the same provider or provider group on the same date of service during the same encounter

Authorization, Billing, and Documentation Actions

Billing Rule

Authorization, documentation and correct modifier use to avoid MPPR

Ensure services meet authorization and medical necessity guidelines and are billed with industry-standard, compliant codes; services must be fully supported in the medical record or office notes. Use proper billing and submission guidelines (CPT, HCPCS, revenue codes) and apply modifier 59 or X{EPSU} when procedures were done the same day but not during the same session to avoid MPPR when appropriate. Incorrect coding or failure to follow billing guidelines may result in claim rejection or denial, recovery/recoupment of payment, or adjustment of reimbursement.

Obtain and document authorization and medical necessity per the procedure, diagnosis, and member’s state of residence. [See source for requirement.]
Bill services using appropriate CPT, HCPCS, and/or revenue codes; ensure the medical record/office notes fully support billed services.
When applicable, append modifier 59 or X[EPSU] to indicate services were not performed during the same session to prevent application of the reduced allowance for second and subsequent procedures.
Be aware that failure to follow coding/billing guidelines or current reimbursement policies may lead to claim rejection/denial, payment recovery/recoupment, or reimbursement adjustment.

Definitions and Modifier Guidance

MPPR (Multiple Procedure Payment Reduction)

DefinitionMultiple Procedure Payment Reduction (MPPR): A reduction applied to subsequent diagnostic imaging procedures identified with CMS MPI=4 when performed by the same provider or provider group on the same date of service during the same member encounter

CMS indicator referencedCMS National Physician Fee Schedule multiple procedure indicator (MPI) = 4 is subject to MPPR

Interaction with allowancesThe global/professional/technical component with the highest allowance reimburses at 100%; subsequent procedures receive reduced allowances per policy

Distinct procedural service modifiers

Modifiers that indicate distinct procedural servicesModifier 59 or X[EPSU] can be used to indicate the procedure was done the same day but not during the same session

Effect on MPPRWhen multiple imaging procedures are reported with modifier 59 or X[EPSU], the reduced allowance for second and subsequent procedures will not apply

Related guidanceSee related policies: Modifier Usage; Modifiers 59, XE, XP, XS, XU: Distinct Procedural Services for additional modifier rules