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PAP232

Simultaneous Preventive, Evaluation and Management Services


Provider Administrative Policy

Section
Claims Submission
Policy Date
November 2007
Status/Date
Revised/July 2009
Provider Type(s)
Physician  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

Simultaneous Preventive, Evaluation and Management Services

If a provider discovers an illness during a preventive exam, he or she may also submit a charge line for the office/outpatient Evaluation and Management (E/M) code by attaching a modifier 25 to that E/M code. To do this, there must be a significant and separately identifiable E/M service performed in addition to the preventative care. The E/M service must be for a non-preventive clinical reason and the ICD-9 CM code(s) for the E/M service should clearly indicate the non-preventive nature of the E/M service.

You must also document the additional physician work and patient risk that resulted from the evaluation and treatment of the diagnosed problem. Link diagnoses to services carefully.

To ensure the diagnosis corresponds to the service line when submitting preventive and office/outpatient E/M services on the same day, provide a wellness diagnosis and a diagnosis for the other E/M service by entering the diagnosis line number in field 24E of the CMS1500 form.

If a member has no preventive benefit, we may reimburse for the office/outpatient E/M service, but not for the preventive services.


Policy History

Date Action Reason
July 2009 Revised Formatting of E/M

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