Evaluation and Management Same Day as Preventive Visit
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Defines Quartz reimbursement when an Evaluation and Management (E/M) service is performed on the same day as a preventive visit for Commercial and Level Funded lines; informs provider billing and reimbursement percentages for the preventive and problem-oriented E/M services.
No material clinical or coverage changes in this revision.
Same-day Preventive and E/M Coverage
Same-day preventive and E/M reimbursement rules
Covered when ALL of the following are met:
ALL of the following
- Service is a professional service billed on the CMS-1500 or electronic equivalent for Quartz Commercial or Level Funded business.
- A preventive visit is performed and, during the same encounter, the provider addresses a chronic or preexisting problem that requires a separate, problem‑oriented E/M service.
- The problem‑oriented E/M is significant and separately identifiable from the preventive service and is appended with modifier 25 when billed.
- Reimbursement: the preventive CPT code is reimbursed at 100% of the allowed amount; the problem‑oriented E/M (with modifier 25) is reimbursed at 75% of the allowed amount.
ALL of the following
- Providers must maintain documentation to support that the E/M was significant and separately identifiable from the preventive visit; Quartz may request supporting documentation during claim review.
- Quartz may conduct post‑payment reviews and audits and may reject, deny, recover payment, or adjust reimbursement if billing guidelines or this policy are not followed.
ALL of the following
- Policy applies to professional services billed on CMS‑1500 or electronic equivalent for Quartz Commercial and Level Funded lines of business.
ALL of the following
- When billing both services, append modifier 25 to the problem‑oriented E/M to indicate a significant, separately identifiable service on the same day as a preventive visit.
Relevant CPT Codes, Modifiers, and Reimbursement Rates
| 99381-99387 | Preventive visit CPT codes |
| 99391-99397 | Preventive visit CPT codes |
| 99202-99215 | Evaluation and Management (E/M) CPT codes |
| Modifier 25 | Significant, separately identifiable E/M on same day as preventive service |
Billing, Documentation, and Audit Expectations
Append Modifier 25 and retain supporting documentation
When billing a problem-oriented E/M on the same day as a preventive visit, append modifier 25 to the E/M service. Quartz may request supporting documentation and conducts post-payment reviews and audits; misuse may lead to recoupment or other corrective action.
- Append Modifier 25 to the problem-oriented E/M when billed in addition to a preventive visit.
- Be prepared to submit supporting clinical documentation if requested during claim review or audit.
- Quartz conducts post‑payment reviews and audits to ensure compliance and may pursue corrective actions for misuse.
Comply with billing and submission guidelines to avoid denial or recovery
Follow Quartz billing and submission guidelines and use industry-standard, compliant codes on all claim submissions. Failure to follow these billing guidelines may result in claim rejection, denial, payment recovery/recoupment, or reimbursement adjustment.
- Bill services with appropriate CPT, HCPCS, and/or revenue codes supported by clinical documentation.
- Quartz may reject or deny claims, recover/recoup payments, or adjust reimbursement for noncompliance.
- Quartz utilizes claim‑editing software and may take corrective action including provider education.
Key Definitions
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