Reimbursement Guidelines
Actual codes include, but are not limited to, the examples provided below.
- If: Multiple related E/M Services on same date of service for same member by same group practice
- Then: One (1) cumulative E/M service reimbursable per day
Reimbursement for multiple Evaluation & Management (E/M) codes performed for the same member by the same provider or group practice will be limited to one E/M service per date of service using the appropriate code level representative of the cumulative related services. This applies to E/M categories defined by levels of service. Please reference CPT® and HCPCS manuals for complete listing of E/M categories.
- If: Preventive Medicine Service (CPT 99381-99397) + Annual Wellness Visit (HCPCS G0438-G0439)
- Then: Preventive Medicine Service (CPT 99381-99397) is reimbursed at 50%
- If: Problem Oriented E/M Service (CPT 99202-99215) + Annual Wellness Visit (HCPCS G0438- G0439) or Preventive Medicine Service (CPT 99381-99397)
- Then: Problem Oriented E/M Service (CPT 99202-99215) is reimbursed at up to 50%
- If: Annual Wellness Visit (HCPCS G0438-G0439), or Problem Oriented E/M Service (CPT® 99202- 99215) + Screening Services (HCPCS G0101, G0102 and Q0091)
- Then: Screening Services (HCPCS G0101, G0102 and Q0091) are not separately reimbursable
Screening services performed for the same member by the same provider or group practice on the same day as annual wellness and/or problem-oriented E/M services are not eligible for separate reimbursement regardless of Modifier 25 usage.
Hospital Discharge Day
Only one hospital discharge day management service (CPT® 99238-99239) will be allowed per member per hospital stay according to CMS policy. Additionally, only the attending physician is to report the discharge day management service. Subsequent hospital discharge day management services will not be eligible for reimbursement after the initial claim for that service has been processed for the same date of service.
Immunization Administration
Evaluation and Management services will not be reimbursed separately when billed with immunization administration codes CPT® 90460 – 90474. If a significant, separately identifiable evaluation and management service is performed in addition to immunization administration, Modifier 25 must be used. (See also Reimbursement Policy titled “Immunization Guidelines”). For information specific to Covid-19 vaccine administration, see the provider news article under “COVID-19 Support Measures: Details and Coding Guidance.”
Medical Records Copying Fee
Medical records copying fee, administrative (HCPCS S9981) and medical records copying, per page (HCPCS S9982) are considered incidental to Evaluation and Management services, Surgical services, and Laboratory services and not eligible for separate reimbursement.
Modifier 25
Modifier 25 is used to indicate that the evaluation and management service was significant and separately identifiable from a minor procedure performed on the same day.
Evaluation and management services performed the same day as a 0 or 10-day global medical or surgical service will be denied as included in the global surgical package, unless the service was significant and separately identifiable from the minor procedure and is indicated with Modifier 25.
E/M services (CPT® 99202-99215, 99221-99223, 99231-99233, 99460) are included as part of critical care services (CPT® 99291) provided on the same day in the same place of service unless shown to be significant and separately identifiable
New Visit Frequency
Blue Cross NC does not automatically reassign or reduce the code level of Evaluation and Management codes billed for covered services, with the exception of the new visit frequency editing as described here.
A member who has received any professional (E/M or other face-to-face) services from a provider within the same group practice (same specialty) within the previous 3 years is no longer considered a new patient when billing Evaluation and Management codes.
When a claim is received reporting a new patient evaluation and management service that does not meet the definition above, the new patient evaluation and management service code will be replaced with the equivalent established patient evaluation and management code if one is available. Otherwise the claim will be denied.
Non-Physician Providers
For non-physician providers, E/M services are only eligible for reimbursement when the rendering provider is an advanced practice registered nurse (nurse practitioner, clinical nurse specialist, or certified nurse midwife), or physician assistant.
Observation Care Services
According to CMS, reimbursement for the initial observation care codes and subsequent observation care code codes encompass the full scope of care provided by the provider who ordered the hospital observation services. The applicable code can only be reported once per day.
Consistent with CMS and CPT® guidance, initial observation care codes and codes that include the initial observation care are only reimbursable on the first day of treatment and are not intended to be billed on subsequent days of the observation care. Likewise, subsequent observation care codes will be reimbursable on each additional day of the observation stay and only by the admitting/ordering provider.
Other providers shall not report observation services and are to bill the applicable outpatient service codes should they render any consultations, evaluations, or additional services during the member’s observation stay.
Observation care discharge day management service is only to be billed on a day other than the initial day of observation. Additionally, providers are not to bill this code separately when the member has been admitted to inpatient status from observation status.
Prolonged Evaluation and Management Service
Prolonged evaluation and management service before and/or after direct (face-to-face) patient care; first hour (CPT® 99358) and each additional 30 minutes (CPT® 99359) is considered incidental to all evaluation and management services, surgical services, and laboratory services and not eligible for separate reimbursement.
Treatment Rooms with Office Evaluation and Management Services
Revenue code 0761 (treatment room) representing office or clinic-based Evaluation and Management services (CPT® 99202-99215, 99241-99245, HCPCS G0463) is not reimbursable. Per UB-04 manual and Uniform Billing Editor, revenue code 0761 should only be used to represent Specialty Services, such as when a specific procedure has been performed or treatment has been rendered.
Use of Modifier 25 is not appropriate to report two or more E/M services when one or more of the E/M codes include “per day” in its definition.
Billing and Coding
Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at www.bcbsnc.com.
