CurrentHealth NetPolicy CC.PP.069

Multiple Procedure Reduction: Ophthalmology

Defines Health Net's payment policy applying CMS-based multiple procedure payment reduction (MPPR) to diagnostic ophthalmology procedures with a CMS MPI of 7 when multiple procedures/units are performed on the same patient by the same provider or same-group providers on the same day.

Policy Summary

PayerHealth Net

PolicyMultiple Procedure Reduction: Ophthalmology

Policy CodePolicy CC.PP.069

Change TypeNo material change

Effective Date

Next Review Date

Key ActionApply MPPR: pay highest-valued diagnostic ophthalmology procedure at 100% and subsequent MPI=7 procedures/units at 80%; modifier -26 exempts the professional component.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100% / 80%reimbursement split

MPI = 7MPI

appliesapplies intra-/inter-claim

exemptsmodifier -26

07/2025last review

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MPPR application and exceptions

Apply the multiple procedure payment reduction (MPPR) when the following conditions are met unless an exception applies:

ALL of the following

Procedure must be assigned MPI = 7 on the CMS National Physician Fee Schedule (NPFS).
Procedures must be performed on the same patient on the same day.
Procedures must be performed by the same physician or by multiple physicians in the same group practice (same group NPI).
When two or more eligible diagnostic ophthalmology procedures/units are performed, the highest-valued procedure/unit is reimbursed at 100% and each subsequent procedure/unit is reimbursed at 80% of the maximum allowance. This reduction applies within a single claim and across claims (inter- and intra-claim).
Exception: The MPPR reduction does not apply when the procedure is billed with modifier -26 (professional component).

ALL of the following

A single diagnostic ophthalmology procedure billed in multiple units is subject to MPPR: the first unit is reimbursed at 100% and subsequent units at 80%.
MPPR is applied to the technical component/units of eligible procedures as identified by MPI = 7 on CMS NPFS.

Application and limitations

Stance and administrative notes governing application of this payment policy:

This payment policy is effective as of the date determined by Health Plan; the date of posting may differ from the effective date. If legal or regulatory requirements conflict with this policy, the law or regulation governs.

This payment policy is a guide to payment and does not constitute medical advice or dictate clinical care. Providers are expected to exercise professional medical judgment and are responsible for treatment decisions.

Providers are independent contractors; this policy does not make providers agents or employees of Health Plan.

For Medicaid patients, state Medicaid coverage provisions take precedence where they conflict with this payment policy. Refer to state Medicaid manuals for applicable provisions.

For Medicare patients, applicable Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) should be reviewed and take precedence as applicable.

Codes, Rates, and Effective Rules

Diagnostic ophthalmology CPT/HCPCS codes referenced (MPI=7 list)CPTCovered

0506T	Macular pigment optical density measurement by heterochromatic.
0507T	Near infrared dual imaging (ie, simultaneous reflective and transilluminated light) of meibomian glands, unilateral or bilateral, with interpretation and report.
0509T	Electroretinography (ERG) with interpretation and report, pattern (PERG).
76510	Ophthalmic ultrasound, diagnostic; B-scan and quantitative A-scan performed during the same patient encounter.
76511	Ophthalmic ultrasound, diagnostic; quantitative A-scan only.
76512	Ophthalmic ultrasound, diagnostic; B-scan with or without superimposed non-quantitative A-scan.
76513	Ophthalmic ultrasound, diagnostic; anterior segment ultrasound, immersion (water bath) B-scan or high resolution biomicroscopy, unilateral or bilateral.
76514	Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral (determination of corneal thickness).
76516	Ophthalmic biometry by ultrasound echography A-scan.
76519	Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation.

1–10 of 35

1/4

Coding references and external determinationsmixed

No codes listed

Reimbursement for subsequent procedures/units (MPPR)

Subsequent procedure/unit reimbursement80% of the maximum amount allowance for each subsequent diagnostic ophthalmology procedure and unit(s)

ApplicabilityApplies when two or more diagnostic ophthalmology procedures with CMS MPI 7 are performed by the same provider on the same patient on the same day

Multiple units of a single codeWhen a single diagnostic procedure is billed in multiple units, the first unit reimbursed at 100% and subsequent units at 80%

Reimbursement for primary procedure/unit (MPPR)

Primary (highest-valued) procedure/unit reimbursement100% of the maximum amount allowance for the first diagnostic procedure or highest-valued unit

Determination of highest-valued unitThe Plan allows 100% for the first diagnostic procedure with the highest cost per unit when multiple MPI 7 procedures are performed

Applies intra- and inter-claimPayment reduction rules apply within the same claim and across claims when performed same day by same provider

Policy effective date and administrative rule

Effective date ruleThis payment policy is effective as of the date determined by Health Plan; the date of posting may not be the effective date

Legal and regulatory precedenceIf there is a discrepancy between the effective date and legal/regulatory requirements, law and regulation govern

Plan rightsHealth Plan may change, amend or withdraw this payment policy at any time

Billing, Modifier Use, and Provider Responsibilities

Billing Rule

Multiple Procedure Reduction rules

Multiple Procedure Reduction applies when the same provider or providers in the same group (same group NPI) perform two or more diagnostic ophthalmology procedures with a CMS NPFS Multiple Procedure Indicator (MPI) of 7 on the same patient on the same day. It also applies when a single diagnostic ophthalmology procedure with MPI 7 is billed in multiple units by the same provider or same-group providers on the same day. This rule applies to procedures billed within the same claim and across claims.

Applies when two or more diagnostic ophthalmology procedures with MPI = 7 are performed by the same provider or by multiple physicians in the same group (same group NPI) on the same patient, same day.
Applies when a single diagnostic ophthalmology procedure with MPI = 7 is billed with multiple units by the same provider or same-group providers on the same day.
Applies to procedures billed within the same claim and across separate claims.

Billing Rule

Modifier exception and reimbursement details

When multiple (two or more) diagnostic ophthalmology procedures with MPI = 7 are performed by the same provider or same-group providers on the same patient, on the same day, reimbursement is 100% of the maximum allowed amount for the highest-cost (per unit) diagnostic procedure (or the first unit when multiple units of the same procedure are billed) and 80% of the maximum allowed amount for each subsequent diagnostic procedure and subsequent units. The claim amount is allocated by units: the highest-priced unit is paid at 100% and all other units are paid at 80%.

100% payment for the single highest-cost diagnostic ophthalmology procedure (or highest-priced unit) performed on the same day.
80% payment for each subsequent diagnostic ophthalmology procedure and for subsequent units of a multi-unit procedure.
Policy uses the CMS NPFS MPI 7 to identify procedures eligible for this reduction.

Note

Policy applicability and provider responsibilities

This payment policy is effective as of the date determined by Health Plan. The posting date may not be the effective date; if state Medicaid or other legal/regulatory requirements conflict with this policy, the applicable law or state Medicaid provisions prevail. Health Plan reserves the right to change, amend, or withdraw this payment policy at any time. Providers are independent contractors, are expected to exercise professional judgment, and are responsible for medical advice and treatment decisions. This policy does not constitute medical advice or dictate clinical practice.

Effective date determined by Health Plan; posting date may differ.
State Medicaid provisions supersede this policy when conflicts exist.
Health Plan may change or withdraw this policy at any time.
Providers remain independently responsible for clinical decisions.

Key Terms

Professional Component (PC)

DefinitionProfessional Component (PC) is the physician or other health care professional work portion of the procedure, including supervision and interpretation that results in a written narrative report and directly contributes to diagnosis and/or treatment

IdentificationIn appropriate circumstances, the PC is identified by appending modifier -26 to the designated procedure code or by reporting a standalone code that describes the Professional Component only

IncludesPhysician work, practice overhead, and malpractice expense as related to the professional portion of the service

Technical Component (TC)

DefinitionTechnical Component (TC) includes the provision of all equipment, supplies, personnel and costs related to the performance of the exam

ScopeRepresents the non‑physician elements of the service necessary to perform the diagnostic test

Relation to PCTC is distinct from the Professional Component, which encompasses physician supervision and interpretation

Same Group Physician

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

Implication for MPPRMPPR applies when procedures are performed by the same physician or by multiple physicians in the same group practice (same group NPI/FTIN)

Group reportingGroup membership is determined by common Federal Tax Identification number as stated

Health Plan

DefinitionHealth Plan: a health plan that has adopted this payment policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or an affiliate

Role of policyThis payment policy is a guide to payment and does not constitute a contract or guarantee regarding payment; coverage determinations remain subject to plan documents and legal requirements

Provider relationshipProviders are independent contractors and not agents or employees of Health Plan; providers are expected to exercise professional medical judgment

OpenPayer

Multiple Procedure Reduction: Ophthalmology

Multiple Procedure Payment Reduction (MPPR) — Application

Codes, Rates, and Effective Rules

Billing, Modifier Use, and Provider Responsibilities

Key Terms