CurrentUnitedHealthcarePolicy 2026R0085A

Multiple Diagnostic Imaging Payment Reductions (CMS 1500)

Defines UnitedHealthcare's reimbursement reductions for multiple diagnostic imaging procedures billed on the CMS-1500 form (professional and technical components) and applies to UnitedHealthcare Commercial and Individual Exchange plans and all providers submitting on CMS-1500.

Policy Summary

PayerUnitedHealthcare

PolicyMultiple Diagnostic Imaging Payment Reductions (CMS 1500)

Policy CodePolicy 2026R0085A

Change TypeAdded ultrasound indicator 0 reductionswording clarifications

Effective Date11/01/2025

Next Review Date

Key ActionSubmit accurate CMS-1500 claims and use modifier 59 or XE to indicate distinct sessions to avoid multiple diagnostic imaging reductions.

SourceLink

POLICY UPDATE CHANGES

UnitedHealthcare will apply reductions to certain ultrasound CPT codes assigned an MPPR Status Indicator of '0' effective 11/01/2025.

Policy verbiage updated to reflect 'Qualified' Health Care Professional.

Policy transferred to a shared template covering both Commercial and Individual Exchange plans.

50%TC reduction for second and subsequent imaging procedures

5%PC reduction for second and subsequent imaging procedures

11/01/2025Ultrasound indicator 0 reductions effective

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When Multiple Diagnostic Imaging Reductions Apply

MDIR application criteria

Covered when ALL of the following are met:

ALL of the following

Procedures have an MPI of 4, or have an MPI of 0 that appears on the Ultrasound Indicator 0 CPT code list (for ultrasound-specific rules).
Procedures are performed on the same patient by the Same Group Physician and/or Other Qualified Health Care Professional during the Same Session.
Also applies when: A single imaging procedure subject to MDIR is submitted with multiple units (MDIR applies to the second unit onward).

Ranking and primary procedure: No reduction is applied to the procedure (or component) ranked primary based on Non-Facility Total RVUs; reductions apply to secondary and subsequent procedures with lower RVUs.

Exclusions (MDIR will not apply)

Procedure billed with Modifier 59 or Modifier XE to indicate it was performed in a separate session on the same day.
Procedures billed on the same day but not by the Same Group Physician and/or Other Qualified Health Care Professional during the Same Session.
Procedure does not have an MPI of 4, and if it has an MPI of 0 it is not on the Ultrasound Indicator 0 CPT code list.

Reductions applied

TC and PC ranking are determined separately using Non-Facility Total RVUs; the component(s) with lower RVUs are subject to MDIR.
For ultrasound Indicator 0 CPT codes: when two or more such codes from the list are performed in the Same Session (same date of service) by the same group (or different physicians within the same group), a 50% TC and 5% PC reduction will be applied beginning 11/01/2025; modifiers may be used where appropriate to indicate separate sessions.

Global billing: When procedures are billed globally, charges will be divided into PC (modifier 26) and TC (modifier TC) using UnitedHealthcare's standard percentage splits; RVUs for each component determine primary vs secondary ranking and corresponding reductions applied to the lesser-ranked components.

Operational notes: Moving a patient to a different room or use of Modifier 76 alone does not constitute a separate session; use Modifier 59 or XE to indicate distinct sessions to avoid MDIR. Allowed Amount calculations for TC use the lesser of charges assigned for modifier TC or the contracted rate when a specific TC contracted rate exists, with reductions applied accordingly.

MPPR Status Indicators, Codes, and Reduction Rates

MPPR Status Indicator 0 and 4 codesCPTCovered

Ultrasound Indicator 0 CPT code list

List of ultrasound CPT codes assigned MPPR Status Indicator '0' subject to reductions when multiple in same session.

Technical Component reduction50%

Professional Component reduction5%

Claims Submission, Modifiers, and Avoiding Reductions

Documentation Required

Claims submission and modifier usage

Submit accurate claims on the CMS-1500 form or its electronic equivalent and append appropriate modifiers when applicable to indicate distinct sessions or separate services.

Use Modifier 59 or Modifier XE (but not both) to indicate a procedure performed in a distinct session when applicable.
Claims must be submitted on the CMS-1500 or electronic equivalent as this policy applies to services reported on that form.

Billing Rule

Avoiding MDIR via modifiers

When multiple diagnostic imaging procedures are performed in the same session by the Same Group Physician and/or Other Qualified Health Care Professional, MDIR reductions will apply; use Modifier 59 or XE to indicate services were performed in a different session to avoid reductions.

Key Terms

Definitions

Allowable AmountDollar amount eligible for reimbursement to the physician or other qualified health care professional on the claim (examples: contracted rate, reasonable charge, or billed charges).

Global ServiceIncludes both a Professional Component and a Technical Component; when billed globally it asserts the same individual provided both PC and TC; may be reported via global code or by reporting component splits.

Professional Component (PC)The physician or other qualified health care professional work portion (supervision, interpretation, and report); often identified by modifier 26 or standalone PC codes.

Technical Component (TC)The performance (technician/equipment/facility) portion of the procedure; often identified by modifier TC or standalone TC codes. Subject to a 50% reduction for second and subsequent imaging procedures meeting MDIR criteria.