CurrentEmblemHealthPolicy RPC20230039

Multiple Procedure Payment Reduction Cardiology/Ophthalmology (Commercial, Medicare, and Medicaid)

Defines how EmblemHealth applies CMS-based Multiple Procedure Payment Reductions (MPPR) to diagnostic cardiovascular and diagnostic ophthalmology procedures for Commercial, Medicare, and Medicaid products; affects providers billing Technical Components (TC) and Global codes when multiple procedures are performed the same day.

Policy Summary

PayerEmblemHealth

PolicyMultiple Procedure Payment Reduction Cardiology/Ophthalmology (Commercial, Medicare, and Medicaid)

Policy CodePolicy RPC20230039

Change TypeClarified and administrative updates

Effective DateAug 1, 2020

Next Review Date

Key ActionFollow CPT, CMS (NCCI/MUE), and specialty coding guidelines; claims may be denied or recouped if coding/billing guidelines are not followed.

SourceLink

POLICY UPDATE CHANGES

Examples explaining how to obtain the TC portion of Global Test Only Codes and how ranking is performed were added/updated.

Policy content was transferred to an individual company-branded template with no change to title or policy number.

25%MDCR reduction

20%MDOR reduction

MPI 6MPI for cardiovascular

MPI 7

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.

MPI for ophthalmology

0.00Codes excluded (0.00 RVU)

Commercial, Medicare, MedicaidPrograms covered

When MPPR Applies and Billing Rules

MPPR application criteria and billing rules

Covered when ALL of the following conditions and billing rules are met:

Multiple Diagnostic Cardiovascular Reductions (MDCR) apply when multiple Diagnostic Cardiovascular Procedures (CMS MPI 6) have their Technical Components (TC) performed on the same patient by the Same Group Physician and/or Other Health Care Professional on the same day.

EmblemHealth uses CMS NPFS MPI of 6 and TC Non‑Facility Total RVUs to determine eligibility and ranking for MDCR.

Reduction amount: reduce the Allowable Amount for the TC of the second and each subsequent cardiovascular procedure by 25%. No reduction is taken on the TC with the highest TC Non‑Facility Total RVU.

MDCR applies to Technical Component Only codes (PC/TC Indicator 3) and to the TC portion of Global Procedure Codes (PC/TC Indicator 1); when global codes are billed, charges are divided into PC and TC (modifiers 26 and TC) and ranking is based on TC Non‑Facility Total RVU.

If a single diagnostic cardiovascular procedure subject to MDCR is submitted with multiple units, the reduction applies to the second unit and subsequent units.

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 use the NPFS for each TC value; if a Global Test Only Code has multiple TC codes, add all TC values together for ranking.

Exceptions / Limitations

Global Test Only Codes (special handling) — follow parent/child mapping and NPFS aggregation for TC values prior to ranking.
Codes with CMS RVU of 0.00 (including some unlisted/gap‑fill codes) are excluded from the Diagnostic Cardiovascular Procedures list and will be excluded from ranking.

Operational note: RVU and dollar examples in the policy are illustrative and may not reflect current NPFS values; payer edits and coding guidelines (CPT/CMS/NCCI/MUE) govern final claim adjudication.

MPPR application and exclusions

EmblemHealth applies MPPR to diagnostic cardiovascular and ophthalmology procedures; TC values are obtained from the NPFS and ranking determines which procedures receive payment reduction. Codes without CMS RVUs or with 0.00 RVU are excluded from ranking.

Multiple Diagnostic Ophthalmology Reductions (MDOR) apply when multiple Diagnostic Ophthalmology Procedures (CMS MPI 7) have their Technical Components (TC) performed on the same patient by the Same Group Physician and/or Other Health Care Professional on the same day.

EmblemHealth uses CMS NPFS MPI of 7 and TC Non‑Facility Total RVUs to determine eligibility and ranking for MDOR.

Reduction amount: reduce the Allowable Amount for the TC of the second and each subsequent ophthalmology procedure by 20%. No reduction is taken on the TC with the highest TC Non‑Facility Total RVU.

MDOR applies to TC‑only services and to the TC portion of Global Procedure Codes; when a single procedure subject to MDOR is submitted with multiple units, reduction applies to the second unit and subsequent units.

Relevant Codes, Indicators, and Examples

MPIs addressedmixed

MPI-6	Diagnostic Cardiovascular Procedures
MPI-7	Diagnostic Ophthalmology Procedures

PC/TC Indicator Mappingmixed

PC/TC Indicator 1	Global procedure — has both Professional and Technical components (TC portion subject to reductions)
PC/TC Indicator 3	Technical Component Only — TC only codes (MDCR/MDOR apply)

Diagnostic Cardiovascular Parent/Child SamplesCPT

93000	Global ECG; parent code — associated TC 93005 and PC 93010
93015	Ambulatory ECG, ECG monitoring for arrhythmia; parent/child set
93040	Cardiac stress test; parent/child set

Example Codes for Illustrative CalculationsCPT

75600	Aorta/iliac angiography (example global)
75726	Peripheral angiography (example global)
93702	Cardiac output determination (example TC)
93225	External electrocardiographic recording (example TC)
93005	ECG tracing only (TC)
93010	ECG interpretation only (PC)
93000	ECG global (parent)

Reduction thresholds

Ranking basis

Billing, Claims Editing, and Operational Guidance

Denial Risk

Follow CPT, CMS, and specialty coding guidelines; noncompliance may lead to denial/recoupment

Follow CPT, CMS (including NCCI and MUE), and specialty coding guidelines; EmblemHealth uses industry-standard claims editing software and applies payer-determined edits when sources conflict. If appropriate coding/billing guidelines or current reimbursement policies are not followed, claims may be denied and/or payment recouped.

We follow CPT® guidelines from the AMA, specialty organizations, and CMS including NCCI and MUE.
We use industry-standard claims editing software and apply the edits we determine are appropriate.
Noncompliance may result in claim denial and/or recoupment of payment.

Billing Rule

Terms and Activity Examples

inv-11: Clinical labor activities

Examples of clinical labor activitiesGreeting the patient; positioning and escorting the patient; providing education and obtaining consent; retrieving prior exams; setting up the IV; preparing and cleaning the room

RationaleEmblemHealth follows CMS guidance that many clinical labor activities are not duplicated when multiple diagnostic procedures occur the same day

ScopeActivities listed are illustrative examples considered not duplicated for subsequent procedures

inv-12: MDCR / MDOR — definitions for Multiple Diagnostic Cardiovascular Reductions and Multiple Diagnostic Ophthalmology Reductions

MDCR — definitionMultiple Diagnostic Cardiovascular Reductions (MDCR): payer‑applied 25% reduction to the Technical Component (TC) of the second and subsequent diagnostic cardiovascular procedures performed the same day by the same group; no reduction to the TC with the highest TC Non‑Facility Total RVU

Policy Summary

PayerEmblemHealth

PolicyMultiple Procedure Payment Reduction Cardiology/Ophthalmology (Commercial, Medicare, and Medicaid)

Policy CodePolicy RPC20230039

Change TypeClarified and administrative updates

Effective DateAug 1, 2020

Next Review Date

Key ActionFollow CPT, CMS (NCCI/MUE), and specialty coding guidelines; claims may be denied or recouped if coding/billing guidelines are not followed.

SourceLink

On This Page

When Global Procedure Codes are billed for procedures subject to MPPR (cardiovascular or ophthalmology), split charges into PC and TC (modifiers 26 and TC) and rank based on TC Non‑Facility Total RVU; for Global Test Only Codes, use the Parent‑Child Table to identify TC codes and sum TC values if multiple exist.

Exclusions

Codes with no assigned CMS RVU or codes assigned an RVU value of 0.00 (gap‑fill/unlisted codes) are not included on the Diagnostic Cardiovascular or Ophthalmology lists and are excluded from ranking.
MDCR/MDOR reductions do not apply to the Professional Component (modifier 26) billings; reductions apply to the TC only.

Operational note: example RVU/dollar values in policy illustrations may not reflect current NPFS; providers must follow CPT and CMS coding guidelines and payer edits for final adjudication.

Determine TC for Global Test Only codes via Parent/Child Table and NPFS

To obtain the Technical Component (TC) for Global Test Only codes, first consult the Cardiovascular Parent/Child Table to identify the associated TC and PC codes, then use the NPFS for each TC code's value; if a Global Test Only code has multiple TC codes, add all TC values together for ranking.

Refer to the Cardiovascular Parent Child Table to identify TC and PC codes associated with the Global Test Only code.
Look up each TC code's value in the CMS/NPFS (TC Non-Facility Total RVU is used for ranking).
If multiple TC codes exist for a Global Test Only code, sum all TC values for ranking purposes.

Billing Rule

Exclude 0.00 RVU and gap-fill codes from ranking

Codes assigned a CMS RVU of 0.00 (including some unlisted/gap-fill codes) are excluded from the Diagnostic Cardiovascular and Ophthalmology MPPR lists and will be excluded from ranking.

Services CMS indicates may be carrier-priced or without CMS-developed RVUs are treated as Gap Fill Codes.
Codes with a 0.00 RVU will not be included in the MPPR subject lists and therefore will not be ranked.

MDOR — definitionMultiple Diagnostic Ophthalmology Reductions (MDOR): payer‑applied 20% reduction to the Technical Component (TC) of the second and subsequent diagnostic ophthalmology procedures performed the same day by the same group; no reduction to the TC with the highest TC Non‑Facility Total RVU

MPI mappingMDCR and MDOR use CMS Multiple Procedure Indicators: MPI 6 for Diagnostic Cardiovascular and MPI 7 for Diagnostic Ophthalmology

inv-13: Global Test Only Code — definition

Global Test Only Code — definitionA Global Test Only Code is a global procedure that maps to one or more TC and PC component codes via the Cardiovascular Parent‑Child Table; to obtain the TC portion, identify associated TC codes and sum their NPFS TC values for ranking

Illustrative treatmentIf a Global Test Only Code has multiple TC codes, add all TC code values together for ranking; use NPFS values as illustrated in the policy examples

NoteExamples in the policy are illustrative and RVU/dollar values may not reflect the current NPFS

inv-14: TC / PC — Technical Component and Professional Component definitions

Technical Component (TC)The portion of a procedure representing equipment, supplies, and non‑physician technical services; reductions (MDCR/MDOR) apply to TC amounts for subsequent procedures

Professional Component (PC)The physician professional work portion (modifier 26); MDCR/MDOR do not apply to PC billings

Global codes handlingWhen global procedure codes are billed, charges are split into PC and TC using CMS splits and ranking is based on TC Non‑Facility Total RVU

inv-15: Gap Fill Codes — definition and treatment

Gap Fill Codes — definitionCodes for which CMS does not develop RVUs or identifies services that may be carrier‑priced; these include some unlisted codes

Treatment for 0.00 RVU codesCodes assigned a CMS RVU value of 0.00 are excluded from the Diagnostic Cardiovascular and Diagnostic Ophthalmology lists and will be excluded from ranking

ImplicationExcluded gap‑fill or 0.00 RVU codes are not considered when determining which TC receives the no‑reduction ranking or when applying MDCR/MDOR