CurrentBlue Cross Blue Shield - NevadaPolicy C-23003

Multiple Procedure Payment Reduction

Defines how the health plan applies multiple procedure payment reductions (MPPR) to technical components of certain diagnostic, endoscopic, surgical, and radiology services when multiple procedures are performed during the same encounter by the same provider or group.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyMultiple Procedure Payment Reduction

Policy CodePolicy C-23003

Change TypeNo material change

Effective DateApr 12, 2023

Next Review Date

Key ActionWhen multiple services are performed on the same date/encounter by the same provider or group, apply MPPR to specified service categories and ensure services meet authorization and medical necessity and are properly coded.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100%/75%Cardiovascular TC rates

100%/80%Ophthalmology TC rates

MPI 6 & 7Referenced MPIs

NonePolicy exemptions

76/77Repeat-procedure modifiers

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Potential payer actions

Multiple Procedure Payment Reduction (MPPR) Criteria

MPPR reimbursement criteria

When two or more procedures with the same MPI are performed (same date/encounter by same provider/group), the plan applies MPPR as follows:

For diagnostic cardiovascular procedures (MPI 6): the technical component (TC) reimburses 100% for the first (highest-RVU) procedure and 75% for the TC of subsequent procedures.

For diagnostic ophthalmology procedures (MPI 7): the technical component (TC) reimburses 100% for the first (highest-RVU) procedure and 80% for the TC of subsequent procedures.

MPPR does not apply to the professional component; professional component services remain reimbursed at 100%.

When two or more procedures with the same MPI are reported as global procedures: the TC RVU for each procedure is reduced by the appropriate percentage, the professional component RVU remains at 100%, the adjusted TC and professional RVUs are summed to obtain a new RVU, and that new RVU is used to compute the percentage of the original global fee schedule to determine the allowance.

Repeat-procedure modifiers (e.g., 76/77) do not override MPPR and are not treated as distinct separate-session services for the purpose of these reductions.

Use of the TC modifier indicates technical component billing; the MPPR reimbursement reductions described above apply to TC billing.

There are no exemptions to this MPPR policy.

Billing and reimbursement rules

Billing and coverage requirements and consequences for noncompliance.

Services must be billed using industry-standard codes (CPT, HCPCS and/or revenue codes) and the codes billed must be fully supported in the medical record and/or office notes.

These reimbursement policies apply to both participating and non-participating professional providers and facilities unless otherwise noted in the policy.

Consequences for noncompliance: If coding/billing guidelines or current reimbursement policies are not followed, Anthem may reject or deny the claim, or recover and/or recoup claim payment.

Policy is subject to federal and state laws and member benefit terms on the date of service; mandates in provider, state, federal, or CMS contracts may supersede these reimbursement policies.

Codes, Modifiers, and Reimbursement Rates

MPPR-related coding and modifiersmixed

MPI 6	Diagnostic cardiovascular procedures (TC reduced 25% for subsequent procedures)
MPI 7	Diagnostic ophthalmology procedures (TC reduced 20% for subsequent procedures)
Modifier TC	Technical component; subsequent TC reimbursement reduction applied per policy
Modifier 26	Professional component; reimbursement remains at 100%
Modifiers 76/77	Repeat procedure modifiers do not override MPPR

Required billing code setsmixed

CPT	Current Procedure Terminology codes must be used to denote services performed and must be supported in the medical record.
HCPCS	Healthcare Common Procedure Coding System codes must be used where applicable and supported in the medical record.
Revenue	Revenue codes should be used as appropriate for facility billing.

Subsequent TC reimbursement percentage — Cardiovascular & Ophthalmology

Cardiovascular (MPI 6)Subsequent TC reimbursed at 75% (first TC reimbursed at 100% for highest-RVU procedure).

Ophthalmology (MPI 7)Subsequent TC reimbursed at 80% (first TC reimbursed at 100% for highest-RVU procedure).

Professional componentMPPR does not apply to the professional component — professional services remain reimbursed at 100%.

Provider Billing, Authorization, and Documentation Expectations

Billing Rule

Provider billing and authorization expectations — When multiple services are performed same date/encounter by same provider/group, MPPR applies to specified service categories; services may be payment‑adjusted per CMS MPI rules

When multiple services are performed on the same date of service, during the same encounter, and are performed by the same provider or provider group, Multiple Procedure Payment Reductions (MPPR) may apply. MPPR is applied per the Centers for Medicare & Medicaid Services (CMS) National Physician Fee Schedule (NPFS) multiple procedure indicator (MPI) payment‑adjustment rules.

MPPR applies to the following service categories: Cardiovascular procedures; Ophthalmology procedures; Endoscopic procedures; Surgical procedures; Radiology services.

Prior Authorization

Authorization and medical necessity — Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, and be documented

Definitions and Key Terms

Multiple Procedure Indicator (MPI)

DefinitionMultiple Procedure Indicator (MPI) indicates which payment adjustment rule for multiple procedures applies to the service.

MPI examplesMPI 6 — diagnostic cardiovascular procedures; MPI 7 — diagnostic ophthalmology procedures.

PurposeUsed to determine whether MPPR reductions apply to technical components when multiple procedures occur the same date/encounter by the same provider or group.

Professional Component

DefinitionProfessional Component — The portion of the service involving interpretation by a physician or other practitioner; reimbursement remains at 100%.

MPPR applicabilityMPPR does not apply to professional component services for cardiovascular (MPI 6) and ophthalmology (MPI 7).

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyMultiple Procedure Payment Reduction

Policy CodePolicy C-23003

Change TypeNo material change

Effective DateApr 12, 2023

Next Review Date

SourceLink

On This Page

Services must meet the member’s benefit plan authorization and medical necessity requirements. Prior authorization may be required by the member’s plan or state/federal mandates; confirm authorization requirements before providing services. All billed services must be supported in the medical record and office notes, and claims must use industry‑standard codes (CPT, HCPCS, revenue codes) that fully reflect the services provided. Reimbursement is determined by benefit coverage and medical necessity; coverage under a member’s benefit plan does not guarantee payment.

Follow the member’s plan authorization rules; obtain prior authorization when required.
Document clinical rationale, procedure details, and supporting diagnosis in the medical record to substantiate medical necessity for each billed service.
Use correct CPT/HCPCS/revenue codes on claims; ensure documentation supports billed codes to avoid denials.
Our reimbursement policies apply to both participating and non‑participating professional providers and facilities unless otherwise noted.

Billing noteReport professional component with appropriate modifier (e.g., Modifier 26) when billing separate professional services; must be supported in the medical record.

Technical Component

DefinitionTechnical Component — The portion of the service that involves the collection of information from the patient; subject to MPPR reductions as specified for subsequent procedures.

MPPR examplesCardiovascular TC — subsequent TCs reimbursed at 75%; Ophthalmology TC — subsequent TCs reimbursed at 80%.

Modifier guidanceWhen billing the technical component, use the appropriate TC modifier; TC billing is subject to the multiple procedure payment reduction rules in this policy.

Relative Value Units (RVUs)

DefinitionRelative Value Units (RVUs) — Units that account for the relative resources used in furnishing a service and determine which procedure is paid at full TC when multiple procedures occur (highest-RVU procedure).

Use in MPPRThe first (highest-RVU) diagnostic procedure's TC is reimbursed at 100%; subsequent procedures' TCs are reduced per MPI-specific percentages.

Global proceduresFor global procedures with same MPI, adjusted TC RVUs (after reduction) are combined with professional RVUs to compute an allowance based on the original global fee schedule.

Reimbursement Policy

Policy purposeReimbursement policies guide accurate claims submission and outline the basis for reimbursement when services are covered by a member's benefit plan.

Billing requirementsClaims must use industry-standard CPT, HCPCS, and/or revenue codes and be fully supported in the medical record and/or office notes.

ApplicabilityReimbursement policies apply to both participating and non-participating professional providers and facilities unless otherwise noted.

Coverage vs. reimbursement

Coverage vs. reimbursementA determination that a service is covered under a member's benefit plan is not a guarantee of reimbursement; claims must meet authorization, medical necessity, and proper coding/documentation to be paid.

ConsequencesIf coding/billing guidelines or reimbursement policies are not followed, Anthem may reject or deny the claim, or recover/recoup claim payment.

Governing rulesPolicies may be superseded by provider, state, federal, or CMS mandates; reimbursement follows applicable laws and member benefit terms on the date of service.