Evaluation and Management (E/M) Services — Medicare Reimbursement Policy
Customize your policy alerts
Sign up for all Blue Cross Blue Shield - North Carolina policy alerts
Know when Blue Cross Blue Shield - North Carolina releases new policies or updates existing guidance.
Monitor payer policy activity
Rules for reimbursing Evaluation and Management (E/M) services for Blue Cross NC Medicare and associated plans, including limits on multiple same-day E/Ms, interactions with preventive and screening services, and related billing rules. Affects providers submitting claims for members covered under specified Blue Medicare and Healthy Blue + Medicare products.
No material clinical or coverage changes in this revision.
E/M Reimbursement Coverage Criteria
E/M reimbursement criteria
Reimbursement criteria and billing rules for Evaluation and Management (E/M) services.
Applicability and payment limitations
Applicability and limitations
Codes and Coding Rules
| CPT 99202-99215 | Problem-oriented office or other outpatient E/M services |
| CPT 99381-99397 | Preventive medicine services |
| HCPCS G0438 | Annual Wellness Visit initial |
| HCPCS G0439 | Annual Wellness Visit subsequent |
| HCPCS G0101 | Cervical or vaginal cancer screening; pelvic and clinical breast exam |
| HCPCS G0102 | Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal cytologic specimen |
| Q0091 | Screening Papanicolaou smear; performed under a screening program |
| CPT 99238-99239 | Hospital discharge day management |
| CPT 99358-99359 | Prolonged E/M service (non-face-to-face) — considered incidental |
| CPT | Use appropriate CPT codes for billed services |
| HCPCS | Use appropriate HCPCS codes for billed services |
| Revenue | Use appropriate revenue codes where applicable |
Provider Billing, Documentation, and Prior Authorization
Report one cumulative E/M per member per day; use Modifier 25 only for significant, separately identifiable services
When multiple related E/M services are provided on the same date of service for the same member by the same group practice, report a single cumulative E/M for that member for the date of service. Use Modifier 25 only when the E/M is significant and separately identifiable from a same-day procedure or immunization; E/Ms performed the same day as a 0- or 10-day global surgical package or critical care are included in those services unless Modifier 25 documents separateness.
- Limit reimbursement to one cumulative E/M service per member per date of service for related services by the same group practice.
- Report Modifier 25 to indicate a significant, separately identifiable E/M when performed same day as a procedure, immunization, or global surgical service.
- Screening services same day as AWV/preventive/problem-oriented E/M are not separately reimbursable regardless of Modifier 25; cervical/vaginal cancer screening or Pap smear may require Modifier 25 to be eligible for separate payment.
Only the attending physician may report one discharge day management service per hospital stay
Only one hospital discharge day management service (CPT 99238–99239) is allowed per member per hospital stay and only the attending physician may report the discharge day management service.
- Subsequent discharge day management services for the same hospital stay/date of service are not eligible for reimbursement after the initial claim has been processed.
Bill with appropriate CPT/HCPCS/revenue codes and support claims with medical record documentation
Bill services using the appropriate CPT, HCPCS, and/or revenue codes and ensure each claim is supported by the member’s medical record documentation; this includes any AI-generated content, recordings, or transcripts when applicable.
- Maintain medical records consistent with scope of practice, regulatory, and licensure requirements to substantiate billed services.
- Providers are responsible for accurate coding and must support billed services with documentation in the medical record.
Noncompliance with coding or documentation may result in claim review, denial, or recovery
Failure to follow the coding and reimbursement guidelines in this policy may prompt claim review, denial, or recovery of payment.
- Blue Cross NC reserves the right to review and revise reimbursement policies and to adjudicate claims according to coding hierarchy and fee schedules.
- Providers who do not comply with the policy’s coding or documentation requirements risk denial or recovery of payments.
Definitions
Background and Related Info
This policy describes Blue Cross Blue Shield of North Carolina’s reimbursement rules for Evaluation and Management (E/M) services. It establishes that Blue Cross NC will reimburse E/M services only in accordance with the specific criteria and billing rules outlined herein, including limits when multiple related E/M services are provided on the same date by the same group practice, interactions between preventive/Annual Wellness Visit (AWV) services and problem‑oriented E/M services, and treatment of screening, immunization, observation, discharge, and prolonged services.
The policy applies to Blue Medicare HMO, Blue Medicare PPO, Blue Medicare Rx, Healthy Blue + Medicare (HMO‑POS D‑SNP), and third‑party Medicare plans administratively supported by Blue Cross NC. It affects participating and non‑participating providers who submit claims for members covered under these products and requires adherence to CPT® and HCPCS coding guidance as well as documentation standards.
Policy Revision History
Policy effective date and most recent review recorded; Blue Cross NC reserves right to review and revise reimbursement policies periodically.
Next policy review scheduled on 2026-06-01 per document metadata.
Effective date: 2026‑08‑15. Last review date: 2026‑08‑15. Next review scheduled: 2026‑06‑01.
There is no material change indicated to the policy. The policy continues to limit reimbursement to one cumulative E/M service per member per day for related services from the same group practice, specifies the 50% reimbursement rule when Preventive Medicine (CPT 99381‑99397) is billed with an AWV (HCPCS G0438‑G0439), and maintains the up to 50% reimbursement rule for problem‑oriented E/M (CPT 99202‑99215) billed the same day as AWV or Preventive Medicine. Providers should confirm member benefits via the member’s Evidence of Coverage (EOC) as benefits may vary by contract.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.