CurrentHumanaPolicy CP2024009

Multiple Evaluation and Management (E/M) Services

Governs Humana's billing requirements and reimbursement when multiple E/M services are performed on the same day by the same provider for Kentucky Medicaid members; affects professional providers submitting claims to Humana for Kentucky Medicaid.

Policy Summary

PayerHumana

PolicyMultiple Evaluation and Management (E/M) Services

Policy CodePolicy CP2024009

Change TypeNo material change

Effective DateJun 1, 2024

Next Review Date

Key ActionAllow only one E/M per provider per date of service unless both a problem-oriented E/M and a preventive E/M are performed the same day; report the problem-oriented E/M with modifier 25 and support it in the medical record.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1E/Ms allowed per day by same provider

2Allowed when problem-oriented + preventive

25Modifier required

Kentucky MedicaidApplicable program

Same-day Multiple E/M Coverage

Same-day multiple E/M coverage criteria

Covered when ALL of the following apply:

General rule: Humana allows one E/M service when multiple E/M services are performed on the same date by the same provider.

Exception (allows both):

Both a problem-oriented E/M and a preventive E/M are performed on the same date by the same provider.
The problem-oriented E/M is reported with modifier 25.
Medical records support the use of modifier 25 for the problem-oriented E/M.

Additional requirements/notes:

Policy Summary

PayerHumana

PolicyMultiple Evaluation and Management (E/M) Services

Policy CodePolicy CP2024009

Change TypeNo material change

Effective DateJun 1, 2024

Next Review Date

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Claims remain subject to medical necessity, reasonableness, and any applicable referral or authorization requirements.

In certain circumstances, additional payment rules may apply (for example, Humana Healthy Horizons in Kentucky out-of-network payment policy).

Action: Reimburse only one E/M unless the exception criteria above are met; when exception met, reimburse both E/M services when documentation supports modifier 25 use.

Modifier and Allowance Details

Modifier requirementsModifierCovered

25	Modifier 25: significant, separately identifiable E/M service by same physician on same day of procedure or other service

Same-day E/M allowance — key thresholds

Policy thresholdOne E/M service is allowed per provider per date of service unless an exception applies.

ScopeApplies to professional services for Kentucky Medicaid members.

Exception summaryException allows additional E/M when both a problem-oriented E/M and a preventive E/M are performed the same day by the same provider (see related criteria).

Billing and Documentation Actions

Billing Rule

Same-day multiple E/M services rule

Other than the exception outlined below, Humana allows only one E/M service when multiple E/M services are performed on the same date by the same provider.

Applies to professional services.
Claims remain subject to medical necessity, reasonableness, and any applicable referral or authorization requirements.

Documentation Required

Exception — Problem-oriented plus preventive E/M on same date

When a problem-oriented E/M service and a preventive E/M service are both performed on the same date by the same provider, Humana allows reimbursement for both E/M services. The problem-oriented E/M service must be reported with modifier 25 and medical records must support its use. Additional payment rules may apply (for example, Humana Healthy Horizons in Kentucky out-of-network payment policy) — see References for relevant guidance.

Report the problem-oriented E/M with modifier 25.
Ensure documentation in the medical record supports the separate and significant evaluation and management service.
Be aware of other applicable payment rules (e.g., out-of-network payment policy) that may affect reimbursement.

Key Terms

Modifier 25 — definition and use

DefinitionModifier 25: A significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified health care professional on the same day of a procedure or other service.

Use requirementWhen a problem-oriented E/M and a preventive E/M are both performed the same day by the same provider, the problem-oriented E/M must be reported with modifier 25 and supported in the medical record.

PurposeSignals that the E/M service is distinct from other services performed on the same date to support separate reimbursement when criteria are met.