CurrentColorado Rocky Mountain Health PlansPolicy N/A

Multiple Diagnostic Imaging Reductions (MDIR)

Defines UnitedHealthcare Community Plan's reimbursement reductions when multiple diagnostic imaging procedures are performed in the same session and billed on CMS-1500 forms; applies to physicians and other qualified health care professionals across products unless state exceptions apply.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyMultiple Diagnostic Imaging Reductions (MDIR)

Policy CodePolicy N/A

Change TypeAdded ultrasound Indicator 0 reductionsclarified state exceptions

Effective DateN/A

Next Review DateN/A

Key ActionPre- and post-pay editing must be facilitated and deployed via the Reimbursement Policy team; no alternate solutions without governance approval.

SourceLink

POLICY UPDATE CHANGES

Effective 11/01/2025 UnitedHealthcare will apply reductions to certain ultrasound CPT codes assigned an MPPR Status Indicator of '0' consistent with codes assigned an MPPR Status Indicator of '4'.

State-specific exceptions list updated (including New Mexico and Arizona verbiage updates).

50%TC reduction for secondary and subsequent imaging procedures

5%PC reduction for secondary and subsequent imaging procedures

11/01/2025effective date for Ultrasound Indicator 0 reductions

CMS MPI 4 & 0

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MPIs used to determine eligibility for MDIR

CMS-1500Form applicability

Multiple Diagnostic Imaging Reductions (MDIR) Criteria

MDIR application criteria

MDIR applies when ALL of the following criteria are met unless a state exception applies:

Procedures eligible for MDIR are identified using the CMS NPFS MPI values of 4 and 0 and ranked using Non-Facility Total Relative Value Units (RVUs).

Multiple diagnostic imaging procedures with an MPI of 4 or 0 are performed on the same patient by the Same Group Physician and/or Other Qualified Health Care Professional during the Same Session.

Ultrasound exception: Two or more diagnostic imaging procedures with an MPI of 0 from the Ultrasound Indicator 0 CPT code list are performed on the same patient during the Same Session by the Same Group Physician and/or Other Qualified Health Care Professional (triggering MDIR for those ultrasound codes).

When a single imaging procedure subject to MDIR is submitted with multiple units, MDIR applies to the second unit (units also remain subject to UnitedHealthcare's Maximum Frequency Per Day Policy).

Ranking/primary procedure: The primary procedure (no reduction) is determined by ranking procedures based on the RVU assigned to the code (and modifier, when applicable); procedures with lower RVUs are subject to MDIR reductions.

Situations where MDIR does NOT apply

Procedure is the primary procedure as ranked by RVUs (no reduction applied).
Procedures billed with modifier 59 or modifier XE to indicate performed on same day but not during the Same Session.
Procedures billed on the same day but not by the Same Group Physician and/or Other Qualified Health Care Professional during the Same Session.
The imaging service does not have an MPI of 4, or has an MPI of 0 but is not included on the Ultrasound Indicator 0 CPT code list.

Global billing: When the Same Group Physician and/or Other Qualified Health Care Professional bills globally for two or more procedures subject to MDIR in the Same Session, UnitedHealthcare will split the global code into PC (modifier 26) and TC (modifier TC) using standard Professional/Technical percentage splits; each component is ranked independently by CMS Non-Facility Total RVUs to determine which component(s) receive reductions.

State exceptions: State-specific exceptions override application of MDIR as listed in the policy (examples include exemptions for Indiana, Kansas, New Mexico, and Wisconsin; Washington does not apply MDIR to the professional component; Arizona policy applies only to Non-Participating providers for Arizona Medicaid).

Codes and Unit-specific Rules

Ultrasound Indicator 0 CPT code listCPT

Ultrasound Indicator 0 CPT code list

Attachment lists CPT ultrasound codes assigned MPPR Status Indicator '0' to which new reductions will apply beginning 11/01/2025.

Multiple unit reduction — MDIR applies to second unit when a single procedure is submitted with multiple units; note on maximum/other constraints

MDIR application for multiple unitsWhen a single imaging procedure subject to MDIR is submitted with multiple units, MDIR applies to the second unit (e.g., code 73702 submitted with 2 units — the second unit is reduced).

Concurrent policy constraintsUnits subject to MDIR are also subject to UnitedHealthcare's Maximum Frequency Per Day Policy.

Triggering conditionsApplies when the procedure is otherwise subject to MDIR (MPI 4 or MPI 0 when on the Ultrasound Indicator 0 list) and multiple units are billed on the same claim.

Editing and Enforcement

Prior Authorization

Enforcement of editing via Reimbursement Policy team

Pre- and post-pay editing for this MDIR policy must be facilitated and deployed by the Reimbursement Policy team; alternate editing solutions are not permitted unless approved through the Reimbursement Policy governance process.

All edits (pre-pay and post-pay) are to be implemented by the Reimbursement Policy team.
No alternate solutioning may be deployed without Reimbursement Policy governance approval.

Definitions Used in This Policy

Professional Component — definition entry

Definition (PC)The Professional Component represents the physician or other health care professional work portion (physician work, practice overhead, malpractice expense) — supervision, interpretation, and report that directly contributes to diagnosis/treatment; identified by modifier 26 or a standalone PC-only code.

What it includesPhysician supervision and interpretation, a written narrative report included in the patient’s record.

How it is reportedAppend modifier 26 to the designated procedure code or report a standalone code describing the Professional Component only.

Technical Component — definition entry

Definition (TC)The Technical Component is the performance (technician, equipment, facility) of the procedure; it may be identified by appending modifier TC or by reporting a standalone TC-only code.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyMultiple Diagnostic Imaging Reductions (MDIR)

Policy CodePolicy N/A

Change TypeAdded ultrasound Indicator 0 reductionsclarified state exceptions

Effective DateN/A

Next Review DateN/A

Key ActionPre- and post-pay editing must be facilitated and deployed via the Reimbursement Policy team; no alternate solutions without governance approval.

SourceLink

On This Page

Technician services, use of equipment, and facility resources required to perform the diagnostic test.

How it is reportedAppend modifier TC to the designated procedure code or report a standalone code describing the Technical Component only.

Same Group Physician — definition describing shared Federal Tax Identification number

DefinitionSame Group Physician and/or Other Qualified Health Care Professional: all physicians and/or other health care professionals of the same group reporting the same Federal Tax Identification number.

Relevance to MDIRMDIR comparisons and reductions are applied when services are performed by providers reporting under the same Federal Tax Identification number.

Billing implicationBilling under the same tax ID constitutes the group for determining Same Group Physician status for policy application.

Same Session — definition describing single patient encounter

DefinitionSame Session: a single patient encounter that encompasses all of the services performed by the same physician or other health care professional.

Temporal scopeAll services performed during that single encounter are considered for MDIR session-based grouping.

Modifier relevanceModifiers indicating separate encounters (e.g., XE) may be used when services occurred in separate encounters and are distinct.

Allowable Amount — definition of allowable amount for physician or health care professional reimbursement

DefinitionAllowable Amount: the dollar amount eligible for reimbursement to the physician or health care professional on the claim (examples include contracted rate, reasonable charge, billed charges).

ApplicationUsed to determine the reduced amounts when MDIR or other reimbursement adjustments are applied.

Influencing factorsAllowable Amount may be affected by coding methodology, reimbursement logic, regulatory requirements, provider contracts, and benefit design.