Problem Oriented E&M Billing
2026/4/6
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Posted by Provider Relations
Fidelis Care would like to remind providers that it is appropriate to bill a problem‑oriented E&M on the same day as a surgical or preventive service when the issue is separate and significant. In these cases, correct use of modifier 25 and proper documentation are essential to ensure accurate reimbursement and to avoid duplicate payment for services not separately performed.
Key Rules
- Use modifier 25 to show the E&M service is distinct from the main procedure or preventive exam.
- Claims are clinically reviewed to confirm the E&M is separate.
- If validated, payment includes:
- 100% of the primary service
- 50% of the problem‑oriented E&M
- Use modifier 57 only when the E&M leads to a decision for a major surgery.
Documentation Must Show
- A separate medical concern addressed
- Medical necessity and work that is beyond the routine surgical global period or preventive exam.
Payment Policies