CurrentFlorida BluePolicy 10-016

Multiple Visit Reduction (preventive medicine and problem-oriented E/M same-day reimbursement)

Governs reimbursement when a preventive medicine E/M and a problem-oriented E/M are billed for the same patient, same provider, same date of service for Florida Blue members across all lines of business.

Policy Summary

PayerFlorida Blue

PolicyMultiple Visit Reduction (preventive medicine and problem-oriented E/M same-day reimbursement)

Policy CodePolicy 10-016

Change TypeTelemedicine codes added; billing clarification

Effective DateDec 22, 2009

Next Review Date

Key ActionAppend modifier 25 to the problem-oriented E/M when it is significant and separately identifiable; reimbursement = preventive medicine code + 50% of the problem-oriented E/M.

SourceLink

POLICY UPDATE CHANGES

Telemedicine E/M Services CPT® codes 98000-98007 (synchronous audio-video) and 98008-98015 (synchronous audio-only) were added to the policy.

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

50%reimbursement when significant

1policy id

2009-12-22original effective

2025-08-14most recent revision

98000-98015telemedicine codes

Same-day Preventive and Problem-Oriented E/M Coverage

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

Covered when ALL of the following conditions are met:

ALL of the following

ONE of
- A preventive medicine E/M code is performed on the same patient, same physician, same date of service.
- A problem-oriented E/M service is performed the same day and is significant enough to require additional work to perform the key components of a problem-oriented E/M service (i.e., the abnormality or preexisting problem is not insignificant or trivial).
The problem-oriented E/M is significant and separately identifiable from the preventive medicine service; modifier 25 is appended to the problem-oriented E/M code to indicate the separately identifiable E/M service.

Policy Summary

PayerFlorida Blue

PolicyMultiple Visit Reduction (preventive medicine and problem-oriented E/M same-day reimbursement)

Policy CodePolicy 10-016

Change TypeTelemedicine codes added; billing clarification

Effective DateDec 22, 2009

Next Review Date

Key ActionAppend modifier 25 to the problem-oriented E/M when it is significant and separately identifiable; reimbursement = preventive medicine code + 50% of the problem-oriented E/M.

SourceLink

On This Page

Applicable Codes and Time-Based Selection

Preventive and problem-oriented E/M and related codes (CPT/HCPCS/Local)mixed

98000	Synchronous audio-video visit - new patient, straightforward MDM (time-based: >=15 minutes)
98001	Synchronous audio-video visit - new patient, low MDM (time-based: >=30 minutes)
98002	Synchronous audio-video visit - new patient, moderate MDM (time-based: >=45 minutes)
98003	Synchronous audio-video visit - new patient, high MDM (time-based: >=60 minutes)
98004	Synchronous audio-video visit - established patient, straightforward MDM (time-based: >=10 minutes)
98005	Synchronous audio-video visit - established patient, low MDM (time-based: >=20 minutes)
98006	Synchronous audio-video visit - established patient, moderate MDM (time-based: >=30 minutes)
98007	Synchronous audio-video visit - established patient, high MDM (time-based: >=40 minutes)
98008	Synchronous audio-only visit - new patient, straightforward MDM, >10 min discussion (time-based: >=15 minutes)
98009	Synchronous audio-only visit - new patient, low MDM, >10 min discussion (time-based: >=30 minutes)

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Time-based code selection minima

Time-based selection minima — selected codesSee individual code descriptions above; common time thresholds include: 99212=10 min; 99213=20 min; 99214=30 min; 99215=40 min; 99202=15 min; 99203=30 min; 99204=45 min; 99205=60 min; select E/M by total time on date of encounter when documented.

Billing, Modifier, and Submission Requirements

Billing Rule

Append modifier 25 and reimbursement = preventive + 50% of problem‑oriented E/M

If a problem-oriented E/M is significant and separately identifiable in the same visit as a preventive medicine E/M, append modifier 25 to the problem-oriented E/M; reimbursement will be the preventive medicine code reimbursement plus 50% of the problem-oriented E/M code reimbursement.

Applies when the problem requires additional work to perform key components of a problem-oriented E/M.
If the problem is insignificant or trivial and does not require additional work, report only the preventive medicine E/M.

Documentation Required

Billing form and definition of “same provider”

This policy applies to billing for services on a CMS-1500 or equivalent claim form. For purposes of this policy, “same provider” includes all physicians and/or other health care professionals reporting under the same Federal Tax Identification number.

Key Definitions

Significant, Separately Identifiable E/M (Modifier 25)

DefinitionSignificant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service.

Modifier to append25 — add to the problem-oriented E/M code to indicate a significant, separately identifiable E/M provided the same day as a preventive service.

Reimbursement impactWhen the problem-oriented E/M is significant and separately identifiable, reimbursement = preventive medicine code reimbursement + 50% of the problem-oriented E/M code reimbursement.

Same provider (definition and billing scope)

Scope of 'same provider'Includes all physicians and/or other health care professionals reporting under the same Federal Tax Identification number for purposes of this policy.

Applicable claim formThis policy applies to billing for services on a CMS-1500 or equivalent claim form.

ContextUsed to determine when a preventive medicine E/M and problem-oriented E/M billed the same day are considered by the same provider for reimbursement adjustment.