CurrentPremera BluecrossPolicy CPPP.388.v1.9

Evaluation and Management (E&M) Visit Billed with Preventive Medicine Examination

Defines how Premera handles evaluation and management (E&M) services billed on the same date as preventive medicine examinations for professional claims (CMS-1500 / 837P) and applicable lines of business.

Policy Summary

PayerPremera Bluecross

PolicyEvaluation and Management (E&M) Visit Billed with Preventive Medicine Examination

Policy CodePolicy CPPP.388.v1.9

Change TypeClarified and revised coding and billing instructions

Effective Date

Next Review Date

Key ActionWhen billing an E&M visit on the same date as a preventive medicine exam, append modifier 25 only when documentation shows a significant, separately billable E&M service and submit both services on the same claim.

SourceLink

POLICY UPDATE CHANGES

Added sentence that the diagnosis billed for the separate and distinct E&M service must reflect the separate and distinct service from the preventive medicine exam.

Appended statement that adding modifier 25 is not a guarantee of payment and documentation must support a significant and separate service.

Updated code descriptions and removed code 99201 (deleted effective 01/01/2021) and updated home visit and preventive service code descriptions per 2023/2024 updates.

100%Preventive exam reimbursed when billed with E&M

50%E&M reimbursed when billed with preventive exam

99202-99215Primary CPT ranges

99341-99350

Policy Summary

PayerPremera Bluecross

PolicyEvaluation and Management (E&M) Visit Billed with Preventive Medicine Examination

Policy CodePolicy CPPP.388.v1.9

Change TypeClarified and revised coding and billing instructions

Effective Date

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.

Same-day E&M with Preventive Medicine — Coverage Rules

Same-day E&M with preventive medicine coverage criteria

Reimbursement rules when E&M and preventive medicine exam are billed same day by same provider:

Preventive medicine examination (CPT codes 99381-99397) billed on the same date of service as an E&M office visit (CPT codes 99202-99215) or home visit (CPT codes 99341-99350) by the same provider will be reimbursed at 100% of the provider's contract allowed amount.

The E&M office or home visit billed on the same date as the preventive medicine exam will be reimbursed at 50% of the provider's contract allowed amount.

Modifier 25 should only be reported on the E&M office or home visit when documentation shows a significant and separately billable E&M service that is distinct from the preventive medicine examination.

Documentation must support the significant and separate E&M service; the diagnosis billed for the separate E&M service must reflect the distinct service or the documentation must explain why the additional E&M service was necessary.

Appending modifier 25 is not a guarantee of payment; claims may be reduced or denied if documentation does not support a separate service.

Both the preventive medicine examination and the E&M service should be submitted on the same claim form.

Violations of these documentation or billing requirements may result in audit, penalties, or contract/employment actions as determined by the Plan.

Applicable CPT Codes and Time Thresholds

Applicable CPT codesCPT

99202-99215	Office/outpatient E&M codes (new and established) with time and decision-making thresholds
99341-99350	Home visit E&M codes (new and established) with time thresholds
99381-99397	Preventive medicine initial and periodic comprehensive exam codes by age

Time thresholds for code selection — E&M and home visit codes

New office visit time ranges (select by total time)99202: 15–29 min; 99203: 30–44 min; 99204: 45–59 min; 99205: 60–74 min.

Established office visit time ranges (select by total time)99212: 10–19 min; 99213: 20–29 min; 99214: 30–39 min; 99215: 40–54 min.

Home visit — new patient time thresholds99341: ≥15 min; 99342–99345: (incremental levels per code as listed in guidelines).

Home visit — established patient time thresholds99347: ≥20 min; 99348: ≥30 min; 99349: ≥40 min; 99350: ≥60 min.

Modifier 25 and Billing Guidance

Billing Rule

Modifier 25 on E&M with preventive exam

When an E&M office visit (99202-99215) or home visit (99341-99350) is billed the same date as a preventive medicine exam (99381-99397) by the same provider, modifier 25 may be appended to the E&M code only when documentation supports a significant, separately identifiable service that is beyond the preventive exam. Documentation must clearly distinguish the additional E&M service from the preventive medicine exam (for example, separate history, exam, medical decision making, and explanation of why the additional visit was necessary). Appending modifier 25 is not a guarantee of payment. The diagnosis submitted for the E&M service must reflect the separate problem addressed or the medical record must explain why the extra E&M service was required.

Applicable E&M codes: 99202-99215; home visits: 99341-99350; preventive medicine codes: 99381-99397
Both services should be billed on the same claim form when provided the same day by the same provider
Reimbursement: preventive medicine exam = 100% of contract allowed amount; E&M office/home visit with valid modifier 25 = 50% of contract allowed amount
Modifier 25 must be supported by distinct documentation; modifier alone does not ensure payment

Key Definitions

Modifier 25 — concise definition and requirements

DefinitionModifier 25 indicates a significant, separately identifiable E&M service on the same day as another service.

Documentation requirementModifier 25 should be reported only when a significant and separately billable service, unrelated to the preventive medicine exam, is documented in the medical record.

Billing instructionBoth the E&M service and the preventive medicine exam should be billed on the same claim form when provided the same day by the same provider.

Payment caveatAppending modifier 25 is not a guarantee of payment; documentation must support the separate service and the diagnosis must reflect the separate service or explain why it was necessary.