CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Preventive Medicine and Other Evaluation and Management Office or Other Outpatient Services

This BCBSRI reimbursement policy governs payment when a preventive medicine E/M service and a new or established E/M office or other outpatient visit are billed for the same date by the same provider or same group, and explains when only one service is reimbursed and when separate payment may be allowed.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPreventive Medicine and Other Evaluation and Management Office or Other Outpatient Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionWhen the same provider or provider group sees a member on the same date for a separate encounter for a problem not present during the preventive exam, submit documentation to report a separate office service.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

99202-99215E/M codes listed

99381-99387; 99391-99397Preventive medicine CPTs

One copayCopayment rule

First serviceReimbursement rule

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Same-day preventive and problem-oriented E/M payment criteria

Payment rules when preventive medicine E/M and new/established E/M office or other outpatient visit are billed for the same date:

If a preventive medicine evaluation and management (E/M) service and a new or established E/M office or other outpatient visit are performed on 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 that is submitted; modifiers 25 or 27 do not affect allowance.

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

Exceptions (Medicare Advantage and Commercial)

If the member is seen on a separate encounter by the same provider or provider group (same specialty) on the same date for a problem that was not present during the preventive exam, a separate office service may be reported if claims are submitted with supporting documentation; the appropriate copayment applies for the second visit.
Services are covered if the preventive E/M and the new/established E/M office or other outpatient visit are provided on the same date by a provider of a different specialty.

Claims systems may not identify separate-encounter situations; submit documentation with the claim to support separate payment.

Documentation, Prior Authorization, and Billing Guidance

Documentation Required

Documentation for same-day separate encounter

Documentation for same-day separate encounter — When the same provider or provider group (same specialty) sees the member on the same date for a separate encounter for a problem that was not present during the preventive services exam, the separate office visit may be reported. Claims must include documentation showing the second visit addressed a distinct problem not present at the preventive visit. As claim systems cannot automatically identify this circumstance, submitters should include supporting clinical documentation with the claim. The appropriate copayment or cost share for the second visit applies.

Apply appropriate copayment for the second visit on the same date of service.
Include clinical documentation demonstrating the problem was not present at the preventive visit.

Prior Authorization

Prior authorization

Prior authorization: Not applicable.

Key Terms

Same provider/group

DefinitionSame provider or same group (same specialty)

Reimbursement implicationIf preventive medicine E/M and a new or established E/M office or other outpatient visit are performed on the same date by the same provider or same group, only one service will be reimbursed.

Submission order rulePayment will be allowed on the first service that is submitted; modifiers 25 or 27 do not affect allowance.

Member billingParticipating physicians/providers may not bill the member for the service that is not separately reimbursed.

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

Preventive medicine E/M

DefinitionPreventive medicine evaluation and management (E/M) service

Interaction with problem-oriented E/MWhen a preventive medicine E/M and a new or established E/M office or other outpatient visit occur the same date by the same provider/group, only one service is reimbursed.

Modifier guidanceModifiers 25 or 27 do not affect allowance for concurrent preventive and problem-oriented E/M services.

Documentation/payment notePayment is allowed on the first service submitted; the non-reimbursed service cannot be billed to the member.