CurrentColorado Rocky Mountain Health PlansPolicy 2026R0085A

CMS-1500 Multiple Diagnostic Imaging Reductions (MPPR/MDIR)

Defines UnitedHealthcare reimbursement adjustments when multiple diagnostic imaging procedures are billed on the CMS-1500 form (professional claims) and how technical (TC) and professional (PC) components are reduced when multiple procedures occur in the same session; applies to UnitedHealthcare Commercial and Individual Exchange plans and all providers billing CMS-1500.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCMS-1500 Multiple Diagnostic Imaging Reductions (MPPR/MDIR)

Policy CodePolicy 2026R0085A

Change TypeMaterial change: added ultrasound MPPR Status Indicator '0' reductionsother clarifications

Effective Date11/01/2025

Next Review Date

Key ActionAppend Modifier 59 or XE to indicate a separate session to avoid MDIR when applicable.

SourceLink

POLICY UPDATE CHANGES

UnitedHealthcare will begin to apply reductions to certain ultrasound CPT codes assigned an MPPR Status Indicator of '0' effective 11/01/2025.

Policy language was updated to reflect 'Qualified' Health Care Professional terminology.

Clarified that the policy applies to services billed on CMS-1500 forms (electronic equivalent/successor) for all products and providers.

50%TC reduction (2nd+)

5%PC reduction (2nd+)

11/01/2025

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Multiple Diagnostic Imaging Reduction (MDIR) — When It Applies

MDIR application criteria

Covered when ALL of the following are met:

ALL of the following

MPI eligibility
- ALL of the following
  - Procedures have MPI of 4
- ALL of the following
  - Procedures have MPI of 0 and are on the Ultrasound Indicator 0 CPT code list (ultrasound interactions effective 11/01/2025)
ALL of the following
- Performed on same patient by the Same Group Physician and/or Other Qualified Health Care Professional
ALL of the following
- Performed during the Same Session
ALL of the following
- Apply MDIR reductions: Technical component (TC) — second and each subsequent procedure reduced by 50%; Professional component (PC) — second and each subsequent procedure reduced by 5%

MDIR will not apply when ONE of the following is met:

Procedure is ranked primary based on Non‑Facility Total RVUs (no reduction applied)
Procedures are appended with Modifier 59 or Modifier XE indicating not the Same Session (no MDIR)
Procedures billed by different group or not during the Same Session (no MDIR)
Procedure does not have MPI of 4 and is not an Ultrasound Indicator 0 CPT code (no MDIR)

MDIR-Eligible Codes and Reduction Thresholds

MDIR-eligible imaging CPT codesCPT

See CMS PFS Relative Value Files

Codes eligible for MDIR are determined by CMS NPFS MPI values (4 and certain 0 ultrasound codes); specific ultrasound Indicator 0 CPT code list is an attachment.

inv-03: Reduction thresholds

TC reduction (second and subsequent procedures)50% reduction to the Allowed Amount for the Technical Component (TC) of the second and each subsequent imaging procedure when performed on the same patient by the Same Group Physician and/or Other Qualified Health Care Professional during the Same Session.

PC reduction (second and subsequent procedures)5% reduction to the Allowed Amount for the Professional Component (PC) of the second and each subsequent imaging procedure when performed on the same patient by the Same Group Physician and/or Other Qualified Health Care Professional during the Same Session.

Ultrasound Indicator 0 interaction effective dateEffective 11/01/2025, reductions (50% TC, 5% PC) apply to certain ultrasound CPT codes assigned an MPPR Status Indicator of '0' when two or more such codes are provided in the Same Session by the same or different physician in the same group.

Billing Guidance to Avoid Unwanted MDIR Reductions

Billing Rule

Provider billing guidance to avoid MDIR

To avoid an unwanted Multiple Diagnostic Imaging Reduction (MDIR), follow these billing practices: Bill only the primary/imaging procedure with the highest RVU (including modifier effects) for services rendered during the same session; append Modifier 59 or Modifier XE to procedures that were performed on the same day but during a different session to indicate a distinct service; ensure procedures performed by different group physicians/qualified health care professionals are billed under the appropriate practitioner to avoid Same Group attribution; do not submit single-unit imaging procedures that should be reported as multiple units when they represent distinct sessions; and when reporting global procedure codes subject to MDIR, expect the global charge to be split into PC and TC portions with MDIR applied to the allowed amount for the second and subsequent procedures.

MDIR applies when multiple imaging procedures with MPI=4 and MPI=0 are performed by the Same Group Physician/Other Qualified HCP during the Same Session.
MDIR also applies when a single imaging procedure subject to MDIR is submitted with multiple units (e.g., 73702 with 2 units).
MDIR will not apply to the primary procedure as ranked by RVU (including modifier effects).
Append Modifier 59 or XE (not both) to indicate procedures performed during a different session; Modifier 76 alone does not prevent MDIR.

Key Terms and Allowable Amount

inv-05: Allowable Amount

Allowable Amount definitionDefined as the dollar amount eligible for reimbursement to the physician or other qualified health care professional on the claim (examples: contracted rate, reasonable charge, or billed charges); for percent-of-charge or discount contracts, the Allowable Amount is determined as the billed amount less the discount).

Application to percent-of-charge contractsFor percent-of-charge or discount contracts the Allowable Amount is the billed amount less the discount; imaging reductions are then applied to that Allowable Amount.

Allowable Amount examplesMay be the contracted rate, reasonable charge, or billed charges depending on the claim and contract terms.

inv-06: Global/PC/TC/Same Group/Same Session definitions

Global ServiceA Global Service includes both a Professional Component (PC) and a Technical Component (TC); billing globally indicates submission for both components.