Payer Updates

Health Plans Tweak Payment, Documentation Policies for Same-Day Preventive, E/M Services

By News Staff
9/8/2009

Family physicians who contract with Humana and who received a recent letter from the health insurance company may be concerned about coding changes that take effect on Oct. 27.

In particular, the AAFP's Practice Support Division has received inquiries from members who are uncertain about Humana's payment policy for a problem-oriented evaluation and management, or E/M, service when the service is performed on the same day as a preventive care visit.

Laura Schmidt, an AAFP private sector advocacy specialist, said Humana will continue to pay physicians at 100 percent for both codes. The only change in the payer's policy, said Schmidt, is that physicians must include a modifier 25 when both preventive and acute services are billed on the same day.

"Until recently, Humana provided payment for both of these codes, even if the appropriate modifier was not included on the problem-oriented code," said Schmidt.

Physicians also should make note of the payment policies of other major health insurance companies.

As of Aug. 15, 2009, Aetna considers the preventive visit to be the primary service and pays that claim at 100 percent of the allowed amount; the problem-oriented E/M service is considered secondary and is paid at 50 percent. The modifier 25 is required.
CIGNA Healthcare pays 100 percent of the preventive service code and 50 percent of the second code. The company recently announced it was temporarily reinstating its documentation requirement for certain code combinations to substantiate the use of the modifier 25 due to an increase in the number of secondary codes appended with the modifier. "However, additional documentation is not needed for same-day preventive and acute service code combinations, based in large part on AAFP's advocacy efforts," said Schmidt.
UnitedHealthcare fully reimburses the preventive medicine visit plus 50 percent of certain E/M codes -- 99201 to 99205 and 99212 to 99215 -- when that code is appended with a modifier 25. However, if the problem-oriented code is minor, or if the code is not submitted with the modifier 25, the physician is not paid for the service.
WellPoint currently pays 100 percent for both services, and the modifier 25 should be included.

Schmidt said that although downward payment changes are always discouraging, these particular policy modifications do not represent a huge payment impact for physicians. However, she added, the changes "do increase the administration expense for physicians because of the time needed to provide additional documentation if requested."

Additional information on payer payment policies is available on individual payer Web sites.

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