CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Preventive Medicine and Other Evaluation and Management Office

Governs reimbursement when preventive medicine services and new or established evaluation and management (E&M) services are billed on the same date by the same provider or provider group; affects Blue Cross Blue Shield of Rhode Island participating providers and members.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPreventive Medicine and Other Evaluation and Management Office

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 7, 2007

Next Review DateN/A

Key ActionWhen preventive medicine and E&M are performed same date by same provider/group, only one service is reimbursed and modifier 25 does not affect payment; submit documentation for a separate same-day encounter if reporting a distinct office service.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

oneonly one service reimbursed when preventive and E&M billed same-day by same provider/group

99201-99215listed E&M CPT code range

99381-99387,99391-99397listed preventive medicine CPT code ranges

oneonly one copayment applies for the office visit when combined

modifier 25 not effective

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPreventive Medicine and Other Evaluation and Management Office

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 7, 2007

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Same-day Preventive and E&M Coverage Rules

Same-day preventive and E&M coverage rules

Conditions under which services are allowed or denied when billed same-day:

If a preventive medicine service and an office evaluation and management (E&M) service are performed on the same date by the same provider or the same group (same specialty), only one service will be reimbursed; payment will be allowed on the first service submitted.

Modifier 25 does not affect the allowance for same‑day preventive and E&M services.

Participating providers may not charge the member for the service that is not separately reimbursed; only one copayment will apply for the combined office visit.

Exception: If the patient is seen in a separate encounter on the same date by the same provider or provider group for a problem not present during the preventive exam, a separate office service may be reported and paid when submitted with supporting documentation. The appropriate copayment will apply for the second visit.

Services are covered when an E&M service and a preventive visit occur on the same date by providers of different specialties.

Applicable CPT code ranges: E&M 99201-99215; Preventive Medicine Services 99381-99387 and 99391-99397.

Applicable CPT Codes

Covered CPT Codes - Evaluation and ManagementCPTCovered

99201-99215

Evaluation and Management Codes

Covered CPT Codes - Preventive Medicine (new patient)CPTCovered

99381-99387

Preventive Medicine Services - new patient

Covered CPT Codes - Preventive Medicine (established patient)CPTCovered

99391-99397

Preventive Medicine Services - established patient

Billing and Documentation Requirements

Documentation Required

Same-day billing and documentation requirements

When a preventive medicine service and an office E&M service are performed the same date by the same provider or same group (same specialty), only one service will be reimbursed. Payment will be allowed on the first service submitted; modifier 25 does not affect the allowance. Participating providers may not charge the member for the service that is not separately reimbursed, and only one copayment applies. If the patient has a separate encounter on the same date for a problem not present during the preventive exam, submit documentation with the claim to support a separate office service so it may be reported and paid; the appropriate copayment applies for the second visit.

Only one service reimbursed when preventive and E&M billed same date by same provider/group; payment on first service submitted.
Modifier 25 does not change allowance.
Providers may not bill member for the non-reimbursed service; only one copayment applies for the combined office visit.
For a separate encounter on same date for an unrelated problem, submit claims with documentation to support separate office service; appropriate copayment applies for the second visit.

Key Terms

Same group — definition and implications

DefinitionSame group = same specialty (providers practicing in the same specialty group).

Reimbursement implicationIf preventive medicine and an office E&M are performed the same date by the same provider or same group (same specialty), only one service will be reimbursed; payment allowed on the first service submitted.

Modifier 25Modifier 25 does not affect allowance when preventive and E&M services are performed same date by the same provider/group.

Member billingParticipating physicians/providers may not charge the member for the service that is not separately reimbursed because the allowance is for the combined services.

CopaymentOnly one copayment will apply for the office visit when services are combined by the same provider/group.

DefinitionSeparate encounter same date = an office service provided on a separate encounter the same date for a problem that was not present during the preventive services exam.

Reporting requirementA separate office service may be reported and paid if the visit is for a distinct problem not present at the preventive exam and is submitted with supporting documentation, because claims systems cannot identify this circumstance automatically.

Copayment for second visitThe appropriate copayment will apply for the second visit on the same date of service.

Payment orderWhen services are not separate encounters, payment will be allowed on the first service submitted (only one service reimbursed).

Modifier 25 noteModifier 25 does not affect allowance; documentation of a separate encounter is required instead of relying on modifier 25.