Currentmoda_health_plan_incPolicy RPM022
Modifier 51 - Multiple Procedure Fee Reductions
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Defines Moda Health's reimbursement rules for applying multiple procedure fee reductions (MPFR) when multiple procedures are performed in the same session; applies to all provider types and claim forms covered by Moda Partners, Inc. and its subsidiaries.
Policy Summary
Payermoda_health_plan_inc
PolicyModifier 51 - Multiple Procedure Fee Reductions
Policy CodePolicy RPM022
Change TypeClarification / non‑material edits
Effective DateJul 8, 2026
Last ReviewJul 8, 2026
Next Review DateJul 8, 2026
Key ActionSubmit all same-day/surgical session procedure codes on the same claim using CMS1500 or CMS1450 (paper or electronic).
SourceLink
POLICY UPDATE CHANGES
Updated description for Multiple Procedure Indicator = '4'.
Clarified procedure codes eligible for reductions and how reductions are applied for indicator '3.'
Idaho added to Scope.
100/50default MPFR processing
20%therapy secondary unit reduction
2000-2026policy history timeline
2026-07-08last reviewed
Multiple Procedure Fee Reduction (MPFR) Rules
MPFR application criteria
Rules for applying multiple procedure fee reductions (MPFR) across claim types and indicators. Covered when the listed conditions and ranking rules are met:
Providers must submit all procedure codes for the same day/surgical session on the same claim.
Multiple procedure fee reductions are applied to secondary procedures even when modifier 51 is omitted due to billing error.
A maximum of one unit of one procedure code is processed as the primary procedure; additional units of that code and any other procedures billed are secondary and subject to secondary procedure rules.
Procedure codes assigned a multiple procedure indicator of '9' are not subject to primary/secondary rules (MPFR does not apply).
Primary procedure determination (ranking): the procedure code with the highest MPFS RVU is primary for professional claims; facility claims with APC contracts use a Medicare pricer tool; all other facility claims use MPFS RVUs; ranking is independent of billed order or billed charges.
For percent-of-charge or discount fee schedules, MPFR rules apply; reductions are applied to the discounted amount, not the billed charges.
Standard professional MPFR
- Primary procedure processed at 100% allowable.
- Secondary procedures processed at 50% (i.e., 100 / 50 / 50 / ...), unless an ASO/self-funded plan contract specifies alternate cutback rates.
When self-funded ASO plan language specifies non-standard MPFR cutback rates (for example 100/50/25/25), the employer plan benefit language takes precedence over provider contract language.
ALL of the following
- Indicator 3: For Medicare Advantage contracted providers, treated as indicator 2 (standard 50% secondary); for MA out-of-network endoscopy, secondary endoscopy procedures reduced by 24%; for Commercial and Medicaid, indicator 3 treated as indicator 2.
- Indicator 4 (diagnostic imaging): TC lines subject to 50% reduction; PC lines with modifier 26 subject to 5% reduction; global (no modifier) subject to 35% reduction; reductions apply before Payment Cap Value limits when those limits apply.
- Indicator 5 (therapy): First unit of first therapy code allowed at full fee schedule; all subsequent units and codes subject to 20% reduction; applies to multiple units of same code and multiple different therapy codes and across therapy disciplines.
- Indicator 6 (diagnostic cardiovascular): If billed with TC, secondary procedures subject to 25% reduction; if billed with modifier 26, processed at full allowable (no reduction); if global, secondary subject to 20% reduction; reductions apply before Payment Cap Value limits when those limits apply.
- Indicator 7 (diagnostic ophthalmology): If billed with TC, secondary procedures subject to 20% reduction; if billed with modifier 26, processed at full allowable (no reduction); if global, secondary subject to 10% reduction.
ASC and outpatient hospital claims: effective July 1, 2018, MPFR applies to ASC and outpatient hospital claims; if contract uses Medicare methodology, CMS MPFR used; otherwise Moda reductions up to 50% may apply. Facility professional revenue lines are treated as though they have modifier 26; other facility revenue codes are treated as TC.
Procedure codes with MPFSDB indicator 0 or 9: MPFR concept does not apply; billing with modifier 51 on indicator 0 or 9 codes is an invalid modifier-to-procedure combination and will deny (e.g., chiropractic/OMT codes 98925-98929, 98940-98943).
Modifier 51 does not bypass clinical edits (subset/redundant denials) and other pricing adjustments (bilateral, assistant surgeon, co-surgery, related within global) may also affect final line item allowable amounts.
History-based coverage notes
Policy history entries record clarifications, formatting updates, and scope changes; the policy notes these edits did not change policy application.
7/8/2026: Updated description for Multiple Procedure Indicator = '4'; acronyms and resources updated. No policy changes.
4/10/2024: Clarified procedure codes eligible for reductions and how reductions are applied for indicator '3.' Formatting updates. No policy changes.
11/9/2022: Idaho added to Scope; clarified ranking method and percent discount calculations; Definition of Terms and Policy History added. Minor rephrasing and formatting updates. No policy changes.
Earlier entries: initial approval 4/10/2013; original effective date 1/1/2000. See provider website for current policy version.
Procedure Indicators, Rates, and Code Guidance
Multiple procedure indicator groupsmixedCovered
| Indicators 1,2,3,4,5,6,7 | Procedure codes with a CMS Physician Fee Schedule multiple procedure indicator of '1', '2', '3', '4', '5', '6', and '7' will allow as valid modifier to procedure combinations when billed with modifier 51. |
| Indicators 0 and 9 | Procedure codes with a CMS PFS multiple procedure indicator of '0' and '9' will deny for invalid modifier to procedure combination when billed with modifier 51. |
| OMT/CMT (98925-98929, 98940-98943) | Osteopathic Manipulative Treatment (OMT) and Chiropractic Manipulative Treatment (CMT) procedure codes have a multiple procedure indicator of '0' and will be denied for invalid modifier to procedure combination when billed with modifier 51. |
procedure code guidance (historic notes)mixed
| Policy history notes clarifications about procedure codes eligible for reductions and Multiple Procedure Indicator descriptions (e.g., indicator '3' and '4'). |
inv-05: Standard MPFR cutback rates
Standard professional MPFR cutbackPrimary procedure processed at 100%; secondary procedures processed at 50% (100 / 50 / 50 / etc.) unless the ASO plan specifies alternate cutbacks.
ASO / self-funded deviationsWhen an Administrative Services Only (ASO) employer plan specifies non-standard MPFR cutback rates (e.g., 100 / 50 / 25 / 25), the employer plan benefit language takes precedence and those rates are applied.
Application to percent-of-charge or discount schedulesMultiple procedure reductions are applied to percent-of-charge or discount fee schedules and are applied to the discounted amount.
Indicator-specific override noteIndicator-specific reductions (radiology, therapy, cardiovascular, ophthalmology) may specify different cutbacks than the standard 50% for secondary procedures.
inv-06: Multiple Procedure Indicator references
Indicator '3' guidanceProcedure codes with MPFSDB multiple procedure indicator '3' are treated with standard multiple procedure fee reductions as if indicator '2' for Commercial and Medicaid; for Medicare Advantage contracted providers the indicator is treated as '2' for contracted providers and out-of-network secondary endoscopy reductions may be 24%.
Indicator '4' updateIndicator '4' diagnostic imaging rules described: TC 50% reduction, PC 5% reduction, global 35% reduction (effective July 1, 2018); description updated in 7/8/2026 history entry with no policy change.
Historic clarificationsPolicy history entries (4/10/2024 and 7/8/2026) note clarifications to indicators '3' and '4' descriptions and formatting updates; no material policy changes recorded.
Billing, Submission, and Resource Guidance
Billing Rule
Submit all same‑day/surgical-session procedures on one claim (CMS1500/CMS1450)
Providers must submit all procedure codes for the same day or surgical session on the same claim using the CMS1500 or CMS1450 claim form (paper or electronic). Multiple procedure fee reductions will be applied to secondary procedures even if modifier 51 is omitted; a maximum of one unit of one procedure code is processed as the primary procedure and additional units are treated as secondary. For percent-of-charge or discount fee schedules, MPFR rules still apply and reductions are applied to the discounted amount.
- Submit all same-day/surgical session procedure codes on the same claim (CMS1500 or CMS1450, paper or electronic).
- If multiple units are billed for the primary procedure, additional units and other procedures are secondary and subject to MPFR rules.
- MPFRs apply to percent-of-charge/discount fee schedules and are applied to the discounted amount, not billed charges.
- MPFRs are applied even when modifier 51 is omitted from a line item.
Documentation Required
Reference resources for coding and Medicare policy guidance
Use the listed CMS and coding resources to guide correct billing, modifier use, and MPFR application.
- CMS National Correct Coding Initiative Policy Manual, Chapter 1, § C.
- CMS Medicare Claims Processing Manual (Pub. 100-4): Chapter 12 Physician Practitioner Billing, §40.6.C and §20 (MPFS guidance).
- CMS Medicare Claims Processing Manual (Pub. 100-4): Chapter 23 Fee Schedule Administration and Coding Requirements (MPFSDB layouts).
- MLN guidance on MPPR and OPPS cap for imaging procedures (MM7703).
- Coding with Modifiers: A Guide to Correct CPT and HCPCS Level II Modifier Usage (Grider).
Terms and Definitions
inv-09: RVU / MPFSDB
RVU / MPFSDB usageModa uses Resource-based Relative Value Units (RVUs) from the Medicare Physician Fee Schedule Database (MPFSDB) to rank procedures and determine the primary procedure for MPFR application.
Which RVU value to useThe Non-Facility Total or Facility Total RVU value from the MPFS is used for pricing depending on place of service.
Ranking effect on paymentThe procedure ranked highest by MPFS RVU is processed at full allowable (primary) and lower-ranked procedures are subject to MPFR cutbacks per indicator rules.
inv-10: Modifier 51
Modifier 51 definitionModifier 51 (Multiple Procedures) identifies additional procedures performed in the same session by the same individual; the primary procedure is reported as listed and additional procedures may be identified by appending modifier 51.
Do not append to add-on codesModifier 51 should not be appended to designated 'add-on' codes per CPT guidance (see Appendix D).
Relation to MPFRPresence of modifier 51 on a claim does not prevent Moda from applying multiple procedure fee reductions where MPFSDB indicators require MPFR; modifier 51 is an identifier, not an exemption from reductions.
inv-11: Modifiers XE/XS/XP/XU/59/77/78/79/SG
Listed modifiersPolicy defines modifiers XE, XS, XP, XU, 59, 77, 78, 79 and SG (separate encounter/practitioner/structure, distinct procedural service, repeat/unplanned/unrelated procedures, ASC service).
Modifiers do not waive MPFRThe presence of XE/XS/XP/XU/59/77/78/79/SG on a claim does not waive the application of multiple procedure fee reductions by Moda Health when MPFR rules or MPFSDB indicators apply.
Use when descriptiveModifier 59 should be used only when no more descriptive modifier is available and when documentation supports a distinct procedural service; other related modifiers should be used when appropriate.
inv-12: Policy History
7/8/2026Updated description for Multiple Procedure Indicator = '4'; Acronyms & Resources updated. No policy changes.
4/10/2024Clarified procedure codes eligible for reductions and how reductions are applied for indicator '3.' Formatting updates. No policy changes.
11/9/2022Idaho added to Scope; clarified ranking method and percent discount calculations; Definition of Terms and Policy History added. No policy changes.
4/10/2013 and 1/1/20004/10/2013: Policy initially approved and published. 1/1/2000: Original effective date referenced for historical basis.
Policy Summary
Payermoda_health_plan_inc
PolicyModifier 51 - Multiple Procedure Fee Reductions
Policy CodePolicy RPM022
Change TypeClarification / non‑material edits
Effective DateJul 8, 2026
Last ReviewJul 8, 2026
Next Review DateJul 8, 2026
Key ActionSubmit all same-day/surgical session procedure codes on the same claim using CMS1500 or CMS1450 (paper or electronic).
SourceLink
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