CurrentUnitedHealthcarePolicy 2025R9023A

UnitedHealthcare Medicare Advantage CMS 1500 Multiple Procedure Payment Reduction Policy

Governs UnitedHealthcare Medicare Advantage reimbursement for services billed on CMS 1500 forms, applying CMS MPPR logic to diagnostic cardiovascular and ophthalmology procedures; affects physicians and other qualified health care professionals billing UnitedHealthcare Medicare Advantage plans.

Policy Summary

PayerUnitedHealthcare

PolicyMedicare Advantage CMS 1500 MPPR for diagnostic cardiovascular and ophthalmology procedures

Policy CodePolicy 2025R9023A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit accurate claims on the CMS 1500 (or electronic equivalent) following CPT/CMS coding guidelines.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

25%Cardiovascular TC reduction

20%Ophthalmology TC reduction

MPI 6MPI (cardio)

MPI 7MPI (ophth)

TC onlyReduction applies to

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Multiple Procedure Payment Reduction (MPPR) Application

MPPR application criteria

Reductions apply when the Technical Component (TC) of two or more eligible diagnostic cardiovascular or ophthalmology procedures are performed on the same patient by the same group on the same day. Covered when the following conditions are met:

Procedures are billed to UnitedHealthcare Medicare Advantage on a CMS 1500 form by the Same Group Physician and/or Other Health Care Professional on the same day.

Diagnostic category

Diagnostic Cardiovascular Procedures identified by CMS NPFS Multiple Procedure Indicator (MPI) 6.
Diagnostic Ophthalmology Procedures identified by CMS NPFS Multiple Procedure Indicator (MPI) 7.

When Global Procedure Codes are billed, charges will be split into Professional (modifier 26) and Technical (modifier TC) portions using UnitedHealthcare Medicare Advantage's standard professional/technical percentage splits; ranking and reductions are applied to the TC portion based on TC Non‑Facility Total RVU.

Codes with 0.00 CMS RVU or services without CMS‑assigned RVUs (carrier‑priced, fill codes, unlisted codes) are excluded from ranking and from MPPR reductions.

Multiple Procedure Indicators, Reduction Rates, and Code Handling

Multiple Procedure Indicatorsmixed

MPI 6	Diagnostic Cardiovascular Procedures subject to Multiple Diagnostic Cardiovascular Reductions (MDCR)
MPI 7	Diagnostic Ophthalmology Procedures subject to Multiple Diagnostic Ophthalmology Reductions (MDOR)

Reduction percentages for secondary/subsequent Technical Components (TC)

Cardiovascular TC reductionSecond and each subsequent Technical Component (TC) allowable amount reduced by 25% (MDCR)

Ophthalmology TC reductionSecond and each subsequent Technical Component (TC) allowable amount reduced by 20% (MDOR)

No reduction on highest‑RVU TCNo reduction is taken on the TC with the highest TC Non‑Facility Total RVU per NPFS

Handling of codes with 0.00 RVU

Zero RVU exclusionCodes assigned an RVU value of 0.00 are excluded from ranking and from MPPR (MDCR/MDOR) reductions

Fill codesCodes for which CMS does not develop RVUs (e.g., unlisted/fill codes) are treated similarly and excluded from MPPR ranking

Claims Submission and Billing Expectations

Documentation Required

Claims submission expectations

Submit accurate claims on the CMS 1500 form (or electronic equivalent) using CPT/CMS and other applicable coding guidelines; this policy applies to all physicians and other qualified health care professionals billing UnitedHealthcare Medicare Advantage plans.

Key Terms

Allowable Amount

DefinitionAllowable Amount = the dollar amount eligible for reimbursement to the physician or health care professional on the claim (examples: contracted rate, reasonable charge, or billed charges as applicable)

Percent/discount contractsFor percent of charge or discount contracts, the Allowable Amount is the billed amount less the discount

UsageUsed as the basis for applying MDCR/MDOR reductions to TC allowable amounts

Global Procedure Code

DefinitionGlobal Procedure Code = a code that includes both Professional and Technical Components; reporting the global code asserts provision of both PC and TC

IdentificationA Global Procedure Code is identified by reporting the appropriate procedure code with no PC or TC modifier attached

Policy Summary

PayerUnitedHealthcare

PolicyMedicare Advantage CMS 1500 MPPR for diagnostic cardiovascular and ophthalmology procedures

Policy CodePolicy 2025R9023A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit accurate claims on the CMS 1500 (or electronic equivalent) following CPT/CMS coding guidelines.

SourceLink

On This Page

Impact on rankingExcluded codes are not considered when determining which TC(s) receive the reduction based on Non‑Facility Total RVU

Billing implicationWhen billed globally, charges are considered to include supervision/interpretation (PC) and technician/equipment/facility (TC)

Technical Component (TC)

DefinitionTechnical Component (TC) = the performance (technician/equipment/facility) portion of the procedure

IdentificationTC is identified in appropriate circumstances by appending modifier TC or by reporting a standalone TC code

Application to reductionsMDCR/MDOR apply to TC only and to the TC portion of Global Procedure Codes

Professional Component (PC)

DefinitionProfessional Component (PC) = the physician or other qualified health care professional work portion (supervision and interpretation) of the procedure

IdentificationPC is identified in appropriate circumstances by appending modifier 26 or by reporting a standalone PC code

Exclusion from reductionsCharges billed as the Professional Component (modifier 26) are not subject to MDCR/MDOR reductions

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

Relevance to MPPRMDCR and MDOR apply when TCs are performed on the same patient by providers of the Same Group on the same day

Includes PC/TC global billingPolicy guidance on global codes and split billing applies when Same Group providers bill global or component codes