CurrentUnitedHealthcarePolicy 2025R0002D

Same Day / Same Service Evaluation and Management (E/M) Billing and Reimbursement

Governs reporting and reimbursement of multiple Evaluation and Management (E/M) services provided to the same patient on the same date of service for UnitedHealthcare Community Plan Medicaid products; affects all network and non-network physicians and qualified health care professionals submitting CMS-1500 or electronic equivalents.

Policy Summary

PayerUnitedHealthcare

PolicySame Day / Same Service Evaluation and Management (E/M) Billing and Reimbursement

Policy CodePolicy 2025R0002D

Change TypeContent revisions and state exceptions updated

Effective Date

Next Review Date

Key ActionSelect a single E/M code that represents all E/M services provided on the same date by the same physician or by physicians of the same group and specialty; do not report multiple per-day E/M services unless unrelated and appropriately modifier-coded.

SourceLink

POLICY UPDATE CHANGES

Overview, Edit Types, Definitions, and Questions and Answers sections were updated and Q&A #9 and #10 were added.

State Exceptions section was updated (Mississippi removed previously) and state exceptions list modified.

Medicaidplan scope

CMS-1500claim form applicability

Modifier 25 allowedmodifier policy

Single E/M/day

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Same Day / Same Service Coverage Criteria

Same Day/Same Service coverage criteria

Reimbursement is limited for multiple E/M services on the same date based on provider relationship, specialty, and code semantics.

If multiple E/M services are provided on the same date by the same physician or by physicians in the same group and the same specialty, report a single E/M code that represents the combined services; separate reimbursement will not be allowed unless exceptions apply.

Contractors pay a physician for only one hospital visit per day for the same patient; per-day inpatient/observation visit codes represent all services provided on that date and are not separately payable.

Exceptions

E/M services may be separately reimbursable when the services are for unrelated problems and documentation supports billing a separate service.
Physicians in different specialties who see the same patient on the same date may both be paid when each visit is for a different aspect of care and billed with different diagnoses.
Modifier 25 may be appended to indicate a significant, separately identifiable E/M service above and beyond the usual pre/postoperative care or other service on the same day when documentation meets E/M level criteria and the secondary service is for an unrelated problem; modifier 25 is not appropriate for per-day codes or when a more comprehensive code describes the services.

Physicians should select the most comprehensive CPT/HCPCS code that accurately describes the combined services; do not unbundle services when a single comprehensive code applies.

UnitedHealthcare applies edits sourced to CMS, NCCI, CPT guidance, and specialty society interpretations to deny or bundle multiple reported services that are not separately payable under this policy.

E/M Codes and Per-Day Payment Rules

E/M and related per-day codesCPT

99201-99499	Range for E/M services referenced as not reportable separately with certain specialty-specific codes or components
94002-94004	Example of codes not to be reported with E/M services per CPT guidance
99218-99223 / 99232	Initial and subsequent per diem hospital E/M examples where separate reimbursement is not allowed
99234-99236	Observation/Inpatient care services including admission and discharge for same-day inpatient encounters
99238-99239	Hospital discharge day management services (not reportable with hospital visit on same day)

Per‑day single payment rule

RuleOnly one hospital visit per patient per day is payable when provided by the same physician or physicians of the same group and same specialty; select a single per‑day E/M code that represents all services for that date (do not report initial and subsequent per‑diem services separately).

ExampleUnitedHealthcare will not separately reimburse for an initial and a subsequent per‑diem service on the same date (e.g., 99223 and 99232).

Per‑day code guidancePer‑day codes include all care for that date; do not report discharge or additional per‑day visits separately on the same date.

Provider Billing and Modifier Guidance

Billing Rule

Same-day E/M reporting requirement

Select a single E/M code that represents all E/M services provided on the same date by the same physician or by physicians of the same group and specialty; do not report multiple per-day E/M services unless the services are for unrelated problems. Instead of billing separately, select a level of service representative of the combined visits and submit the appropriate code for that level. Contractors pay a physician for only one hospital visit per day for the same patient; inpatient 'per day' visit codes represent all services provided on that date.

When multiple E/Ms occur on the same date by the same individual or by physicians of the same group and specialty, report one E/M code that reflects the combined services.
Per-day hospital visit codes include all care for that date and are not separately payable; choose the code that reflects all services provided that day.
Separate payment may be allowed only when E/Ms are for unrelated problems or other exceptions in policy apply.

Key Definitions

Same Specialty Physician or Other Qualified Health Care Professional

DefinitionPhysicians and/or other qualified health care professionals of the same group and same specialty reporting the same federal Tax Identification Number (TIN).

Qualified health care professionalsFor qualified health care professionals, United may identify same specialty by related taxonomy codes.

Same Individual Physician or Other Qualified Health Care Professional

DefinitionThe same individual rendering health care services, reporting the same National Provider Identifier (NPI).

ImplicationServices reported with the same NPI are treated as provided by the same individual for same‑day/same‑service reimbursement rules.

State exceptionsSome states have regulatory exceptions affecting use of NPI to determine multiple provider billing; consult state rules.