CurrentUnitedHealthcarePolicy 2026R9034A

CMS 1500 Same Day / Same Service E/M reimbursement

Governs how UnitedHealthcare Medicare Advantage reimburses Evaluation and Management (E/M) services billed on CMS 1500 forms when multiple services occur on the same date; applies to network physicians and other qualified health care professionals participating in UnitedHealthcare Medicare Advantage plans.

Policy Summary

PayerUnitedHealthcare

PolicyCMS 1500 Same Day / Same Service E/M reimbursement

Policy CodePolicy 2026R9034A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit accurate claims using CMS 1500 form or electronic equivalent.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS1500forms covered by policy

one E/M/daypayment stance

limited usemodifier 25

per‑dayhospital per-day codes

CMS Manualauthoritative source

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 / Same Service E/M reimbursement criteria

Covered when ALL of the following apply:

If multiple face-to-face E/M services are provided on the same date to the same patient by the same physician or by physicians of the same specialty in the same group, only one E/M service may be reported unless the E/M services are for unrelated problems. Instead of billing separately, select a level of service representative of the combined visits and submit the appropriate single code (roll-up).

Per‑diem inpatient E/M codes (Initial hospital inpatient/observation care CPT codes 99221–99223 and Subsequent hospital inpatient/observation care CPT codes 99231–99233) may be reported only once per day by the same physician or physicians of the same specialty from the same group practice.

When critical care (CPT codes 99291 and 99292) is subsequently required on the same date as a non‑critical care E/M and the patient did not require critical care at the earlier time, both the critical care and the previous E/M may be paid on the same date. Hospital emergency department services are not paid on the same date as critical care when provided by the same physician. Retain documentation to support claims when both critical care and other E/M services are reported on the same date.

Modifier 25 may be reported to indicate a significant, separately identifiable E/M above and beyond other services when a second physician in the same group and specialty provides a separate E/M on the same day for an unrelated problem; modifier 25 is not appropriate when one E/M is a per‑day code or when a more comprehensive single code describes the services.

Separate reimbursement allowed when ANY of the following apply:

Different physicians are of different specialties (even within the same group) and bill with different diagnoses — separate payment may be allowed for same‑date services.
Physicians are each responsible for different aspects of the patient’s care and are different specialties with different diagnoses documented.

Do not report hospital visit and discharge day management together; when admission and discharge occur the same day use observation/inpatient admission/discharge codes (CPT 99234–99236) as appropriate. Services billed in conjunction with an admission that are part of the initial hospital care should not be separately reported.

Physicians must report the most comprehensive CPT code that describes the services performed and must not unbundle services described by a single comprehensive CPT/HCPCS code.

Codes and Reporting Rules

E/M and related hospital codes referencedCPT

99221-99223	Initial hospital inpatient or observation care (per day)
99231-99233	Subsequent hospital inpatient or observation care (per day)
99291-99292	Critical care services
99234-99236	Observation or inpatient care services including admission and discharge
99238-99239	Hospital discharge day management services

inv-03: Combined same-day E/M reporting

Policy ruleWhen multiple E/M services are provided on the same date to the same patient by the same specialty or by physicians of the same specialty within the same group, only one E/M service should be reported; select the single code level representative of the combined visits (roll-up).

Exception — unrelated problemSeparate E/Ms may be reported when documentation shows the services were for unrelated problems; modifier 25 may be used when a second physician in the same group and specialty provides a significant, separately identifiable E/M for an unrelated problem.

Modifier 25 limitationModifier 25 is not appropriate when one E/M is a per‑day code or when a more comprehensive single code describes the services being reported.

Definitions Relevant to Same-Day E/M Reporting

inv-05: Same Specialty Physician or Other Qualified Health Care Professional

Definition (term)Same Specialty Physician or Other Qualified Health Care Professional

MeaningA physician and/or other qualified health care professional of the same group and same specialty reporting the same Federal Tax Identification number.

ScopeUsed to determine when multiple E/M services billed by same‑specialty/group clinicians on the same date should be combined into a single reportable E/M.

inv-06: Same Physician or Other Health Care Professional

Definition — Same PhysicianThe same individual rendering health care services reporting the same National Provider Identifier (NPI) number.

Definition — Same GroupAll physicians and/or other qualified health care professionals of the same group reporting the same Federal Tax Identification number.

inv-07: Same Group Physician and/or Other Qualified Health Care Professional

DefinitionSame Group Physician and/or Other Qualified Health Care Professional

MeaningAll physicians and/or other qualified health care professionals of the same group reporting the same Federal Tax Identification number.

RelevanceEstablishes the group identity used when applying the one‑E/M‑per‑patient‑per‑day rule and modifier 25 considerations.

OpenPayer

CMS 1500 Same Day / Same Service E/M reimbursement

Same Day / Same Service E/M Reimbursement Criteria

Codes and Reporting Rules

Claims Submission and Billing Actions

Definitions Relevant to Same-Day E/M Reporting