CurrentUnitedHealthcarePolicy 2026R0125A

CMS 1500 Multiple Diagnostic Procedure Reductions (Cardiovascular & Ophthalmology)

Defines UnitedHealthcare's application of CMS-based Multiple Procedure Payment Reductions for diagnostic cardiovascular and ophthalmology procedures billed on CMS-1500 forms, affecting providers submitting claims (network and non-network) for UnitedHealthcare Commercial and Individual Exchange plans.

Policy Summary

PayerUnitedHealthcare

PolicyCMS 1500 Multiple Diagnostic Procedure Reductions (Cardiovascular & Ophthalmology)

Policy CodePolicy 2026R0125A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit accurate CMS-1500 claims; reductions apply when multiple diagnostic cardiovascular (MPI 6) or ophthalmology (MPI 7) procedures' technical components are performed same day by the same group/provider.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

25%MDCR TC reduction

20%MDOR TC reduction

MPI 6Cardiovascular MPI

MPI 7Ophthalmology MPI

1,3,4PC/TC indicator

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Application of MDCR / MDOR Reductions

MDCR / MDOR application criteria and rules

Apply reductions when multiple Diagnostic Cardiovascular (MPI 6) or Diagnostic Ophthalmology (MPI 7) technical components are performed the same day by the Same Group Physician and/or Other Health Care Professional (same TIN).

Procedure(s) have CMS MPI 6 (Diagnostic Cardiovascular) or CMS MPI 7 (Diagnostic Ophthalmology)

Procedures are performed on the same patient on the same day

Performed by the Same Group Physician and/or Other Health Care Professional (same Federal Tax Identification Number)

Determine technical components (TC) for each billed procedure (TC-only codes, TC portion of global codes, and TC portion of global test-only codes)

Rank procedures by Non‑Facility Total RVUs for the TC using the CMS NPFS (UnitedHealthcare uses NPFS Non‑Facility Total RVUs)

Exclude codes with 0.00 CMS RVU from MPPR ranking (gap-fill/0.00 RVU codes are excluded)

Do not apply reduction to the TC with the highest Non‑Facility Total RVU

When multiple Diagnostic Cardiovascular Procedures (MPI 6)

Apply a 25% reduction to the Allowable Amount for the TC of the second and each subsequent Diagnostic Cardiovascular Procedure

When multiple Diagnostic Ophthalmology Procedures (MPI 7)

Apply a 20% reduction to the Allowable Amount for the TC of the second and each subsequent Diagnostic Ophthalmology Procedure

Do not apply MDCR/MDOR reductions to services billed with modifier 26 (professional component) — reductions apply only to technical components

When global procedure codes are billed, UnitedHealthcare will split charges into Professional Component (PC) and Technical Component (TC) using UnitedHealthcare's standard PC/TC percentage splits prior to ranking and reduction

If a global test-only code maps to multiple TC codes, combine the TC values for ranking as applicable

If multiple units are submitted for a procedure, reductions apply to the second and subsequent units' TC; units remain subject to the Maximum Frequency Per Day Policy

Policy edits and applicable MPI/PCTC indicator information may be referenced on the CMS NPFS relative value files (MULT PROC and PCTC IND columns)

Affected Codes, Ranking, and Examples

Example Diagnostic Cardiovascular parent-child codesCPT

93000	Electrocardiogram, example parent-child mapping shown
93005	First TC for 93000 (example)
93010	First PC for 93000 (example)
93015	Parent code (93015) with first TC = 93017; first PC = 93016; second PC = 93018
93017	First TC for 93015 (example)
93016	First PC for 93015 (example)
93018	Second PC for 93015 (example)
93040	Parent code (93040) with first TC = 93041; first PC = 93042
93041	First TC for 93040 (example)
93042	First PC for 93040 (example)

1–10 of 22

1/3

Diagnostic Cardiovascular parent-child mappings (compact)CPT

93000	First TC = 93005; First PC = 93010
93015	First TC = 93017; First PC = 93016; Second PC = 93018
93040	First TC = 93041; First PC = 93042
93224	First TC = 93225; First PC = 93227; Second TC = 93226
93268	First TC = 93270; First PC = 93272; Second TC = 93271
93784	First TC = 93786; First PC = 93790; Second TC = 93788

inv-03: Ranking basis

Ranking basisNon‑Facility Total RVUs from the CMS Physician Fee Schedule (NPFS) are used to rank Technical Components; the TC with the highest Non‑Facility Total RVU is exempt from reduction.

Applicable MPIsDiagnostic Cardiovascular = MPI 6; Diagnostic Ophthalmology = MPI 7.

Scope of rankingRanking applies to TC-only codes (PC/TC indicator 3), the TC portion of Global Procedure Codes (indicator 1), and Global Test Only TC codes (indicator 4).

Exclusions from rankingCodes with a 0.00 RVU are excluded from MPPR ranking; Gap Fill codes use Optum The Essential RBRVS RVUs when available.

Claims Submission, Modifiers, and Billing Rules

Note

Claims submission and applicability

This reimbursement policy applies to services reported on the CMS-1500 (or electronic equivalent) for all products and all network and non-network physicians and other qualified health care professionals. When submitting claims, ensure the provider/group and billing details reflect the Same Group Physician and/or Other Health Care Professional when rules below are applicable.

Applies to services reported using the CMS-1500 (or electronic equivalent).
Policy applies to all products and to network and non-network physicians and other qualified health care professionals.

Billing Rule

Modifier 26 exclusion

Do not append modifier 26 to Technical Component (TC) billing to avoid incorrect exclusion of MPPR/MDCR/MDOR adjustments. Modifier 26 identifies the Professional Component (PC) and when a global code has been split into PC and TC for ranking and MPPR purposes, the appropriate PC/TC modifiers (26 and TC) must follow UnitedHealthcare Professional/Technical split guidance. Providers should follow the Employer & Individual Professional/Technical Component Policy for correct modifier use.

Key Terms and Code Handling Definitions

inv-08: Technical Component (TC)

DefinitionTechnical Component (TC) = the performance (technician/equipment/facility) portion of the procedure; identified by modifier TC or TC‑designated codes.

Reduction targetUnitedHealthcare applies MPPR reductions to the Technical Component only (PC reductions are not applied).

PC/TC indicatorsPolicy applies to PC/TC indicator 3 (TC only), the TC portion of indicator 1 (global), and indicator 4 (global test only) as applicable.

Global code handlingWhen a global code is billed, charges are split into PC and TC using UnitedHealthcare's standard PC/TC percentage splits before ranking and applying TC reductions.

inv-09: Professional Component (PC)

DefinitionProfessional Component (PC) = the physician or other health care professional work portion (supervision/interpretation/report); identified by modifier 26 or standalone PC codes.

Policy Summary

PayerUnitedHealthcare

PolicyCMS 1500 Multiple Diagnostic Procedure Reductions (Cardiovascular & Ophthalmology)

Policy CodePolicy 2026R0125A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

Do not use modifier 26 to indicate a technical-only service; modifier 26 represents the professional component.
When billing global codes that are split, follow UnitedHealthcare's PC/TC percentage splits and modifier guidance.

Billing Rule

Multiple units handling

When a single procedure subject to MDCR or MDOR is reported with multiple units, the reduction policy applies to the TC of the second (and subsequent) unit(s). Example: 78445 billed with 2 units — MDCR applies to the TC of the second unit. Example: 92060 billed with 2 units — MDOR applies to the TC of the second unit. Unit allowances remain subject to UnitedHealthcare's Maximum Frequency Per Day Policy.

Multiple units of a single Diagnostic Cardiovascular Procedure (MPI 6) — MDCR applies to TC of subsequent units.
Multiple units of a single Diagnostic Ophthalmology Procedure (MPI 7) — MDOR applies to TC of subsequent units.
Units are also subject to UnitedHealthcare's Maximum Frequency Per Day Policy.

Billing Rule

Global code splitting and ranking

When multiple global procedure codes (PC/TC indicator 1) or global test-only codes (PC/TC indicator 4) subject to MDCR/MDOR are billed by the Same Group Physician and/or Other Health Care Professional on the same day, UnitedHealthcare will: split global charges into PC and TC using UnitedHealthcare's standard PC/TC percentage splits; rank procedures by TC Non-Facility Total RVU; and apply reductions (25% for MDCR; 20% for MDOR) to the TC of secondary and subsequent procedures. For Global Test Only cardiovascular codes (PC/TC indicator 4), a 25% reduction applies to the corresponding TC-only codes (PC/TC indicator 3) and no reduction applies to the corresponding PC-only codes.

Global codes are divided into PC and TC using UnitedHealthcare's PC/TC splits.
Ranking is based on TC Non-Facility Total RVU.
MDCR reduction = 25% to TC of secondary/subsequent procedures.
MDOR reduction = 20% to TC of secondary/subsequent procedures.
For Global Test Only (cardiovascular) codes, apply 25% reduction to TC-only codes; PC-only codes are not reduced.

Reduction exemptionReductions are not applied to the Professional Component; services billed with modifier 26 are excluded from MDCR/MDOR.

Relation to Global codesFor global services, the PC portion (when identifiable) is not subject to the technical‑component reduction after PC/TC splitting.

inv-10: Gap Fill Codes / 0.00 RVU

Gap Fill CodesCodes without CMS‑developed RVUs (Gap Fill Codes) use RVUs from the first quarter update of Optum 'The Essential RBRVS' when available.

0.00 RVU codesCodes assigned an RVU value of 0.00 are excluded from MPPR ranking and will not be included in the Diagnostic Cardiovascular or Ophthalmology lists subject to MPPR.

Modifier useModifiers 26 and TC cannot be used with some global or gap‑filled codes where CMS does not assign separate PC/TC modifiers; total RVUs for global codes include work, practice expense, and malpractice.

inv-11: Same Group Physician

DefinitionSame Group Physician and/or Other Qualified Health Care Professional = providers of the same group reporting the same Federal Tax Identification Number.

Same‑day/same‑patient ruleMDCR/MDOR apply when multiple qualifying procedures' TCs are performed on the same patient on the same day by the Same Group Physician/Other Qualified Health Care Professional.

Claims form requirementPolicy applies to services reported using the CMS‑1500 (1500 Health Insurance Claim Form) or its electronic equivalent.