Problem-Oriented or Preventive E/M Service with a Preventive Digital Rectal examination on the Same Day
All claims submitted under this policy’s section will be processed according to the policy effective date and associated revision effective dates in effect on the date of process.
Prostate cancer screening, digital rectal examinations (G0102) is considered an inherent component of a problem-oriented E/M. Separate reimbursement will not be made for G0102 when billed on the same date of service by the same performing physician/QHP submitting a problem-oriented E/M.
Preventive E/M and Problem-Oriented E/M on the Same Day
All claims submitted under this policy’s section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing.
When an abnormality or pre-existing problem is addressed on the same day as a preventive medicine visit, the appropriate problem-oriented E/M code may be submitted in addition to the preventive medicine code for reimbursement consideration.
Providers may bill for both a problem-oriented E/M service and a Preventive E/M service when the below are met:
- New or preexisting problem is addressed during a Preventive E/M service and
- New or preexisting problem is significant enough to require additional work to perform the key components of a problem-oriented E/M
If ALL of the above criteria are met, both the Preventive E/M and the problem-oriented E/M codes may be billed for reimbursement consideration. Providers should append modifier 25 to the problem-oriented E/M code based on the AMA E/M Preventive Medicine Services Coding Guidelines.
While the CPT manual may not clearly state that a new patient problem-oriented E/M should not be billed with a new patient preventive exam, BCBSND will not reimburse two new patient services at the same encounter. Because the patient already received professional services as part of the preventive E/M service, the patient no longer meets the “new patient” criteria. Any additional problem-oriented E/M service during the same visit would be considered an established patient and the above section must be followed.
Providers should not submit a Preventive E/M and a problem-oriented E/M service when:
- New problem is addressed during a Preventive E/M service requiring no additional work
- Preexisting problem acknowledged in the record however no additional work was done for the problem
Preventive E/M and Other Preventive Services on the Same Day
All claims submitted under this policy’s section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.
When a physician/QHP performs a cervical or vaginal cancer screening, including pelvic and clinical breast examination (G0101) and a preventive examination (9938X or 9939X) on the same day, there is significant overlap of the components of these two services (i.e., history, blood pressure, weight checks, and/or system gender and age-appropriate physical examination). However, the preventive examination may include services beyond the scope of the gynecological exam, such as counseling and anticipatory guidance, risk factor intervention, age-appropriate lab work, and certain screening tests (e.g., Pap Smear). Providers should report the Preventive E/M (9938X or 9939X) and pelvic examination add-on code (99459) when rendering a cervical or vaginal cancer screening and Preventive E/M service.
When a physician/QHP performs a Pap Smear obtaining the specimen, preparing the slide, and conveyance (Q0091) on the same day as a cervical or vaginal cancer screening, including pelvic and clinical breast examination, (G0101) or preventive E/M (9938X or 9939X), the physician/QHP should not report the Q0091 separately as the specimen collection is an inherent component of G0101, 9938X, and 9939X.
Medical Services on the Same Day as Preventive E/M or Problem-orientated E/M
All claims submitted under this policy’s section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.
CPT Guidelines must be followed when separately reporting services that are components of a Preventive E/M or problem-oriented E/M service. When any of the below are reported on the same day by the same performing physician/QHP or another physician/QHP with the same specialty in the same group practice, payment for the below services will be included in the allowance for the E/M service.
- 96127 - Brief emotional/behavioral assessment will not be considered for reimbursement on the same day as a problem-oriented E/M service.
- 99172 and 99173 - Visual function screening, automated or semi-automated will not be considered for reimbursement on the same day as an ophthalmological service or a non-preventive E/M service.
Preventive E/M codes include counseling/anticipatory guidance/risk factor reduction interventions and age and gender specific screening services. Due to this the below services will not allow reimbursement if rendered by the same physician/QHP or another physician/QHP with the same specialty in the same group practice on the same day as a preventive E/M. The services will be considered for reimbursement if rendered on the same day as an unrelated and separately identifiable problem-oriented E/M if the E/M has an appropriate modifier appended.
- 96110
- 99401 – 99412
- G0296
- G0396, G0397
- G0443
- G0445 – G0447
- G0473
- G2011
CPT instructs physicians/QHP to use the appropriate E/M codes when providing medical nutrition therapy assessment/intervention. Codes 97802, 97803, 97804, G0270, and G0271 will not be reimbursed separately when provided by the same physician/QHP or another physician/QHP with the same specialty in the same group practice on the same day as a preventive medicine service.
The above list is not an all-inclusive list of services not separately billable with a Preventive or problem-oriented E/M service. Providers must refer to the National Correct Coding Initiative (NCCI) and the CPT and HCPCS Coding Guidelines.
Urgent Care Visits
All claims submitted under this policy’s section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service, regardless of service date.
For claims processed on or after June 1, 2022, services provided in an Urgent Care Center must be submitted with POS 20 and the Office Visit E/M codes based on the appropriate level of service rendered to the member. Urgent Care Centers must report the applicable E/M code in accordance with the AMA guidelines. Urgent Care Centers may bill for any additional services rendered during the visit that are separately identifiable from the E/M service.
E/M and Behavioral Health
All Medicaid Expansion claims submitted under this policy’s section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service, regardless of service date.
AF Modifier Use
Physicians and QHPs billing Office or Outpatient Office Visit E/Ms, 99202-99215, for Behavioral Health diagnosis must append Modifier AF to receive the Behavioral Health fee schedule amount. Modifier AF does not need to be reported on any other E/M Behavioral Health diagnosis. For example: Emergency Room, Observation, Inpatient, etc. Appending modifier AF to E/Ms outside of 99202-99215 will not have an impact on provider reimbursement.
