Payment Policy: E&M and Preventive Medicine Policy
Effective Date: 01/01/2025
LOB: Medicaid, HIV SNP, CHP, MetroPlus Gold, Goldcare I&II, QHP, Essential, HARP
1. POLICY DESCRIPTION:
This payment policy provides guidelines for modifier-25 usage and MetroPlusHealth’s payment policy when a modifier-25 is appended to a problem-oriented E/M service when billed on the same day as a preventive medicine visit.
Modifier misuse that overrides correct coding edits reduces overall effectiveness of healthcare delivery. Preventive medicine services are comprehensive in nature but on occasion may require a s separate Evaluation and Management service (E/M) during the preventive visit when a significant problem or abnormality is addressed during the preventive visit.
Only on these rare instances when the provider must take additional steps or perform additional tests of a problem-oriented E/M service beyond what is encompassed in a Preventive Medicine visit would it be appropriate to override correct coding edits with a modifier. Medical records must demonstrate each service and the “significant work” associated with them that would not be addressed during the preventive service.
Note: Modifier -25 should not be used to bill for preventive medicine counseling on the same day as a preventive medicine service as counseling services are already included in (with no separate reimbursement from) preventive medicine services.
2. RESPONSIBLE PARTIES:
Medical Management Administration, Utilization Management, Claims Department, Contracting, Provider Network Operations.
3. DEFINITIONS:
Preventive Medicine Services: Comprehensive routine health care that reflect age and gender appropriate history and includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.
CPT Code (99381-99387, 99391-99397, G0438-G0439)
Modifier 25 appended Problem-oriented E/M Service: 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 CPT Code (99202-99205, 99211-99215, G0463)
Preventive Medicine Counseling: Counseling provided at an encounter separate from a preventive medicine visit.
CPT codes (99401-99412)
4. POLICY:
Providers should only submit a Preventive Medicine Service and a separate E&M code with modifier 25 applied when there is a significant abnormality or a condition requiring substantial additional work to perform the key components of the E &M Service.
MetroPlusHealth will reimburse Preventive medicine and a problem oriented E&M visit for the same patient, by the same specialty physician on the same date of service when submitted with a modifier 25 with the following schedule:
- Preventive medicine reimbursed at 100% of the Fee Schedule
- E and M visit billed with modifier 25 to identify a separate identifiable service reimbursed at 50% of the fee schedule
The payment reduction addresses duplication of services already considered in reimbursement of the preventive service including but not limited to: Documenting patient history, vitals, use of examination room, administrative services etc.
MetroPlusHealth will deny preventive medicine counseling when billed for the same patient, by the same specialty provider on the same date of service as a preventive medicine service. MetroPlus will reimburse 100% of the preventive medicine service.
This is a payment policy and not related to medical necessity.
5. LIMITATIONS/ EXCLUSIONS:
Place of Service
The policy will be effective for professional claims submitted in the office setting.
6. APPLICABLE PROCEDURE CODES:
7. REFERENCES:
- Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services.
- American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services.
