Find policies, billing codes, payers, states, and providers
Multiple Procedure Payment Reduction for Diagnostic Cardiovascular Procedures
Customize your policy alerts
Sign up for Blue Cross Blue Shield - Maine Policy C-23003 alerts
Get alerted when Policy C-23003 changes without checking for updates manually.
Monitor payer policy activity
Defines how the health plan applies multiple procedure payment reductions (MPPR) to the technical component of diagnostic cardiovascular (and ophthalmology) procedures when multiple services are performed on the same date/encounter by the same provider or group.
No material clinical or coverage changes in this revision.
Multiple Procedure Payment Reduction (MPPR) Coverage Criteria
MPPR Coverage Criteria
Covered when ALL of the following apply:
Cardiovascular (MPI = 6)
- The technical component (TC) for cardiovascular procedures reimburses at 100% for the first diagnostic cardiovascular procedure with the highest Relative Value Unit (RVU).
- The TC for subsequent cardiovascular procedures reimburses at 75%.
- MPPR does not apply to professional component services; professional component RVUs remain at 100%.
Ophthalmology (MPI = 7)
- The technical component (TC) for ophthalmology procedures reimburses at 100% for the first diagnostic ophthalmology procedure with the highest RVU.
- The TC for subsequent ophthalmology procedures reimburses at 80%.
- MPPR does not apply to professional component services; professional component RVUs remain at 100%.
Billing and Coding Guidance
Authorization, Claim Submission, and Provider Responsibilities
Authorization and Claim Submission Requirements
Follow all applicable provider, state, and federal contracts and authorization and medical necessity guidelines before submitting claims for diagnostic cardiovascular (and related) procedures; services must meet authorization and medical necessity requirements appropriate to the procedure, diagnosis, and the member's state of residence. Use industry-standard CPT, HCPCS, and/or revenue codes on all claim submissions and ensure billed services are fully supported in the medical record and/or office notes. Failure to follow coding, billing, or policy requirements may result in claim rejection, denial, or recovery/recoupment of payment.
- Obtain authorization and confirm medical necessity per payer, state, or federal requirements prior to furnishing services when required.
- Bill using appropriate CPT, HCPCS, and/or revenue codes and ensure documentation in the medical record/office notes fully supports the billed services.
- Be aware that reimbursement policies may be superseded by provider, state, federal, or CMS mandates; noncompliance can lead to claim rejection, denial, or recoupment.
Key Terms and Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.