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 code 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 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.
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 25% 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 include but are not limited to:
E&M Services Codes include but are not limited to:
- 99202-99205
- 99211-99215
- 99242-99245
- G0245-G0246
- G0463
- S0285
- S0610
- S0612
References
- Optum Encoder Pro Evaluation and Management (E&M) Section Guidelines.
Cross References
- Mod 103 - Modifier 25; Significant, Separately Identifiable Service
