ModifiedEmblemHealthPolicy RPC2O230039

Multiple Procedure Payment Reduction — Cardiology and Ophthalmology

Defines EmblemHealth/ConnectiCare application of CMS Multiple Procedure Payment Reduction (MPPR) for diagnostic cardiovascular (MPI=6) and diagnostic ophthalmology (MPI=7) procedures affecting technical components when multiple procedures are performed the same day by the same group/provider.

Policy Summary

PayerEmblemHealth

PolicyMultiple Procedure Payment Reduction — Cardiology and Ophthalmology

Policy CodePolicy RPC2O230039

Change TypeNon‑clinical examples and formatting updates

Effective DateAug 1, 2020

Next Review Date

Key ActionWhen billing two or more procedures subject to MPPR, divide the global charge into PC and TC (modifiers 26 and TC) and rank by non‑facility total RVU to determine which technical components receive the reduction.

SourceLink

POLICY UPDATE CHANGES

Updated Example # under Multiple Diagnostic Cardiovascular and Ophthalmology Procedures Billed Globally section.

Added Examples #1 & #2 under Multiple Diagnostic Cardiovascular and Ophthalmology Procedures Billed Globally section.

Reformatted and reorganized policy and transferred content to new template with new Reimbursement Policy Number.

25%MDCR reduction to technical component for subsequent diagnostic cardiovascular procedures

20%MDOR reduction to technical component for subsequent diagnostic ophthalmology procedures

MPI 6Multiple Procedure Indicator for Diagnostic Cardiovascular Procedures

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Application of Multiple Procedure Payment Reduction (MPPR)

MDCR and MDOR application rules

When multiple diagnostic cardiovascular (MPI=6) or ophthalmology (MPI=7) procedures are performed on the same day by the same group physician or other health care professional, EmblemHealth/ConnectiCare applies reductions to the technical component as follows.

MDCR (Diagnostic Cardiovascular) and MDOR (Diagnostic Ophthalmology) apply only when multiple eligible procedures are performed on the same patient by the Same Group Physician and/or Other Health Care Professional on the same day.

Apply when

Two or more Diagnostic Cardiovascular Procedures with MPI = 6 are performed on the same patient by the Same Group Physician and/or Other Health Care Professional on the same day.
Two or more Diagnostic Ophthalmology Procedures with MPI = 7 are performed on the same patient by the Same Group Physician and/or Other Health Care Professional on the same day.
A single Diagnostic Cardiovascular Procedure subject to MDCR is submitted with multiple units (e.g., second unit TC is subject to reduction).
A single Diagnostic Ophthalmology Procedure subject to MDOR is submitted with multiple units (e.g., second unit TC is subject to reduction).

Do not apply when

Procedure is billed with modifier 26 (Professional Component) only; MDCR/MDOR are not applied to the PC.
Procedure does not have the applicable MPI (not MPI = 6 for cardiovascular or not MPI = 7 for ophthalmology).

Scope: Reductions apply to Technical Component only codes (PC/TC indicator 3) and to the TC portion of Global Procedure Codes (PC/TC indicator 1).

Reduction amounts: For qualifying Diagnostic Cardiovascular Procedures (MPI 6) reduce the allowable amount for the TC of the second and subsequent procedures by 25% (MDCR). For qualifying Diagnostic Ophthalmology Procedures (MPI 7) reduce the allowable amount for the TC of the second and subsequent procedures by 20% (MDOR).

Ranking rule for reductions: No reduction is taken on the TC with the highest TC Non-Facility Total RVU according to the NPFS; subsequent procedures are ranked by TC Non-Facility Total RVU to determine which are reduced.

Global Test Only codes (PC/TC indicator 4): For Diagnostic Cardiovascular Global Test Only codes, the reduction is applied to the corresponding TC-only code(s) (PC/TC indicator 3); no reduction applies to the corresponding PC-only code(s).

MPPR application criteria

Rules for applying MPPR and ranking components when multiple diagnostic cardiovascular or ophthalmology procedures are billed:

When a provider bills globally for two or more procedures subject to MPPR, the global charge will be divided into Professional Component (modifier 26) and Technical Component (modifier TC) using CMS standard professional/technical percentage splits; ranking is based on each code's TC Non-Facility Total RVU.

To obtain the TC portion of a Global Test Only Code, first refer to the Cardiovascular Parent/Child Table to identify associated TC and PC codes, then refer to the NPFS for the TC values; if a Global Test Only Code maps to multiple TC codes, sum the TC values for ranking.

Ranking exclusions: Codes that CMS assigns an RVU of 0.00 or codes for which CMS does not develop RVUs (Fill Codes) are excluded from MPPR ranking and reduction calculations and will not be included in the lists of procedures subject to MPPR.

Operational note: Examples in the policy illustrate dividing global charges into PC/TC, summing TC RVUs where multiple TC codes exist, and ordering by Non-Facility Total RVU to determine which TC(s) receive the MDCR (25%) or MDOR (20%); RVU values in examples are illustrative only and may not reflect current NPFS values.

Codes, Indicators, and Reduction Values

Diagnostic Cardiovascular and Ophthalmology Codes (Affected)CPTCovered

93000	Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report (Global)
93005	Electrocardiogram, routine ECG with at least 12 leads; technical component only
93010	Electrocardiogram, routine ECG with at least 12 leads; interpretation and report (professional component)
93015	Cardiovascular stress test using maximal or submaximal exercise and continuous ECG monitoring; with physician supervision (Global)
93016	Cardiovascular stress test; interpretation and report (professional component)
93017	Cardiovascular stress test; technical component only
93018	Cardiovascular stress test; technical component, monitoring only (example TC variant)
93040	Cardiovascular stress test other than treadmill exercise, with continuous ECG monitoring; with physician supervision (Global)
93041	Cardiovascular stress test other than treadmill exercise; technical component only
93042	Cardiovascular stress test other than treadmill exercise; interpretation and report (professional component)

1–10 of 22

1/3

Diagnostic Cardiovascular Parent/Child Mappings (selected)mixed

93000	First TC Procedure mapping: 93005 (TC), 93010 (PC). Effective 2018-06-01 - Expiration 2999-12-31.
93015	First TC Procedure mapping: 93017 (TC); Second PC Procedure: 93016; additional mapping: 93018. Effective 2018-06-01 - Expiration 2999-12-31.
93040	First TC Procedure mapping: 93041 (TC), 93042 (PC). Effective 2018-06-01 - Expiration 2999-12-31.
93224	First TC Procedure mapping: 93225 (TC); Second PC Procedure: 93227; Second TC Procedure: 93226. Effective 2018-06-01 - Expiration 2999-12-31.
93268	First TC Procedure mapping: 93270 (TC); Second PC Procedure: 93272; Second TC Procedure: 93271. Effective 2018-06-01 - Expiration 2999-12-31.
93784	First TC Procedure mapping: 93786 (TC); Second PC Procedure: 93790; Second TC Procedure: 93788. Effective 2018-06-01 - Expiration 2999-12-31.

Illustrative Codes and ExamplesCPT

93225	TC Only example used in ranking illustration (high TC RVU example).
93702	TC Only example in illustrative ranking (RVU shown for example purposes).
75600	Global procedure example used in illustration (split into TC/PC for ranking).
75726	Global procedure example used in illustration (split into TC/PC for ranking).
93000	ECG Global used as example parent/child mapping in parent/child table.
93005	ECG TC used in parent/child mapping example.
93010	ECG PC used in parent/child mapping example.

Billing, Ranking, and EviCore Exceptions

Prior Authorization

EviCore‑administered exceptions — follow eviCore rules

This policy does not apply to EmblemHealth Commercial/Medicaid plans and providers who are contracted with eviCore; those providers must follow EviCore-administered radiology/cardiology/ultrasound rules referenced on the EmblemHealth website.

Billing Rule

Billing and ranking rules when billing global procedures subject to MPPR

When multiple procedures subject to MPPR are billed globally, the global charge must be divided into Professional Component (modifier 26) and Technical Component (modifier TC) portions, and ranking for reduction is determined by Non‑Facility Total RVU of each code; for Global Test Only codes, consult the Cardiovascular Parent‑Child Table and NPFS for TC values and sum multiple TC codes for ranking.

Divide global procedure charge into PC (modifier 26) and TC (modifier TC) when billing global codes subject to MPPR.

Key Terms and Abbreviations

inv-10: MPI

MPI definitionMultiple Procedure Indicator (MPI) is the CMS NPFS indicator used to identify procedures subject to MPPR; MPI 6 = Diagnostic Cardiovascular Procedures, MPI 7 = Diagnostic Ophthalmology Procedures

PurposeMPIs are used with NPFS Non‑Facility Total RVUs to determine ranking and application of MPPR reductions

Scope noteApplies when multiple procedures are performed the same day by the same group physician or other health care professional

inv-11: Technical Component (TC)

DefinitionTechnical Component (TC) is the portion of a service representing equipment, technical work and related non‑physician activities; reductions are applied to the TC and to the TC portion of global codes

Codes targetedMDCR and MDOR apply to TC‑only services (PCITC indicator 3) and to the TC portion of Global Procedure Codes (PCITC indicator 1)

Policy Change Log

2024-11-26example_updateLatest

Updated example under 'Multiple Diagnostic Cardiovascular and Ophthalmology Procedures Billed Globally' section (Example updated).

2024-04-10example_addition

Added Examples #1 & #2 under 'Multiple Diagnostic Cardiovascular and Ophthalmology Procedures Billed Globally' to illustrate ranking and TC/PC allocation.

2023-09-13administrative_reformat