Posted in NY Providers, Payer Updates, Payers and CPT reinbursement, Training, Updates

MVP Health Plans: reimbursement of sick E&M codes billed w/preventative codes -05/01/23

According to the latest announcement MVP Health Plan will change the reimbursement of sick E/M codes when they are billed on the same day as a preventative codes.

This policy applies to Primary Care Physicians.

According to the new reimbursement policy the sick E&M codes will be reimbursed at 50% of allowable amount if the codes are billed on the same date of service as the preventative codes.

The reimbursement will be applied with or without the modifier 25 present.

Policy applies to the following codes:

Preventive medicine services are represented in evaluation and management (E/M) codes 99381–99429. These E/M codes may be reported by any qualified physician or other qualified healthcare professional.

Preventative cpt codes 99381–99397 for comprehensive preventive evaluations are age-specific, beginning with infancy and ranging through patients age 65 and over for both new and established office patients.

E&M codes may include: 99202-99205, 99212-99215

For more information please refer to MVP Evaluation and Management (E&M) policy.

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EmblemHealth (NY) E&M codes reimbursement policy: updated for 2021

With the changes to the E&M codes, for the year 2021, EmblemHealth updated their reimbursement policy for providers.

The following is now the guidelines/reminder for E&M Reimbursement: documentation requirements

• The CPT® coding guideline updates only apply to 99202-99215.
– Other codes within the evaluation and management section of the CPT book are still subject to previous reimbursement policies.
• Chief complaint (Reason for visit) must be clearly documented.
• A clinically appropriate history and exam are still required.
• Medical Necessity, Medical Decision Making and Assessment & Plan are required to be
When time is the determining factor for code selection, all start and stop times must be documented to substantiate total time on the date of the encounter.