ModifiedEmblemHealthPolicy RPC2O220023

Evaluation and Management (E/M) Services Reimbursement

This policy governs reimbursement, documentation, coding and payment rules for Evaluation and Management (EIM/E/M) services (office/outpatient, ED, consultations, time/MDM rules) for EmblemHealth commercial, Medicare and Medicaid plans. It affects physicians and other qualified health care professionals billing E/M services to EmblemHealth.

Policy Summary

PayerEmblemHealth

PolicyEvaluation and Management (E/M) Services Reimbursement

Policy CodePolicy RPC2O220023

Change TypeMaterial updates to MDM/Time selection and G2211 billing rules

Effective DateSep 1, 2022

Next Review Date

Key ActionDocument E/M visits using either the revised 4-level MDM or total time and retain supporting records for audits.

SourceLink

POLICY UPDATE CHANGES

Office and outpatient E/M visits (99202-99205; 99211-99215) adopt the 4-level MDM structure effective January 1, 2023 and allow clinicians to select level based on MDM or total time.

EmblemHealth will consider payment for add-on CPT code G2211 when reported with new and established patient E/M services effective 1/1/2024 for applicable lines; Medicaid-specific rule about G2211 and modifier 25 effective 1/1/2025.

4E/M office/outpatient code levels (per updated MDM effective 1/1/2023)

99202-99205; 99211-99215Primary office/outpatient E/M CPT ranges addressed

G2211Add-on code addressed for visit complexity (payment considered 2024; Medicaid rule 2025)

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99242-99245; 99252-99255Consultation codes not reimbursed

oneE/M service reimbursed per patient per day from same provider/group

modifier 25Modifier 25 allowed in certain same-day circumstances

Coverage and Documentation Requirements

E/M documentation and bundling criteria

Covered when ALL of the following documentation and billing requirements are met:

Medical record must be complete, legible, dated, authenticated, and include the provider's signature; amendments must be signed and dated and clearly identifiable.

Diagnoses and treatment codes reported on the claim must be supported by the medical record.

Entries must include practitioner name and credentials; records must be documented by the provider/observer of services or a certified scribe; vitals, ROS and PFSH may be documented by ancillary staff but must be reviewed and attested by the physician or non-physician practitioner.

Time may be used to select office/outpatient E/M level when appropriately documented; acceptable time elements include start/end times and activities such as exam/evaluation, counseling/education, prep, documentation/interpretation, care coordination, orders and communications.

Exclude from time totals: time spent by clinical staff, patient wait time, travel, general teaching not specific to the patient, and distinct procedures performed the same day as the E/M visit.

Routine pre- and post-procedural E/M work is bundled into the procedure global payment and is not separately reportable unless a significant, separately identifiable E/M service is performed; if so, report the E/M code with modifier 25 and ensure documentation supports the separate service.

G2211 add-on guidance: bill per CMS examples; EmblemHealth will consider payment for G2211 with applicable E/M services per policy and applicable lines; G2211 must not be reported with modifier 25 per Medicaid-specific timing rules as described in policy.

Examples of non-covered or bundled services

Consultation CPT codes 99242-99245 and 99252-99255 are not reimbursed; use non-consultative E/M codes that best describe the service.
E/M services that are usual pre/post procedural work for a minor surgery (0- or 10-day global period) or for endoscopic/diagnostic/therapeutic procedures are included in the procedure payment and are not separately reimbursable unless a significant, separately identifiable E/M service is performed.

E/M reimbursement criteria

EmblemHealth reimburses E/M services subject to the following exclusions, bundling rules, same-day limits, and modifier requirements:

Consultation CPT codes 99242-99245 and 99252-99255 are excluded from reimbursement; report the non-consultative E/M code that best describes the service provided.

When E/M work is part of routine pre/post-procedure care included in a procedure's global period, separate E/M reimbursement is not allowed; modifier 25 should not be used to bypass bundling unless a significant, separately identifiable E/M service occurred and is documented.

When a significant, separately identifiable E/M service occurs on the same day as a minor surgery or endoscopic/diagnostic/therapeutic procedure, report the E/M code with modifier 25 and ensure documentation supports the separate service.

Only one E/M service per patient per day will be reimbursed when multiple providers within the same billing group and same specialty (same TIN) bill for E/M services on the same day; exception if one service is a per-day code.

Coding Rules and Code Lists

Consultation CPT Codes — Not ReimbursedCPTNot Covered

99242	Consultation — Office or other outpatient visit, typically 30 minutes
99243	Consultation — Office or other outpatient visit, typically 40 minutes
99244	Consultation — Office or other outpatient visit, typically 60 minutes
99245	Consultation — Office or other outpatient visit, typically 80 minutes
99252	Initial inpatient consultation, low complexity
99253	Initial inpatient consultation, moderate complexity
99254	Initial inpatient consultation, high complexity
99255	Initial inpatient consultation, comprehensive, high complexity

Office/Outpatient E/M CPT Codes — Covered (general guidance)CPTCovered

99202-99205	New patient office/outpatient E/M codes — use MDM or Time; 4-level MDM effective 1/1/2023
99211-99215	Established patient office/outpatient E/M codes — use MDM or Time; 4-level MDM effective 1/1/2023

Office/Outpatient MDM Levelsmixed

4-level MDM

Effective 1/1/2023: CMS adopted AMA revised MDM guidance reducing office/outpatient E/M to 4 levels. Clinicians may choose level based on MDM or total Time spent.

Per-day E/M Reimbursement Limitmixed

Single E/M per patient per day

EmblemHealth reimburses only one E/M service per patient per day from the same provider/group (same TIN). Exception: when one of the E/M services is a 'per day' code or when visits are for different specialties or different groups and billed with different diagnoses. Modifier 25 allowed only for separate visits at different times of day for unrelated problems; documentation may be required (appeal/notes).

Provider Responsibilities and Billing Actions

Documentation Required

Medical record requests for audit

EmblemHealth may request medical records for audit when a provider's billing pattern deviates significantly from peers or when claim attributes indicate possible billing errors; records must be made available upon request for review.

Prior Authorization

Modifier and same-day visit actions

Append Modifier 25 only when documentation shows a significant, separately identifiable E/M service on the same day as a preventive visit or minor procedure; such claims must include medical record evidence and may initially deny and require appeal or notes to substantiate medical necessity. Use Modifier 57 when the E/M results in the initial decision for a major (90‑day global) surgery; the decision must be documented and available upon request. Only one E/M service per patient per day is reimbursed when billed by providers within the same billing group and specialty (same TIN), except when a per‑day code applies.

Modifier 25: allowed for separate, significant E/M on same day as preventive visit or minor surgery when documentation supports separate work; documentation components from the preventive visit cannot be double‑counted.

Key Definitions

New patient

DefinitionNew patient: a patient who has not received any professional services from the physician or other qualified health care professionals of the same specialty in the same group practice (same TIN) within the past three years.

Considered providersIncludes other qualified health care professionals (e.g., physician assistants, nurse practitioners) of the same specialty in the same group (same TIN).

PurposeUsed to determine billing status for new versus established patient E/M coding.

Established patient

DefinitionEstablished patient: a patient who has received professional services within the past three years by the same provider or other qualified health care professionals of the same specialty in the same group practice reporting the same TIN.

Includes

Policy Summary

PayerEmblemHealth

PolicyEvaluation and Management (E/M) Services Reimbursement

Policy CodePolicy RPC2O220023

Change TypeMaterial updates to MDM/Time selection and G2211 billing rules

Effective DateSep 1, 2022

Next Review Date

Key ActionDocument E/M visits using either the revised 4-level MDM or total time and retain supporting records for audits.

SourceLink

On This Page

Modifier 25 may be allowed when two separate visits occur at different times of day for unrelated problems that could not reasonably have been addressed in a single encounter; such claims may initially deny and require appeal or supporting notes.

Only one hospital visit per physician per patient per day is reimbursed; separate hospital visits may be reimbursed when physicians are different specialties or different groups (different TIN) and bill different diagnoses.

E/M services that result in the initial decision to perform a major procedure (90-day global) may be eligible for separate reimbursement when reported with modifier 57, when the decision occurs pre-operatively or on the same day, and when documentation supports the decision; modifier 57 does not override denials for excluded scenarios (e.g., services that were solely preoperative evaluations or associated with planned/staged major surgery).

EmblemHealth applies same-day/same-service edits consistent with CPT and CMS NCCI guidance (for example, disallowing initial and subsequent per diem E/M services on the same date and other specified code pairings); follow applicable coding guidance to avoid denials.

Claims may be subject to postpayment audit; documentation inconsistencies can result in education, pre-pay review, SIU referral, recoupment, or termination of in-network status.

Modifier 57: append when E/M results in decision for major (90‑day global) surgery; decision must be documented and available upon request.

Per‑day limit: EmblemHealth reimburses only one E/M per patient per day per provider group/specialty (same TIN); exceptions for per‑day codes or different specialties/groups with different diagnoses.

Applies to services by other qualified health care professionals in same specialty and group (same TIN).

TimeframeThree-year lookback period to determine established status.

Cloned documentation

DefinitionCloned documentation: records that appear copied/pasted or replicated from another record (EHR or paper), including HPI, exam, or MDM content.

AcceptabilityCloned documentation would not be acceptable to support the claim as billed.

TemplatesUse of proprietary templates is not prohibited, but templates with prepopulated responses are strongly discouraged.

Medical Decision Making (MDM)

ComponentsMDM includes: number and complexity of problems addressed; amount and/or complexity of data reviewed and analyzed; and risk of complications and/or morbidity or mortality of patient management.

ExclusionsInterpretation/report codes (e.g., ECG interpretation codes) should not be counted in MDM or reported time when those services are separately reported.

Use in level selectionMDM is an allowed basis for selecting the appropriate E/M level per policy and AMA/CMS guidance.

Consultation services

DefinitionConsultation services: E/M services requested by a physician or qualified healthcare professional to obtain advice or an opinion concerning a specific condition or problem.

Reimbursement stanceEmblemHealth will not reimburse consultation CPT codes 99242-99245 and 99252-99255; use non-consultative E/M codes that best describe the service.

Coding noteProviders should select the E/M code that accurately describes the service provided rather than consultation codes excluded by policy.

Major vs Minor Surgery (Global Days)

Major vs Minor surgery by global daysMajor surgery: procedures with a 90 post‑operative day global period; Minor surgery: procedures with 0 or 10 post‑operative day global periods per CMS NPFS global surgery indicator.

Implication for E/ME/M services that result in the initial decision to perform major surgery (90‑day global) may be eligible for separate reimbursement when reported with modifier 57 and documentation supports the decision.

Global period basisClassification follows the CMS National Physician Fee Schedule (NPFS) global surgery days field.

Modifier 25

DefinitionModifier 25: indicates a significant, separately identifiable E/M service on the same day as a procedure or preventive visit when additional work beyond the usual pre/post procedural or preventive components is documented.

When to appendUse modifier 25 when a significant, separately identifiable problem‑oriented E/M service is performed the same day as a preventive visit or minor procedure and documentation supports both services.

Documentation requirementMedical record documentation must support both the separate E/M service and the procedure/preventive service components; claims may require appeal or notes to substantiate medical necessity.

Modifier 57

DefinitionModifier 57: indicates the E/M service resulted in the decision to perform surgery (decision for surgery), typically for major procedures (90‑day global).

When it permits separate reimbursementE/M services that result in the initial decision for a major procedure may be eligible for separate reimbursement when reported with modifier 57, when the decision is documented, and when other policy conditions are met.

LimitationsAppending modifier 57 will not override denials for E/M services associated with planned/staged major surgery, E/M solely for preoperative evaluation, or E/M for minor procedures where the E/M is bundled into the global fee.