Preventive Medicine Evaluation and Management Visits

Policy No: 133
Originally Created: 11/01/2017
Section: Administrative
Last Reviewed: 10/01/2018
Last Revised: 11/01/2017
Approved: 10/04/2018
Effective: 11/01/2018

This policy applies to physicians, other qualified health care professionals and facilities.

This policy will not apply to Medicare Advantage line of business.

Definitions

Preventive Medicine Visit
Preventive visit that requires documentation to support an "annual physical". Includes an age and gender-appropriate history and physical examination, counseling or anticipatory guidance, and risk factor reduction interventions.

Evaluation and Management (E&M) Services
Services that requires three key components: problem or comprehensive history and examination; medical decision making; counseling and/or coordination of care with other physicians or other healthcare providers.

Modifier 25
Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.

Policy Statement

Our health plan will consider reimbursement for both a preventive medicine Current Procedural Terminology (CPT®) or Health Care Common Procedure Coding System (HCPCS) code and E&M when modifier 25 is applied to the E&M visit for the same patient, by the same provider, on the same date of service.

Providers should only submit a preventive code and a separate E&M code when there is a significant abnormality or pre-existing condition addressed and additional work is required to perform the key components of the E&M service.

The preventive medicine code will be reimbursed at 100% of the allowable contracted rate. The E&M visit, when billed with modifier 25 to identify a separately identifiable service, will be subject to a 50% reduction. This payment reduction made on the E&M visit is due to the duplication of overlapping services (e.g., practice expense - costs associated with maintaining a practice) already being considered in the reimbursement of the preventive service.

Preventive Medicine Service Codes
99381-99387
99391-99397

E&M Services Codes
99201-99205
99211-99215
99241-99245
G0245-G0246
G0463
S0285
S0610
S0612

References

Optum Encoder Pro Evaluation and Management (E&M) Section Guidelines

Cross References

None

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.