Preventive Medicine Evaluation and Management Visits

Policy ID: Adm 133

Effective Date: January 01, 2027

Last Reviewed: September 01, 2026

Applies To: Migrated Commercial

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

Definitions

Code/Term

Code Description/Term Definition

Current Procedural Terminology (CPT^®)

A medical code set maintained by the American Medical Association (AMA) that is used to report medical, surgical, and diagnostic procedures and services performed by physicians and other qualified healthcare professionals. CPT^® codes are included in Level I of the Healthcare Common Procedure Coding System (HCPCS).

Established Patient

The AMA defines an established patient as one who has received professional services from a physician or other qualified healthcare professional (QHP) or another physician or other QHP of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

Evaluation and Management (E&M) Services

Services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination are determined by the treating physician or other QHP reporting the service.

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.

New Patient

A patient who has not received any professional services from a physician or other QHP, or another physician or QHP of the exact same specialty or subspecialty who belongs to the same group practice within the past three years.

Preventive E&M 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, usually separate from disease-related diagnoses.

Problem-oriented E&M

Per the AMA, a problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter.

Policy Statement

Our health plan will consider separate reimbursement for both a preventive E/M and a problem-oriented E&M service when both services are provided to the same patient by the same provider on the same date of service and modifier 25 is appended to the problem-oriented E&M service.

Providers should only submit a preventive E&M code and a separate problem-oriented E&M code with modifier 25 when there is a significant abnormality or a pre-existing condition addressed, and additional work is required to perform the key components of the E&M service. The clinical documentation needs to support the additional services provided.

If a new patient preventive E&M visit and a separately identifiable problem-oriented E&M visit are provided on the same date of service, the problem-oriented E&M visit must be reported using the appropriate established patient problem-oriented E&M code.

The preventive E&M medicine code will be reimbursed at 100% of the allowable contracted rate. The problem-oriented E&M code, when billed with modifier 25 to identify a separately identifiable service, will be subject to a 25% reduction. This payment reduction made on the problem-oriented 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 E&M visit.

Preventive E&M Service Codes include but are not limited to:

99381-99387
99391-99397

Problem-Oriented E&M Services Codes include but are not limited to:

99202-99205
99211-99215
99242-99245
G0245-G0246

References

Optum Encoder Pro Evaluation and Management (E&M) Section Guidelines.
Current Procedural Terminology (CPT) Manual, American Medical Association. Current year version

Cross References

Mod 103 - Modifier 25; Significant, Separately Identifiable Service

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.

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