CurrentHumanaPolicy CP2024009

Multiple Evaluation and Management (E/M) Services

Humana's Kentucky Medicaid claims payment policy governing billing and reimbursement when multiple E/M services are performed on the same date by the same provider; applies to professional services for Humana members in Kentucky.

Policy Summary

PayerHumana

PolicyMultiple Evaluation and Management (E/M) Services

Policy CodePolicy CP2024009

Change TypeNo material change

Effective Date06/2024

Next Review Date

Key ActionReport the problem-oriented E/M with modifier 25 when billed the same day as a preventive E/M and ensure medical records support its use.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

one E/M allowedDefault allowed

allows twoException

modifier 25Required modifier

Kentucky MedicaidJurisdiction

Coverage Criteria for Same-day E/M Services

Same-day E/M coverage rules

Covered when ALL of the following are met:

ALL of the following

Allow one E/M service when multiple E/M services are performed on the same date by the same provider.
Exception — BOTH may be reimbursed when ALL of the following are true:
- Services include a preventive E/M performed on the same date by the same provider.
- Services include a problem-oriented E/M performed on the same date by the same provider.
- The problem-oriented E/M is reported with modifier 25.

Policy Summary

PayerHumana

PolicyMultiple Evaluation and Management (E/M) Services

Policy CodePolicy CP2024009

Change TypeNo material change

Effective Date06/2024

Next Review Date

Key ActionReport the problem-oriented E/M with modifier 25 when billed the same day as a preventive E/M and ensure medical records support its use.

SourceLink

On This Page

Coding and Modifier Requirements

Modifier requirementsModifierCovered

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

E/M duplication rule — Allow only one E/M per provider per date unless exception applies

Default ruleAllow only one E/M service when multiple E/M services are performed on the same date by the same provider.

Exception for preventive + problem-oriented E/MIf a preventive E/M and a problem-oriented E/M are both performed on the same date by the same provider, Humana allows reimbursement for both services when conditions met.

Documentation requirementThe provider must report the problem-oriented E/M with modifier 25 and medical records must support the use of modifier 25.

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

Billing and Documentation Requirements

Billing Rule

Billing requirement for same-day E/M services

When a problem-oriented E/M and a preventive E/M are both performed on the same date by the same provider, report the problem-oriented E/M with modifier 25 and ensure the medical record clearly supports the separate and significant E/M service. Failure to document medical necessity for the additional E/M may result in denial or adjustment. Action steps: confirm modifier 25 is appended to the problem-oriented E/M line, include documentation of the distinct problem-focused history, exam, and medical decision making for the problem visit, and retain records to justify the separate service.

Modifier 25 required on problem-oriented E/M when billed same day as preventive E/M
Medical records must support the use of modifier 25 and demonstrate a separate, significant, and identifiable E/M service
Claims may be subject to other payment rules (e.g., out-of-network payment policy) — review applicable Humana guidance

Definitions

Modifier 25 — definition of a significant, separately identifiable E/M service by same clinician

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.

When requiredAppend modifier 25 to the problem-oriented E/M when billed the same day as a preventive E/M to allow reimbursement of both services.

Documentation supportMedical records must support that the problem-oriented E/M was a distinct, separately identifiable service when modifier 25 is used.

Coding contextModifier 25 is used to distinguish a significant, separately identifiable E/M from other services performed on the same day by the same provider.