Preventive and E/M billed on same day
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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.
No material clinical or coverage changes in this revision.
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:
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.
- E/M represents significant, separately identifiable services (report modifier 25 as appropriate).
If modifier 25 is reported and documentation supports a significant, separately identifiable E/M, payment interaction still applies per guidelines.
- When criteria above are met, E/M code reimbursed at 50% of the allowed amount.
Codes and Payment Details
| Preventive CPT/HCPCS | Preventive medicine CPT or HCPCS codes (per CPT/HCPCS coding guidelines) |
| Problem-oriented E/M CPT | Problem-oriented evaluation and management CPT codes |
| 25 | Modifier 25 (significant, separately identifiable E/M) |
Billing and Modifier Guidance
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
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