CurrentArizona Complete HealthPolicy CC.PP.052

Problem Oriented Visits Billed with Surgical Procedures

Defines payment and documentation criteria for billing problem-oriented evaluation and management (E&M) services on the same day as surgical procedures with 0-, 10-, or 90-day global periods for physicians and other qualified health professionals.

Policy Summary

PayerArizona Complete Health

PolicyProblem Oriented Visits Billed with Surgical Procedures

Policy CodePolicy CC.PP.052

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit both the problem-oriented E&M CPT and the surgical procedure code on the same date for clinical claims review; if validated, the procedure is reimbursed plus 50% of the E&M.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

50%reimbursement rate for problem-oriented E&M when billed with surgery (if clinically validated)

0-/10-/90-dayglobal surgical periods referenced

CC.PP.013clinical validation policy referenced

Multiple CPTsexample E&M codes included

Problem-oriented E&M with Surgical Procedures

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Problem-oriented E&M with surgical procedures

Payment and documentation criteria when an E&M is billed on the same date as a surgical procedure with a global period.

If clinical claims review supports that the problem-oriented E&M is significant and separately identifiable, the health plan will reimburse the surgical procedure plus 50% of the problem-oriented E&M code.

The health plan conducts a clinical claims review of E&M and surgery coding combinations when a problem-oriented visit is billed with a surgical procedure with a 0-, 10- or 90-day global surgical period regardless of whether modifier -25 is present.

If the E&M service resulted in the decision to perform surgery, append modifier -57 to the E&M procedure code for consideration of payment when the decision for surgery was made within the global surgical period.

Reimbursement recommended if ANY of the following documentation criteria are met:

E/M service is the first time the provider has seen the patient or evaluated a major condition.
A diagnosis on the claim indicates a separate medical condition was treated in addition to the procedure performed.
Patient's condition is worsening as evidenced by diagnostic procedures performed on or around the date of service.
Provider billed supplies or equipment on or around the same date that are unrelated to the procedure but would have required an E/M service to determine the patient's need.

Referenced E&M, Modifier and Time Threshold Codes

Referenced E&M and modifier codesCPT

99202	Office/outpatient visit for a new patient; straightforward; 15 minutes
99203	New patient; low level MDM; 30 minutes
99204	New patient; moderate MDM; 45 minutes
99205	New patient; high MDM; 60 minutes
99212	Established patient; straightforward; 10 minutes
99213	Established patient; low level MDM; 20 minutes
99214	Established patient; moderate MDM; 30 minutes
99215	Established patient; high MDM; 40 minutes
G0463	Hospital outpatient clinic visit for assessment and management
25	Modifier -25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service

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1/2

Time thresholds for code selection

9920215 minutes (new patient; straightforward)

9920330 minutes (new patient; low MDM)

9920445 minutes (new patient; moderate MDM)

9920560 minutes (new patient; high MDM)

9921210 minutes (established patient; straightforward)

9921320 minutes (established patient; low MDM)

GuidanceWhen using total time on the date of the encounter for code selection, the specified minutes for each CPT must be met or exceeded.

Submission and Clinical Review

Billing Rule

Submit both problem‑oriented E&M CPT and surgical procedure code on same date; clinical claims review will determine if E&M is significant and separately identifiable.

Modifier -25 represents a significant and separately identifiable E&M service by the same physician or other qualified health care professional on the same day of the procedure or other service. A physician or other qualified health professional may submit both a problem‑oriented E&M CPT code and a surgical procedure code on the same date of service for the same member. The health plan will perform clinical claims review (see CC.PP.013 Clinical Validation of Modifier -25) to determine whether the problem‑oriented E&M is significant and separately identifiable. If clinical review supports that the E&M is significant and separately identifiable, the E&M procedure will be reimbursed at a reduced rate.

Providers may submit both a problem‑oriented E&M CPT and a surgical procedure code on the same date for the same member.
The health plan conducts clinical claims review of E&M + surgery coding combinations when a problem‑oriented visit is billed with a surgical procedure with a -0, -10, or -90 day global surgical period, regardless of whether modifier -25 is present.
If clinical review supports a significant and separately identifiable E&M, reimbursement is the surgical procedure plus 50% of the problem‑oriented E&M code.
If the E&M service resulted in the decision to perform surgery and that decision was made within the global surgical period, append modifier -57 to the E&M code for consideration of payment.

Key Terms

Global Surgical Procedure

Global periods referenced0-, 10- or 90-day postoperative period that includes follow-up visits related to recovery.

Included visitsFollow-up office visits during the global period that are related to recovery from the surgery.

ApplicabilityApplies to procedures with defined global surgical periods when evaluating same-day E&M billing.

Problem-Oriented Evaluation and Management Service

DefinitionAn abnormality or preexisting condition encountered during a patient’s preventative E&M that requires additional physician work to perform the key components of a problem-oriented E&M service.

ContextUsed to determine when an E&M on the same day as a procedure represents separate, payable work beyond routine preoperative or postoperative care.

Reimbursement noteIf clinically validated as problem-oriented, the E&M may be reimbursed at a reduced rate when billed with a surgical procedure.

Modifier -25

DefinitionModifier -25 indicates a significant and separately identifiable E&M service by the same physician or qualified health professional on the same day as a procedure or other service.

BillingA provider may submit both a problem-oriented E&M CPT code and a surgical procedure code on the same date of service for the same member when appropriate.

Clinical validationOnce clinically validated (see CC.PP.013), a significant, separately identifiable problem-oriented E&M may be reimbursed at a reduced rate in addition to the surgical procedure.