CurrentAnthemPolicy G-12002

Multiple Radiology Payment Reduction

Defines Anthem's reimbursement approach when multiple diagnostic imaging procedures with CMS MPI=4 are performed by the same provider or provider group on the same date of service; affects professional and facility claims for Anthem Blue Cross and Blue Shield Medicare Advantage members in listed states.

Policy Summary

PayerAnthem

PolicyMultiple Radiology Payment Reduction

Policy CodePolicy G-12002

Change TypeMaterial edits — MPI 4 language added; CT scan exception removed

Effective Date04/01/2026

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines and follow billing/coding rules to avoid claim denials or recoupments.

SourceLink

POLICY UPDATE CHANGES

Added language of MPI 4 to policy body.

Removed language that CT scan services are not subject to a multiple procedure payment reduction.

95%Professional subsequent

50%Technical subsequent

MPI = 4MPI subject to MPPR

2026-04-01Effective

Multiple Imaging Payment Rules

Multiple imaging payment rules

Coverage and payment rules for multiple diagnostic imaging procedures:

Applies to multiple diagnostic imaging procedures with CMS NPFS multiple procedure indicator (MPI) = 4 performed by the same provider or provider group on the same date of service during the same member encounter.

The global procedure, or the professional component (26), or the technical component (TC) service with the highest allowance reimburses at 100% of the contracted/negotiated rate.

Reimbursement for second and subsequent procedures: professional component reimburses at 95% and technical component reimburses at 50%.

Exception: The reduced allowance for second and subsequent procedures does not apply when modifier 59 or modifier X{EPSU} is reported to indicate the procedures were done on the same day but not during the same session.

A single imaging procedure submitted with multiple units is subject to multiple imaging reductions.

Coding and Reimbursement Details

Coding expectationsmixed

CPT/HCPCS

Standard correct coding applies; use industry-standard CPT and HCPCS codes as appropriate.

Professional component reimbursement

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

First (highest-allowance) professional componentReimbursed at 100% of contracted/negotiated rate

Exception with distinct-procedure modifierReduced allowance does not apply if modifier 59 or X{EPSU} is used

Technical component reimbursement

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

First (highest-allowance) technical componentReimbursed at 100% of contracted/negotiated rate

Single-procedure multiple unitsA single imaging procedure submitted with multiple units is subject to multiple imaging reductions

Authorization, Claims, and MPPR Applicability

Billing Rule

MPPR applicability and payment adjustments

Multiple diagnostic imaging procedures with a CMS National Physician Fee Schedule (NPFS) multiple procedure indicator (MPI) of 4 are subject to a multiple procedure payment reduction (MPPR) when performed by the same provider or provider group on the same date of service during the same member encounter. The global procedure, professional component, or technical component with the highest allowance will reimburse at 100% of the contracted/negotiated rate; reimbursement for subsequent procedures will be reduced as described below.

Second and subsequent professional components: reimbursed at 95% of the professional component allowance.
Second and subsequent technical components: reimbursed at 50% of the technical component allowance.
MPPR does NOT apply when multiple imaging procedures are reported with modifier 59 or X{EPSU} (or other appropriate modifiers) to indicate services were performed on the same day but not during the same session.
When a single imaging procedure is reported with multiple units, the procedure is subject to multiple imaging reductions as applicable.
MPPR applies regardless of participating or non‑participating provider status unless superseded by provider, state, federal, or CMS contract requirements.

Prior Authorization

Authorization and claim handling

Providers must follow applicable authorization and medical necessity requirements and submit claims using correct, industry‑standard codes (CPT, HCPCS, revenue codes). Failure to follow coding/billing guidelines or current reimbursement policies may result in claim rejection or denial, recovery/recoupment of payment, or adjustment of reimbursement to reflect appropriate services performed. Policies may be superseded by mandates in provider, state, federal, or CMS contracts.

Use proper modifiers to avoid improper MPPR application (e.g., 59 or appropriate X modifiers when procedures are distinct sessions).
Ensure documentation in the medical record supports billing for professional and technical components and any modifiers used.
Authorization and medical necessity must be met per the member's benefit plan and state requirements.

Terminology

Multiple Procedure Payment Reduction (MPPR)

MPPR definitionMultiple Procedure Payment Reduction (MPPR): a reduction applied to subsequent imaging procedure reimbursements when multiple diagnostic imaging procedures with CMS NPFS MPI=4 are performed by the same provider or provider group on the same date of service during the same member encounter.

ScopeApplies to professional and facility reimbursement unless superseded by provider, state, federal, or CMS contracts/requirements.

Application to single-procedure unitsA single imaging procedure submitted with multiple units is subject to multiple imaging reductions.

Modifiers indicating distinct procedural services

Modifiers that indicate distinct procedural servicesModifier 59 or X{EPSU}: when used to indicate procedures were done the same day but not during the same session, the MPPR reduced allowance does not apply.

Related modifier guidanceSee related policies: Modifier Usage; Modifiers 26 and TC; Modifiers 59, XE, XP, XS, XU: Distinct Procedural Services.

Effect on reimbursementWhen modifier 59 or X{EPSU} is present, second and subsequent procedure reductions are not applied.