Policy No: 133
Originally Created: 11/01/2017
Section: Administrative
Last Reviewed: 10/01/2024
Last Revised: 02/01/2023
Approved: 10/10/2024
Effective: 11/01/2024
Policy Applies To: Group and Individual
This policy applies to physicians, other qualified health care professionals and facilities.
Evaluation and Management (E&M) Services
Services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination are determined by the treating physician or other qualified healthcare professional reporting the service.
Modifier 25
Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.
Preventive Medicine Visit
Preventive visit that requires documentation to support an "annual physical". Includes an age and gender-appropriate history and physical examination, counseling or anticipatory guidance, and risk factor reduction interventions.
Our health plan will consider reimbursement for both a preventive medicine Current Procedural Terminology (CPT®) or Health Care Common Procedure Coding System (HCPCS) code and E&M when modifier 25 is applied to the E&M visit for the same patient, by the same provider, on the same date of service.
Providers should only submit a preventive code and a separate E&M code when there is a significant abnormality or pre-existing condition addressed and additional work is required to perform the key components of the E&M service.
The preventive medicine code will be reimbursed at 100% of the allowable contracted rate. The E&M visit, when billed with modifier 25 to identify a separately identifiable service, will be subject to a 50% reduction. This payment reduction made on the E&M visit is due to the duplication of overlapping services (e.g., practice expense - costs associated with maintaining a practice) already being considered in the reimbursement of the preventive service.
Preventive Medicine Service Codes
- 99381-99387
99391-99397
E&M Services Codes
- 99202-99205
- 99211-99215
- 99242-99245
- G0245-G0246
- G0463
- S0285
- S0610
S0612
Optum Encoder Pro Evaluation and Management (E&M) Section Guidelines
None
Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.