ModifiedEmblemHealthPolicy RP20240021

Radiology-Cardiology-Ultrasound Bundling Rules (Commercial & Medicaid)

Defines bundling and reimbursement formulas when multiple radiology, cardiology, and ultrasound CPT procedure codes are billed together for EmblemHealth (Commercial & Medicaid), administered by EviCore/Evernorth; applies to providers submitting claims to EmblemHealth.

Policy Summary

PayerEmblemHealth

PolicyRadiology-Cardiology-Ultrasound Bundling Rules (Commercial & Medicaid)

Policy CodePolicy RP20240021

Change TypeRevised (material change) and clarification

Effective Date

Next Review Date

Key ActionApply specified reimbursement splits when multiple procedures are billed together (e.g., pay 100% highest RVU, 50% second, 25% third; apply PET/MRI and 1/1/2026 special-code rules).

SourceLink

POLICY UPDATE CHANGES

Reimbursement rule change effective 1/1/2026 when codes 72197, 72198, 73725 are billed together: 100% of 72198, 50% of 73725, 0% of 72197.

PET/MRI bundling formula: when PET code 78812 is billed with one or more MRI codes, reimbursement is 100% for the PET exam, 50% for the MRI with the highest RVU, and 25% for any additional MRIs with lesser RVUs.

Commercial & MedicaidProducts covered

100% / 50% / 25%Typical split (multi-procedure)

100% / 50%Two-procedure split

72197/72198/73725

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.

Code-specific change

Bundling and Reimbursement Criteria

Bundling and reimbursement rules

When multiple procedures are billed together, apply the following reimbursement formulas based on number of procedures and relative RVUs.

Two procedures billed together: Reimburse 100% of the procedure with the highest RVU and 50% of the second.

Three procedures billed together: Reimburse 100% of the procedure with the highest RVU, 50% of the second, and 25% of the third.

Examples

Selected CT/neck/thorax examples follow the 100%/50% (two) and 100%/50%/25% (three) formulas as shown in code listings.

Bundling reimbursement rules

Reimbursement formulas for bundled imaging procedures

When a code from Column A is billed with a code from Column B (two-procedure bundle): reimburse 100% for the procedure with the highest RVU and 50% for the second.

When three Column A procedures are billed together: reimburse 100% for the highest-RVU procedure, 50% for the second, and 25% for the third.

Code series mapping: Specific code series (examples: MRI brain/orbit series, CT thorax/abdomen/pelvis series, spine MRI series) are listed with crosswalks and should be adjudicated using the formulas above as indicated in the code tables.

bundling reimbursement criteria

When two or more procedures from the listed code groups are billed together the following reimbursement formulas apply depending on the code group:

General formula for many code groups: reimburse 100% for the procedure with the highest RVU, 50% for the second, and 25% for the third or additional procedures.

For some extremity MRI and certain MRA/MRI pairs: reimburse 100% for the highest-RVU procedure and 75% for the second (instead of 50%).

Specific exceptions: Pelvis/MRA/lower-extremity combinations: documented exceptions specify alternate splits (see listed codes); some listed combinations use a uniquely specified allocation rather than the general tiers.

CT angiography bundles generally follow the 100%/50%/25% tiers when multiple Column A codes are billed together.

Ultrasound/obstetric:

Bundling and reimbursement criteria

Reimbursement formulas when multiple procedures are billed together are specified by code groups and column relationships.

General bundling formula: 100% for the procedure with the highest RVU, 50% for the second highest, and 25% for the third (applies to many listed code groups).

Abdominal/retroperitoneal exception: When three or more abdominal/retroperitoneal Column A codes are billed together: reimburse 100% for 76700, 50% for 76775, and 0% for 76705 and 76770.

Administration note: Multiple sections indicate utilization/administration by EviCore by Evernorth for application of these bundling rules.

Examples

76805 and 76817 billed together: apply 100% to the highest-RVU procedure and 50% to the second.

Reimbursement and bundling criteria

When specified PET and MRI CPT codes are billed together, apply the following reimbursement formulas and special rules.

PET+MRI general rule: When PET code 78812 is billed with one or more MRI codes, reimburse 100% for the PET exam, 50% for the MRI with the highest RVU, and 25% for any additional MRIs with lesser RVUs.

Effective 1/1/2026 special rule: Effective 1/1/2026, when codes 72197, 72198, and 73725 are billed together in any combination: pay 100% of 72198, 50% of 73725, and 0% of 72197.

Annotation: Some MRI codes listed in the PET/MRI examples are noted as bilateral eligible; apply bilateral eligibility per the code descriptors where indicated.

Code Listings and Examples

Selected CT head/maxillofacial bundling examplesCPTCovered

70486	CT maxillofacial WO / CT head WO — bundled with related head/neck CTs; reimbursement rules when billed with column B codes
70487	CT maxillofacial W / CT head W — bundled with related head/neck CTs
70488	CT maxillofacial W/WO / CT head W/WO — reimbursement: highest RVU, 50% of second

MRI and CT thorax/pelvis groupingCPTCovered

70540-70553	MRI orbit/face/neck and brain/MRA head/neck series — when billed with related codes, reimbursement: 100% highest RVU, 50% of second
71250-71270	CT thorax/pelvis series — examples showing pair/bundling reimbursement: 100% highest RVU, 50% second

Examples of code series with bundling rulesCPTCovered

70551-70553	MRI brain/stem and related MRA variants listed with bundling rules (multiple mappings to other internal codes)
71250-71270	CT thorax/abd/pelvis W/WO series with bundling rules

Spine and pelvis MRI seriesCPTCovered

72141-72158	MRI spine C/T/L series (WO, W, W/WO) with bundling formulas when codes billed together
72195-72197	MRI pelvis/abd series with crosswalks to 7418x codes and bundling notes

spine MRI codes (example entries)CPT

72141	MRI Spine WO
72148	MRI L-spine WO
72156	MRI C-spine W/WO
72146	MRI T-spine WO
72142	MRI C-spine W

extremity MRI codesCPT

73218	MRI upper extremity other than joint WO
73219	MRI upper extremity other than joint W
73220	MRI upper extremity other than joint W/WO
73718	MRI lower extremity other than joint WO
73719	MRI lower extremity other than joint W contrast
73720	MRI lower extremity other than joint W/WO

MRA head/neck codesCPT

70544	MRA head/neck WO
70545	MRA head/neck W
70546	MRA head/neck W/WO

CT angiography codesCPT

70496	CT angiography head
70498	CT angiography neck
71275	CT angiography noncoronary chest
73206	CT angiography upper extremity
73706	CT angiography lower extremity

ultrasound and obstetric codesCPT

76816	Ultrasound pregnant uterus, follow up, trans abd approach, per fetus
76817	Ultrasound pregnant uterus, transvaginal
76818	Fetal biophysical profile with non-stress
76819	Fetal biophysical profile without non-stress
76820	Doppler velocimetry, fetal; umbilical artery
76821	Doppler velocimetry, fetal; middle cerebral artery
76770	Ultrasound, retroperitoneal, complete
76775	Ultrasound, retroperitoneal, limited
76830	Ultrasound, transvaginal
76856	Ultrasound pelvic, nonobstetric

1–10 of 11

1/2

Ultrasound / fetal imaging / PET-MRI codesCPTCovered

76805	Ultrasound, pregnant uterus after first trimester; single or first gestation
76817	Ultrasound, pregnant uterus, transvaginal
76700	Ultrasound, abdominal, complete
76775	Ultrasound, retroperitoneal, limited
76770	Ultrasound, retroperitoneal, complete
76830	Ultrasound, transvaginal
76856	Ultrasound, pelvic, nonobstetric
76857	Ultrasound, pelvic, limited or follow-up
76825	Echocardiography, fetal cardiovascular system
76820	Doppler velocimetry, fetal; umbilical artery

1–10 of 18

1/2

PET/MRI bundling examplesCPTCovered

78812	PET imaging; skull base to thigh (paired with various MRI CPTs)
70540	MRI orbit, face, neck, WO contrast (example paired with 78812)
73218	MRI upper extremity other than joint, WO contrast (example paired with 78812)
71550	MRI chest, WO contrast (example paired with 78812)
74181	MRI abdomen, WO contrast (example paired with 78812)
72195	MRI pelvis WO contrast (example paired with 78812)
73718	MRI lower extremity (other than joint), WO contrast (example paired with 78812)

Codes with explicit 1/1/2026 reimbursement ruleCPTCovered

72197	Pelvis or related MRI code referenced in 1/1/2026 reimbursement change
72198	Pelvis MRI code receiving 100% when billed with 72197/73725 per 1/1/2026 change
73725	Lower extremity MRI code receiving 50% when billed with 72197/72198 per 1/1/2026 change

Bundle payment tiers

Two procedures billedReimburse 100% of the procedure with the highest RVU and 50% of the second procedure.

Three procedures billedReimburse 100% of the highest RVU, 50% of the second, and 25% of the third procedure.

Application contextApplies when column A codes are billed together or when a column A code is billed with column B codes as noted in code tables.

Bundling reimbursement thresholds

Billing, Coding & Utilization Management

Denial Risk

Coding edits and potential claim denials/recoupment

EmblemHealth follows industry coding edits (CPT, NCCI, MUE) and uses industry-standard claims editing software; if appropriate coding/billing guidelines or current reimbursement policies are not followed, EmblemHealth may deny the claim and/or recoup claim payment. Explanations of how specific coding issues are handled are available upon request.

Coding edits referenced include CPT guidelines from the AMA, specialty organizations, and CMS (including NCCI and MUE).

Prior Authorization

Utilization management administered by EviCore by EVERNORTH

Utilization management for the rules in this policy is administered by EviCore by EVERNORTH.

Key Terms and Operational Definitions

Relative Value Unit used to determine which procedure is highest for reimbursement splits

Definition: RVURelative Value Unit (RVU) is used to determine which procedure in a billed bundle has the highest value for reimbursement allocation.

PurposeRVU ranking establishes which procedure receives the 100% payment and the ordering for secondary/tertiary percentage splits.

Referenced in formulasAll bundling and reimbursement formulas in this policy reference RVU to determine payment priority within bundles.

Internal grouping columns referenced in the policy indicating primary and secondary procedure groupings for bundling rules

Column A / Column BInternal grouping columns used throughout the policy to indicate primary (column A) and paired (column B) procedures for bundling rules.

Policy Summary

PayerEmblemHealth

PolicyRadiology-Cardiology-Ultrasound Bundling Rules (Commercial & Medicaid)

Policy CodePolicy RP20240021

Change TypeRevised (material change) and clarification

Effective Date

Next Review Date

Key ActionApply specified reimbursement splits when multiple procedures are billed together (e.g., pay 100% highest RVU, 50% second, 25% third; apply PET/MRI and 1/1/2026 special-code rules).

SourceLink

On This Page

Ultrasound obstetric and nonobstetric bundles generally follow the 100%/50%/25% tiers; some pairings are adjudicated as 100%/50% per the listings.

76825/76805/76817 billed together: apply 100% (highest), 50% (second), 25% (third).

Column A + Column B pairingWhen a code from column A is billed with a code from column B, reimbursement is 100% for the procedure with the highest RVU and 50% for the second.

Multiple column A codesWhen multiple column A codes are billed together, reimbursement follows the highest-RVU-first approach (100% / 50% / 25% as applicable).

Code series mappingSpecific code series (e.g., MRI spine 7214x-7215x) list mappings and apply these thresholds per the tables.

bundling reimbursement formula tiers

Standard formula100% of the highest-RVU procedure; typically 50% for the second and 25% for the third.

75% variationFor some extremity MRI and certain MRA/MRI pairs, the second procedure may be reimbursed at 75% instead of 50%.

Exceptions notedSpecific code combinations include overrides (see code listings for exact percentage exceptions).

Three-or-more abdominal/retroperitoneal rule

Three-or-more abdominal/retroperitonealWhen three or more column A abdominal/retroperitoneal codes are billed together: reimburse 100% for 76700, 50% for 76775, and 0% for 76705 and 76770.

General abdominal/retroperitoneal ruleOther column A abdominal ultrasound codes follow the standard 100%/50%/25% tiers unless overridden by the above exception.

Reference for claims processingThis exception supersedes the typical 25% third-tier for the specific listed codes when three or more are billed.

PET/MRI bundling formula

PET + MRI bundling formulaWhen PET code 78812 is billed with one or more MRI codes, reimburse 100% for the PET exam, 50% for the MRI with the highest RVU, and 25% for any additional MRIs with lesser RVUs.

Examples of paired MRI CPTsListed MRI examples paired with 78812 include 70540, 73218, 71550, 74181, 72195, and 73718.

Applies when authorizedThis PET/MRI rule applies where PET/MRI exams are authorized per the policy section.

Reimbursement split for PET+MRI bundles

Reimbursement split for PET+MRIAllocate 100% to the PET study (78812), 50% to the MRI with the highest RVU, and 25% to any additional MRI studies with lesser RVUs.

Ordering of allocationRVU is used to determine which MRI receives the 50% allocation when multiple MRIs are present.

Policy noteSee PET/MRI examples in the code table for specific MRI CPT pairings with 78812.

Documentation Required

External administration managed by EviCore by EVERNORTH

Certain external administration functions for this policy are managed by EviCore by EVERNORTH.

Documentation Required

Ultrasound and fetal imaging UM administered by EviCore by Evernorth

Some ultrasound and fetal imaging rules in this policy are administered by EviCore by Evernorth (utilization management).

Documentation Required

Policy administered by EviCore by EVERNORTH

Utilization management vendor noted for this policy: EviCore by EVERNORTH.

When a column A code is billed with column B codes the policy prescribes specific reimbursement formulas (e.g., 100%/50% splits).

Appears in code tablesMany code entries reference the column A/column B relationship to define applicable bundling and percentages.

Column A / Column B bundling

Column A with Column B billingWhen a code from column A is billed with a code from column B, reimbursement is allocated as 100% of the procedure with the highest RVU and 50% of the second.

Multiple column A billingWhen multiple column A codes are billed together, a third procedure may be reimbursed at 25% per the standard formula unless an exception applies.

See code listingsSpecific code pairings and mappings in the code tables show where these column relationships apply.

bundling reimbursement formula

Bundling reimbursement formulaWhen column A codes are billed together, reimbursement is calculated as a percentage of the procedure with the highest RVU (commonly 100% for highest, 50% for second, 25% for third).

Exceptions and variationsSome bundles specify the second procedure at 75% or other overrides; always consult the specific code entry for exceptions.

Operational noteClaims editing applies these percentages programmatically based on RVU ranking and code groupings.

administration

EviCore administrationSome bundles and utilization management functions referenced in this policy are administered by EviCore by Evernorth.

Sections noting administrationMultiple sections (including PET/MRI and ultrasound) note that authorization or UM processes are handled by EviCore.

Provider action implicationProviders should follow EviCore authorization/UM instructions where indicated to ensure correct payment handling.

EviCore by Evernorth

Utilization management vendorEviCore by Evernorth is the utilization management administrator referenced in this policy.

ScopeEviCore administration is noted for PET/MRI, ultrasound, and other bundled imaging rules where authorization is required.

Contact implicationProviders should comply with EviCore authorization requirements when submitting claims for bundled procedures.

PET/MRI bundling rule

PET/MRI rule (78812)When PET code 78812 is billed with one or more MRI codes from column B, reimbursement is allocated across the studies per the PET/MRI formula (100% PET; 50% highest-RVU MRI; 25% additional MRIs).

Examples providedThe policy lists multiple MRI CPTs paired with 78812 to illustrate this rule (see PET/MRI code table entries).

Authorization conditionRule applies where PET/MRI exams are authorized per the policy section.