Multiple Evaluation and Management (E/M) Services
This document governs Humana's billing requirements and reimbursement for multiple E/M services performed on the same day by the same provider under Kentucky Medicaid; it affects providers submitting professional E/M claims to Humana for Kentucky Medicaid members.
No material clinical or coverage changes in this revision.
Coverage Criteria for Multiple E/M Services
Coverage criteria for multiple E/M services
Covered when ALL of the following are met:
Applies to professional services; claims remain subject to medical necessity, reasonableness, and applicable referral/authorization requirements.
Exception (allows both services when):
- A problem-oriented E/M service and a preventive E/M service are both performed on the same date by the same provider.
- The problem-oriented E/M service is reported with modifier 25.
Modifier 25 = significant, separately identifiable E/M service by the same clinician on the same day.
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