E&M Billing and Coverage Guidance
October 17, 2022 Update: This policy has been updated to effective date September 8, 2022. Please read new communications.
April 16, 2021 Update: This communication has been updated with a revised link to the Medical Policy Update for Evaluation and Management Services.
Effective June 1st, 2021, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will implement a new policy for the reimbursement of Evaluation and Management (E&M) related services. This policy change will be available on our Medical Policy Updates site on March 31, 2021 titled “Evaluation and Management Services.”
Claims will be processed according to the new policy. Providers will need to ensure that they are correctly coding these services.
These changes apply to the following lines of business: Administrative Services Only (ASO), fully insured membership, IPP Host, and the State Health Plan (SHP).
| Scenarios for same day, same member, same practice and specialty | Related E&M Services (Within each E&M category defined by levels of service) | Problem Oriented E&M Service (CPT® 99202-99215) | Preventative Medicine Service (CPT® 99381-99397) | Annual Wellness Visit (HCPCS G0438, G0439) | Screening Services (HCPCS G0101, G0102 and Q0091) |
|---|---|---|---|---|---|
| Related E&M Services (Within each E&M category defined by levels of service) | One (1) cumulative E&M service reimbursable per day for related services | ||||
| Problem Oriented E&M Service (CPT® 99202-99215) | One (1) cumulative E&M service reimbursable per day for related services | Problem Oriented E&M Service (99202-99215) is reimbursed at up to 50% | Problem Oriented E&M Service (99202-99215) is reimbursed at up to 50% | Screening Services (G0101, G0102 and Q0091) are not separately reimbursable | |
| Preventative Medicine Service (CPT® 99381-99397) | Problem Oriented E&M Service (99202-99215) is reimbursed at up to 50% | Annual Wellness Visit (G0438, G0439) is not separately reimbursable | Screening Services (G0101, G0102 and Q0091) are not separately reimbursable | ||
| Annual Wellness Visit (HCPCS G0438, G0439) | Problem Oriented E&M Service (99202-99215) is reimbursed at up to 50% | Annual Wellness Visit (G0438, G0439) is not separately reimbursable | Screening Services (G0101, G0102 and Q0091) are not separately reimbursable | ||
| Screening Services (HCPCS G0101, G0102 and Q0091) | Screening Services (G0101, G0102 and Q0091) are not separately reimbursable | Screening Services (G0101, G0102 and Q0091) are not separately reimbursable | Screening Services (G0101, G0102 and Q0091) are not separately reimbursable |
Following CPT and CMS guidance, modifier 25 is appropriate to indicate a significant and separately identifiable E&M service by the physician or other qualified health care provider in the same group practice and same specialty provides a separate E/M service on the same day for an unrelated problem.
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.
For additional medical policy notifications, please visit our Medical Policy Updates page.
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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