CurrentUnitedHealthcarePolicy 2025R9023A

CMS MPPR-based reductions for diagnostic cardiovascular and ophthalmology procedures

Defines UnitedHealthcare Medicare Advantage reimbursement reductions when multiple diagnostic cardiovascular (MPI 6) or ophthalmology (MPI 7) procedures' technical components are performed the same day by the same group/provider and billed on the CMS 1500 form; applies to Medicare Advantage products and all physicians and other qualified health care professionals.

Policy Summary

PayerUnitedHealthcare

PolicyCMS MPPR-based reductions for diagnostic cardiovascular and ophthalmology procedures

Policy CodePolicy 2025R9023A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionApply a 25% reduction to the technical component of second and subsequent Diagnostic Cardiovascular procedures (MPI 6) and a 20% reduction to the technical component of second and subsequent Diagnostic Ophthalmology procedures (MPI 7) when performed same day by the same group/provider.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

25%Diagnostic Cardiovascular TC reduction

20%Diagnostic Ophthalmology TC reduction

MPI 6MPI for Cardiovascular

MPI 7MPI for Ophthalmology

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Applies to PC/TC indicators

MPPR Application Criteria

MPPR application criteria

When multiple procedures are performed same day by Same Group Physician and/or Other Health Care Professional:

Diagnostic Cardiovascular (MPI 6): When the technical component (TC) for two or more Diagnostic Cardiovascular Procedures are performed on the same patient by the Same Group Physician and/or Other Health Care Professional on the same day, reduce the Allowable Amount for the TC of the second and each subsequent procedure by 25%; no reduction is taken on the TC with the highest TC Non‑Facility Total RVU.

Diagnostic Ophthalmology (MPI 7): When the technical component (TC) for two or more Diagnostic Ophthalmology Procedures are performed on the same patient by the Same Group Physician and/or Other Health Care Professional on the same day, reduce the Allowable Amount for the TC of the second and each subsequent procedure by 20%; no reduction is taken on the TC with the highest TC Non‑Facility Total RVU.

Scope of application: MDCR/MDOR apply to Technical Component Only codes (PC/TC indicator 3) and to the TC portion of Global Procedure Codes (PC/TC indicator 1); do not apply when procedures are billed only with modifier 26 (professional component only).

Multiple units: If a single procedure subject to MDCR or MDOR is submitted with multiple units, the reduction applies to the TC of the second unit onward (example: code 78445 with 2 units for MDCR; code 92060 with 2 units for MDOR).

Global billing and ranking: When multiple Global Procedure Codes (PC/TC indicator 1) are billed, charges will be split into PC and TC using UnitedHealthcare's standard professional/technical percentage splits; procedures are ranked by TC Non‑Facility Total RVU to determine which TCs receive reduction (25% for MDCR; 20% for MDOR).

Exclusions from ranking and MPPR: Codes assigned an RVU of 0.00 and gap‑fill codes without RVUs (including Global Test Only Codes) are excluded from ranking and are not subject to MDCR/MDOR.

MPIs, PC/TC Indicators, and Reduction Details

MPIs relevant to MPPR reductionsmixed

MPI 6	Diagnostic Cardiovascular Procedures (CMS Multiple Procedure Indicator 6)
MPI 7	Diagnostic Ophthalmology Procedures (CMS Multiple Procedure Indicator 7)

PC/TC indicators relevant to MPPR reductionsmixed

PC/TC 1	Global Procedure Codes (both Professional and Technical Components) - TC portion subject to reduction
PC/TC 3	Technical Component Only codes - TC services subject to reduction

Reduction percentages

Diagnostic Cardiovascular Technical Component ReductionReduce the Allowable Amount for the TC of the second and each subsequent Diagnostic Cardiovascular procedure by 25% when two or more TCs are performed same day by the Same Group Physician and/or Other Health Care Professional; no reduction on the TC with the highest TC non‑facility total RVU.

Diagnostic Ophthalmology Technical Component ReductionReduce the Allowable Amount for the TC of the second and each subsequent Diagnostic Ophthalmology procedure by 20% when two or more TCs are performed same day by the Same Group Physician and/or Other Health Care Professional; no reduction on the TC with the highest TC non‑facility total RVU.

Application to multiple unitsIf a single procedure subject to the reduction is submitted with multiple units, the reduction applies to the TC of the second unit onward (example: code 92060 with 2 units).

Billing and Modifier Guidance

Billing Rule

Application — CMS 1500 and Medicare Advantage scope

This reimbursement policy applies to all Medicare Advantage products and for services reported using the 1500 Health Insurance Claim Form (CMS 1500) or its electronic equivalent. The policy applies to all physicians and other qualified health care professionals submitting claims on that form.

Billing Rule

Modifier 26 exclusion — reductions apply to TC only

Do not apply the Multiple Diagnostic Cardiovascular Reductions (MDCR) or Multiple Diagnostic Ophthalmology Reductions (MDOR) when procedures are billed with modifier 26 (professional component) only; the reductions apply to technical component (TC) services and the TC portion of global procedure codes.

Key Terms

Allowable Amount — definition and examples

DefinitionAllowable Amount = the dollar amount eligible for reimbursement to the physician or health care professional on the claim; examples include contracted rate, reasonable charge, or billed charges (for percent of charge/discount contracts, determined as billed amount less the discount).

Role in MPPRUsed as the base dollar amount from which MDCR/MDOR percentage reductions are calculated for technical components when multiple eligible procedures are performed same day.

ExamplesContracted rate; reasonable charge; billed charges (percent/discount contracts use billed amount less discount).

Global Procedure Code — definition

DefinitionGlobal Procedure Code = a code that includes both Professional and Technical Components; submission without modifier indicates both components (provider asserts they furnished supervision/interpretation and the technician, equipment, and facility).

Policy Summary

PayerUnitedHealthcare

PolicyCMS MPPR-based reductions for diagnostic cardiovascular and ophthalmology procedures

Policy CodePolicy 2025R9023A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

IdentificationReported by submitting the appropriate procedure code with no PC/TC modifier attached; used when billing for both PC and TC together.

Relevance to MPPRWhen billed globally, UnitedHealthcare splits charges into PC and TC percentages and applies MDCR/MDOR to the TC portion as specified by policy.

Professional Component (PC) — definition and identification

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

IdentificationTypically identified by appending modifier 26 to the procedure code or by reporting a standalone PC‑only code when applicable.

MPPR handlingMDCR/MDOR are not applied when services are billed as PC only (modifier 26); reductions apply to technical components only.

Technical Component (TC) — definition and identification

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

IdentificationTypically identified by appending modifier TC to the procedure code or by reporting a standalone TC‑only code (PC/TC indicator 3).

MPPR handlingMDCR/MDOR apply to TC‑only codes (PC/TC indicator 3) and to the TC portion of Global Procedure Codes (PC/TC indicator 1); reductions target the TC Allowable Amounts.

Same Group Physician and/or Other Health Care Professional — definition

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 MPPRMDCR/MDOR are applied when multiple eligible TCs are performed on the same patient the same day by providers in the same group (same Federal Tax ID).

Group reportingGroup‑level reporting determines whether procedures are considered performed by the Same Group for purposes of ranking and applying technical component reductions.