Tips when billing E/M with preventive services

Blue Cross Blue Shield of Michigan and Blue Care Network commercial plans recently began reimbursing evaluation and management, or E/M, services at 50% of the allowed amount when billed on the same day as a preventive service. This was effective with dates of service beginning June 1, 2024, and was announced in the June 2024 issue of The Record and the July-August 2024 issue of BCN Provider News, Page 29.

Since June, some members have complained about being charged a copay, coinsurance or deductible following their preventive service when an E/M service was also billed. To maintain a positive member experience, Blue Cross and BCN recommend the following:

• Inform the patient when adding the E/M service — During a preventive service encounter, the practitioner should let the patient know when an additional service is going to be considered not preventive and potentially result in cost to the member. Then the patient can decide whether to proceed with that service.
• Explain that combining the service could possibly save them money — If the patient has coinsurance or a deductible, combining the service with the preventive service could save the patient money. Since the service is reimbursed at 50% of the allowed amount, out-of-pocket cost that’s based on the service cost will also be lower.
• Let the patient know that two services will be billed — If the patient goes forward with the additional service, you should explain that the patient will see two services billed — one for the preventive service with no out-of-pocket cost and one for the medical examination for the additional service, which may require a copay, coinsurance or a deductible, depending on the patient’s benefits.

Notes

• Members with fixed dollar copays will usually pay the same copay if the E/M service is provided on the same day as a preventive service. The only time the fixed dollar copay would be reduced is if 50% of the allowed amount for the E/M service is less than the member’s copay. In such a case, the member would pay the lower amount.
• Providers who are paid via capitation for BCN won’t receive additional reimbursement as these E/M codes and preventive services are included in capitation payments.
• Our Medicare Advantage plans, Medicare Plus Blue℠ and BCN Advantage℠, reimburse E/M on the same day as preventive services in alignment with Medicare rules.