CurrentFlorida BluePolicy 20-068

Evaluation and Management Services by Physicians in the Same Group Practice

Defines Florida Blue's coverage and reimbursement approach when multiple E/M services for the same patient are reported by physicians in the same group and specialty on the same date; applies to billing on a CMS-1500 or equivalent claim form and affects providers across all lines of business.

Policy Summary

PayerFlorida Blue

PolicyEvaluation and Management Services by Physicians in the Same Group Practice

Policy CodePolicy 20-068

Change TypeClarification

Effective Date06/15/2020

Next Review Date

Key ActionOnly one E/M service may be reported for the same patient on the same day by physicians in the same group and specialty unless the services are for unrelated problems; select a level representative of the combined visits.

SourceLink

POLICY UPDATE CHANGES

Clarifying language added to indicate this policy applies to billing for services on a CMS-1500 or equivalent claim form.

1payment policy identifier

06/15/2020Original effective date

06/12/2025Most recent revision date

All LOBpolicy applicability

Coverage Criteria for Same-Day E/M Services

Coverage criteria for same-day E/M services

When multiple E/M services for the same patient on the same date are reported by physicians in the same group and specialty:

Treat physicians in the same group practice who are in the same specialty as a single physician for E/M reporting; only one E/M service may be reported for the same patient on the same date unless the E/M services are for unrelated problems.

If services are for unrelated problems, separate E/M codes may be reported when documentation supports that the services addressed separate, distinct problems.

Physicians in the same group practice who have different specialties may bill and be paid without regard to their membership in the same group.

ALL of the following

The E/M visit was provided prior to the critical care services at a time when the patient did not require critical care.

Policy Summary

PayerFlorida Blue

PolicyEvaluation and Management Services by Physicians in the Same Group Practice

Policy CodePolicy 20-068

Change TypeClarification

Effective Date06/15/2020

Next Review Date

SourceLink

On This Page

E/M Coding, Modifiers, and Allowed Multiple E/M

E/M coding and modifier guidanceCPT

Refer to current AMA CPT manual for E/M codes and selection guidance; use modifier 25 for same-day significant, separately identifiable E/M when billed with critical care per CMS guidance.

Same-day multiple E/M allowance

Policy allowanceOnly one evaluation and management (E/M) service may be reported per patient per day when provided by the same physician or by more than one physician in the same specialty and group; physicians should select a level representative of the combined visits.

Exception — unrelated problemsMultiple E/M services may be reported on the same day if the services are for unrelated problems (separate, distinct problems) and are documented as such.

Different specialties in same groupPhysicians in the same group practice who have different specialties may bill and be paid without regard to group membership.

Critical care interactionWhen an E/M visit and critical care occur on the same calendar date, both may be billed if documentation shows the E/M occurred prior to critical care, services were medically necessary, and were separate and distinct; report modifier 25 for the E/M.

Billing and Provider Guidance

Billing Rule

Same-day multiple E/M billing guidance

If more than one E/M face-to-face service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one E/M service may be reported unless the services are for unrelated problems; physicians should select a level representative of the combined visits. When an E/M visit and critical care occur on the same calendar date, both may be billed if the E/M was provided prior to the critical care, services were medically necessary, and services were separate and distinct; report modifier 25 for the E/M when documentation supports separation.

Treat physicians in the same group and same specialty as a single physician for E/M reporting; report only one E/M per patient per day unless documented as unrelated problems.
Select and report the single E/M code level that represents the combined visits rather than billing multiple E/M codes.
If E/M and critical care occur same day and documentation shows the E/M was prior, medically necessary, and distinct, bill both and append modifier 25 to the E/M.

Definitions

Same group practice

DefinitionPhysician and/or other qualified health care professionals with the same specialty reporting the same Federal Tax Identification number are considered providers in the same group.

Implication for billingProviders in the same group and same specialty must bill and be paid as though they were a single physician for E/M services on the same day.

ScopeApplies to services billed on a CMS-1500 or equivalent claim form.

Unrelated problems

DefinitionUnrelated problems are separate, distinct problems for which E/M services may be reported multiple times on the same day when documentation supports that the problems and services were distinct.

Documentation requirementMedical record must document that each E/M was for a distinct problem to permit multiple E/M reporting on the same date.

Relation to combined visits ruleIf problems are not unrelated, physicians in the same specialty/group should select a single E/M level representative of the combined visits rather than billing separately.