CurrentColorado Rocky Mountain Health PlansPolicy 2025R9023A

CMS 1500 reimbursement rules for multiple diagnostic cardiovascular and ophthalmology procedures

Governs reimbursement and multiple procedure payment reductions (MPPR) for services billed on CMS 1500 forms to UnitedHealthcare Medicare Advantage plans, affecting physicians and other qualified health care professionals performing diagnostic cardiovascular and ophthalmology procedures.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCMS 1500 reimbursement rules for multiple diagnostic cardiovascular and ophthalmology procedures

Policy CodePolicy 2025R9023A

Change TypeNo material changes noted

Effective Date

Next Review Date

Key ActionSubmit accurate CMS 1500 claims using appropriate CPT/CMS coding.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

25%Cardio TC reduction

20%Ophth TC reduction

MPI 6Cardio MPI

MPI 7Ophth MPI

PC/TC 1 & 3Applies to

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Multiple Diagnostic Procedure Reductions — When They Apply

inv-01: MDCR / MDOR application criteria

Criteria for applying Multiple Diagnostic Cardiovascular Reductions (MDCR):

ALL of the following

Same patient, same day
Performed by the Same Group Physician and/or Other Health Care Professional
Procedure has CMS NPFS Multiple Procedure Indicator (MPI) = 6 (Diagnostic Cardiovascular Procedures)
Reduction target: Reduce the Technical Component (TC) Allowable Amount for the second and each subsequent cardiovascular procedure by 25%
Exemptions
- No reduction is taken on the TC with the highest TC Non‑Facility Total RVU according to the NPFS
- No reduction applied to Professional Component (PC) services billed with modifier 26 (PC)
- Global Test Only codes (PC/TC indicator 4) with 0.00 RVU are excluded from ranking
Applies to TC‑only codes (PC/TC indicator 3) and to the TC portion of Global Procedure Codes (PC/TC indicator 1)
When a single eligible cardiovascular procedure is submitted with multiple units, the MDCR applies to the TC of the second unit
When multiple global cardiovascular procedure codes are billed, charges will be split into PC and TC using UnitedHealthcare Medicare Advantage's standard professional/technical percentage splits and ranking is based on TC Non‑Facility Total RVU

inv-02: Payment calculation and coding references

Illustrative payment calculation guidance and coding resources:

ALL of the following

Sample calculation format: separate PC, TC, and Global components and apply MDCR/MDOR percentages to eligible TCs (examples show formulas such as Global = $69 + $92 + (0.80 x $53) and TC calculation $92 + (0.80 x $53))
Example sample values: cardiovascular sample lists PC = $69.00; TC values $92.00 and $53.00 with Global totals shown ($214.00 current; $203.40 prior) to demonstrate application of reductions
Coding and fee schedule sources: reference the CPT code section and the National Physician Fee Schedule (NPFS) Relative Value File for RVUs and MPI assignments
Additional resources: CMS PFS Relative Value Files and MLN Matters guidance (e.g., MLN Matters MM7848)

Codes, Indicators, and Reduction Rates

MPPR-related code groupsmixed

MPI 6	Diagnostic Cardiovascular Procedures (subject to MPPR)
MPI 7	Diagnostic Ophthalmology Procedures (subject to MPPR)
PC/TC=1	Global Procedure Code (both PC and TC)
PC/TC=3	Technical Component only code

MDCR/MDOR reduction thresholds (context)mixed

25%	Reduction applied to TC of second and subsequent Diagnostic Cardiovascular procedures
20%	Reduction applied to TC of second and subsequent Diagnostic Ophthalmology procedures

MPI application notesmixed

Same Group Physician	Reduction applies when procedures performed on same patient, same day, by Same Group Physician and/or Other Qualified Health Care Professional
Exclusion Global Test Only	Global Test Only codes with 0.00 RVU are excluded from TC ranking and reductions

CPT and fee schedule sourcesCPT

CPT code section	Referenced as primary coding source for procedures subject to MPPR
National Physician Fee Schedule Relative Value File	Source file for Medicare physician fee schedule values and MPI assignments

Additional resourcesmixed

CMS	www.cms.gov - Centers for Medicare and Medicaid Services: PFS Relative Value Files
MLN Matters MM7848	Medicare Learning Network resource referenced

MDCR/MDOR reduction thresholds

Cardiovascular TC reductionReduce the Allowable Amount for the TC of the second and each subsequent Diagnostic Cardiovascular procedure by 25% (no reduction on the TC with the highest TC Non‑facility Total RVU).

Ophthalmology TC reductionReduce the Allowable Amount for the TC of the second and each subsequent Diagnostic Ophthalmology procedure by 20% (no reduction on the TC with the highest TC Non‑facility Total RVU).

Applies whenTwo or more relevant procedures performed same patient, same day by the Same Group Physician and/or Other Health Care Professional.

Eligible code indicatorsApplies to TC‑only codes (PC/TC indicator 3) and the TC portion of Global Procedure Codes (PC/TC indicator 1).

Payment calculation formulas

Billing, Submission, and Reconciliation Guidance

Documentation Required

Submit accurate CMS 1500 claims with appropriate coding

You are responsible for submission of accurate CMS 1500 claims using CPT/CMS coding that correctly describes the services provided; this policy applies to all services billed on CMS 1500 forms and to all physicians and other qualified health care professionals.

Use Current Procedural Terminology (CPT®), CMS, or other coding guidelines referenced in the policy.
Ensure claims reflect the code or codes that correctly describe the health care services provided.

Billing Rule

Use provided sample payment calculations to validate claims

When reconciling payments, use the sample payment calculations in the policy to compare current and prior payments — examples include professional (PC), technical (TC), and global payment formulas (e.g., Global = $69 + $92 + (0.80 x $53)).

Terminology and Reference Definitions

Allowable Amount

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

Percent‑of‑charge/discount contractsFor percent of charge or discount contracts, the Allowable Amount is determined as the billed amount less the discount.

Context of useUsed to calculate reimbursements and to apply MDCR/MDOR reductions to technical component amounts where applicable.

Diagnostic Cardiovascular Procedures

DefinitionDiagnostic Cardiovascular Procedures = those procedures listed in the Diagnostic Cardiovascular Procedures Subject to MPPR Policy Lists set forth in this policy and identified using CMS NPFS MPI 6.

MDCR applicability

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCMS 1500 reimbursement rules for multiple diagnostic cardiovascular and ophthalmology procedures

Policy CodePolicy 2025R9023A

Change TypeNo material changes noted

Effective Date

Next Review Date

Key ActionSubmit accurate CMS 1500 claims using appropriate CPT/CMS coding.

SourceLink

On This Page

Global payment example formula

Global Payment = PC + TC(primary) + (0.80 x TC(secondary)) — illustrated as $69 + $92 + (0.80 x $53).

TC calculation exampleTC payment example shown as $92 + (0.80 x $53) where 0.80 represents the 20% reduction applied to the secondary TC in sample calculations.

PC treatmentProfessional Component (PC) in sample cardiovascular example shows no reduction (PC total = $69.00).

Use of NPFS valuesPayment calculations use NPFS Non‑Facility Total RVU and fee schedule dollar amounts to rank TCs and determine which TCs receive reductions.

Sample cardiovascular example: PC Total Current = $69.00; TC Payment Calculation = $92 + (0.80 x $53); Global Total Current = $214.00.
Use the provided code pair examples (e.g., Code 78452 = Code 92235; Code 93306 = Code 92250) and the numeric values shown when validating submitted charges.

When TC for two or more such procedures are performed same patient/same day by Same Group Physician and/or Other Health Care Professional, MDCR may reduce TC Allowable Amounts.

RVU rankingNo reduction is taken on the TC with the highest TC Non‑facility Total RVU according to the NPFS when applying MDCR.

Diagnostic Ophthalmology Procedures

DefinitionDiagnostic Ophthalmology Procedures = those procedures listed in the Diagnostic Ophthalmology Procedures Subject to MPPR Policy List set forth in this policy and identified using CMS NPFS MPI 7.

MDOR applicabilityWhen TC for two or more such procedures are performed same patient/same day by Same Group Physician and/or Other Health Care Professional, MDOR may reduce TC Allowable Amounts.

RVU rankingNo reduction is taken on the TC with the highest TC Non‑facility Total RVU according to the NPFS when applying MDOR.

Global Procedure Code

DefinitionGlobal Procedure Code = a code that includes both Professional and Technical Components; billing a global code asserts the provider furnished both supervision/interpretation (PC) and technician/equipment/facility (TC).

IdentificationGlobal procedures are identified by reporting the appropriate PC/TC eligible procedure code with no modifier attached.

Treatment under MPPRWhen billed globally, the TC portion of a Global Procedure Code is subject to MDCR/MDOR reductions as applicable; Global Test Only Codes (PC/TC indicator 4) are excluded where noted.

TC / PC / PC/TC indicators

PC (Professional Component)Represents physician or qualified health care professional work (supervision and interpretation). Typically identified by modifier 26 or a standalone PC code.

TC (Technical Component)Represents performance (technician/equipment/facility) of the procedure. Typically identified by modifier TC or a standalone TC code (PC/TC indicator 3).

PC/TC indicatorsCMS NPFS PC/TC indicators: 1 = Global, 3 = Technical Component only, 4 = Global Test Only (excluded from some reductions); indicators determine applicability to MDCR/MDOR.

Same Group Physician

Same Group Physician definitionAll physicians and/or other health care professionals of the same group reporting the same Federal Tax Identification number.

ApplicabilityMDCR/MDOR apply when procedures are performed by providers within the Same Group on the same patient the same day.

Claims implicationGrouping by Federal Tax ID is used to determine whether reductions apply for multiple procedures billed on CMS 1500 forms.

Payment categories: PC = Professional Component, TC = Technical Component, Global = Combined professional and technical

PC = Professional ComponentThe physician or other qualified health care professional work portion (supervision and interpretation).

TC = Technical ComponentThe performance portion (technician/equipment/facility) of the procedure; TC amounts are subject to MDCR/MDOR reductions for secondary/subsequent procedures.

Global = Combined professional and technicalA Global code includes both PC and TC; when billed globally the TC portion may be reduced per policy while PC may be excluded from reduction (e.g., modifier 26 prevents TC reduction).

Source file for Medicare physician fee schedule values

Primary source fileNational Physician Fee Schedule Relative Value File (NPFS RVF) used for fee schedule values and Non‑Facility Total RVUs.

CPT referenceCPT code section referenced for code identification and mapping used in examples.

CMS resourcesCMS website and Medicare Learning Network (MLN Matters MM7848) listed as supporting resources for fee schedule and policy details.