CurrentWPS Health InsurancePolicy 1020

Preventive and E/M billed on same day

Defines WPS reimbursement when a preventive medicine code and a problem-oriented E/M code are billed for the same patient on the same date by the same specialty physician or qualified health professional; applies to all commercial lines, network and non-network providers.

Policy Summary

PayerWPS Health Insurance

PolicyPreventive and E/M billed on same day

Policy CodePolicy 1020

Change TypeNo material change

Effective DateJun 1, 2025

Next Review DateAug 1, 202647d

Key ActionReport modifier 25 when the problem-oriented E/M represents significant, separately identifiable services; preventive codes reimbursed at 100% and E/M at 50% when billed same day by the same provider/specialty.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100%preventive reimbursement

50%E/M reimbursement

All Commerciallines covered

UB-04 & CMS-1500claim forms

Same-day Preventive and E/M Payment Rules

Same-day preventive and E/M payment rules

When a preventive medicine code and a problem-oriented E/M code are both billed for the same patient on the same date by the same specialty physician or qualified health professional:

Preventive code reimbursed at 100% of the allowed amount when billed same day by the same specialty physician or qualified health professional.

Preventive code is a preventive medicine CPT or HCPCS code billed on the same date of service as a problem-oriented E/M code.

WPS considers costs for supplies, equipment, staff and overhead bundled into the preventive code; these costs are reduced from the E/M code when billed same day.

ALL of the following

Problem-oriented E/M code billed on the same date of service by the same specialty physician or qualified health professional.

Policy Summary

PayerWPS Health Insurance

PolicyPreventive and E/M billed on same day

Policy CodePolicy 1020

Change TypeNo material change

Effective DateJun 1, 2025

Next Review DateAug 1, 202647d

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.

Codes and Payment Details

Preventive CPT/HCPCSCPT

Preventive CPT/HCPCS

Preventive medicine CPT or HCPCS codes (per CPT/HCPCS coding guidelines)

Problem-oriented E/M CPTCPT

Problem-oriented E/M CPT

Problem-oriented evaluation and management CPT codes

Modifier 25Modifier

25	Modifier 25 (significant, separately identifiable E/M)

E/M payment reduction when same-day with preventive

E/M payment reductionWhen a problem-oriented E/M is billed same day as a preventive service, WPS reimburses the E/M at 50% of the allowed amount.

Applicable situationApplies when preventive medicine CPT/HCPCS and problem-oriented E/M CPT are billed for the same patient, same date, by the same specialty physician or QHP.

ReasoningWPS bundles costs for supplies, equipment, staff and overhead into the preventive code and reduces those costs from the E/M via the 50% reduction.

Reimbursement pairingPreventive code reimbursed at 100% of allowed amount while E/M receives 50% when both billed same day and criteria met.

Billing and Modifier Guidance

Billing Rule

Billing when preventive and E/M billed same day — report modifier 25 as appropriate

If a preventive medicine CPT or HCPCS code and a problem-oriented E/M CPT code are billed for the same patient by the same specialty physician or qualified health professional on the same date of service, report modifier 25 on the E/M when the E/M represents a significant, separately identifiable service. WPS will reimburse the preventive code at 100% of the allowed amount and will reimburse the E/M code at 50% of the allowed amount when billed the same day. WPS considers routine costs (medical supplies, equipment, staff and overhead) included in the preventive service and reduces the E/M payment accordingly when both services occur on the same date of service.

Applicable when preventive and problem-oriented E/M are billed by the same provider/QHP on the same date
Report modifier 25 on the E/M when it is significant and separately identifiable
Preventive code reimbursed at 100% of allowed amount; E/M reimbursed at 50% of allowed amount

Key Terms and Abbreviations

CPT

TermCPT — Current Procedural Terminology

ScopeStandard code set used to describe medical, surgical, and diagnostic services.

Reference in policyUsed to identify preventive medicine and problem-oriented E/M procedure codes in this reimbursement policy.

E/M

TermE/M — Evaluation and Management

Use in policyRefers to problem-oriented evaluation and management CPT codes that may be billed with preventive services.

Billing noteWhen E/M represents significant, separately identifiable services, modifier 25 may be reported per policy.

HCPCS

TermHCPCS — Healthcare Common Procedure Coding System

RoleIncludes certain preventive medicine codes recognized by the policy when billed with E/M services.

InteractionPolicy treats preventive HCPCS codes similarly to preventive CPT codes for same-day billing rules.

QHP

TermQHP — Qualified Healthcare Professional

DefinitionA qualified healthcare professional authorized to bill for preventive and E/M services under this policy.

ApplicabilitySame-day billing rules apply when services are provided by the same specialty physician or QHP.