CurrentCentenePolicy CC.PP.052

Problem Oriented Visits Billed with Surgical Procedures

Defines Centene's payment rules for evaluation and management (E&M) problem‑oriented visits billed on the same day as surgical procedures with 0-, 10- or 90-day global periods and applies to physicians and other qualified health professionals.

Policy Summary

PayerCentene

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 code and the surgical procedure code on the same date for clinical claims review; if validated, the surgical procedure is reimbursed and 50% of the E&M is paid.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

50%reimbursement rate when validated

0-, 10-, 90-dayglobal surgical periods

CC.PP.013related policy

99202-99205 / 99212-99215example CPT codes

2017-2025revision history

Coverage Criteria

Coverage criteria for problem-oriented E&M on same day as surgery

When a problem-oriented E&M is billed the same day as a surgical procedure with a 0-, 10- or 90-day global period:

If clinical claims review (regardless of presence of modifier -25) supports the E&M as significant and separately identifiable, reimburse the surgical procedure plus 50% of the problem-oriented E&M code.

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.

Health plan conducts 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 period regardless of whether modifier -25 is present.

Providers should not be reimbursed for duplicate indirect expenses (for example, vital signs, scheduling, room costs, staffing, lighting, and basic examination room supplies) that are not consumed twice; reimbursement should avoid duplication for these services.

Policy Summary

PayerCentene

PolicyProblem Oriented Visits Billed with Surgical Procedures

Policy CodePolicy CC.PP.052

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

Coding — E&M and Modifiers

Covered CPT CodesCPTCovered

99202	Office or other outpatient visit for the evaluation and management of a new patient; requires medically appropriate history and/or examination and straightforward medical decision making. Time-based selection: >= 15 minutes total time on date of encounter.
99203	Office or other outpatient visit for the evaluation and management of a new patient; requires medically appropriate history and/or examination and low level of medical decision making. Time-based selection: >= 30 minutes total time on date of encounter.
99204	Office or other outpatient visit for the evaluation and management of a new patient; requires medically appropriate history and/or examination and moderate level of medical decision making. Time-based selection: >= 45 minutes total time on date of encounter.
99205	Office or other outpatient visit for the evaluation and management of a new patient; requires medically appropriate history and/or examination and high level of medical decision making. Time-based selection: >= 60 minutes total time on date of encounter.
99212	Office or other outpatient visit for the evaluation and management of an established patient; requires medically appropriate history and/or examination and straightforward medical decision making. Time-based selection: >= 10 minutes total time on date of encounter.
99213	Office or other outpatient visit for the evaluation and management of an established patient; requires medically appropriate history and/or examination and low level of medical decision making. Time-based selection: >= 20 minutes total time on date of encounter.
99214	Office or other outpatient visit for the evaluation and management of an established patient; requires medically appropriate history and/or examination and moderate level of medical decision making. Time-based selection: >= 30 minutes total time on date of encounter.
99215	Office or other outpatient visit for the evaluation and management of an established patient; requires medically appropriate history and/or examination and high level of medical decision making. Time-based selection: >= 40 minutes total time on date of encounter.

Covered HCPCS CodesHCPCSCovered

G0463

Hospital outpatient clinic visit for assessment and management of a patient.

ModifiersModifier

25	Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service.
57	Decision for Surgery.

inv-03: Time‑based code selection thresholds

99202-99205 time thresholds99202 >=15 min; 99203 >=30 min; 99204 >=45 min; 99205 >=60 min

99212-99215 time thresholds99212 >=10 min; 99213 >=20 min; 99214 >=30 min; 99215 >=40 min

G0463Hospital outpatient clinic visit for assessment and management

Provider Actions and Billing Expectations

Note

Submit Both E&M and Procedure; Expect Clinical Claims Review and Reduced E&M Payment

Submit both the problem‑oriented E&M CPT code and the surgical procedure code on the same date of service; the health plan will perform clinical claims review to validate whether the E&M is a significant and separately identifiable service. If clinical review supports the E&M, the surgical procedure is reimbursed and 50% of the E&M will be paid. If the E&M resulted in the decision to perform surgery within the global period, append modifier -57 to the E&M for consideration of payment.

Clinical validation follows CC.PP.013 for modifier -25 determinations.
Health plan conducts clinical claims review for E&M + surgery combinations for procedures with 0-, 10- or 90-day global periods regardless of presence of modifier -25.
Reimbursement avoids duplicate payment for indirect expenses (vitals, scheduling, room costs).

Definitions

Global Surgical Procedure

DefinitionProcedures with a 0-, 10- or 90-day postoperative period including follow-up office visits related to recovery from the surgery.

ScopeIncludes post-operative follow-up visits during the global period that are related to recovery from the surgery.

Payment contextWhen a problem-oriented E&M is billed the same day as a surgical procedure within a global period, clinical validation determines if reduced-rate E&M reimbursement applies.

Problem‑Oriented Evaluation and Management Service

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

When billed with surgeryA problem-oriented E&M may be submitted on the same date as a surgical procedure; clinical claims review will determine if it is significant and separately identifiable for reduced reimbursement.

Documentation examples for reimbursementReimbursement recommended if any one condition met: first time provider has seen patient for major condition; separate diagnosis on claim; worsening condition with diagnostic procedures; provider billed unrelated supplies/equipment on/around DOS.

Modifier -25

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

Billing implicationA provider may submit both a problem-oriented E&M CPT and a surgical procedure code on the same date; if clinically validated, the E&M is reimbursed at a reduced rate.

Clinical validation referenceClinical validation process referenced: see policy CC.PP.013 for clinical validation of Modifier -25 determinations.