Policy No: 133
Originally Created: 11/01/2017
Last Reviewed: 10/01/2018
Last Revised: 11/01/2017
This policy applies to physicians, other qualified health care professionals and facilities.
This policy will not apply to Medicare Advantage line of business.
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.
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.
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
E&M Services Codes
Optum Encoder Pro Evaluation and Management (E&M) Section Guidelines
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