CurrentAnthemPolicy G-06049

EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) reimbursement

Governs Anthem HealthKeepers Medicaid reimbursement for EPSDT preventive services and component services, including billing and claim requirements for providers serving members in Virginia.

Policy Summary

PayerAnthem

PolicyEPSDT (Early and Periodic Screening, Diagnostic, and Treatment) reimbursement

Policy CodePolicy G-06049

Change TypeRevised modifier 25 claim guidance

Effective DateJul 21, 2025

Next Review Date

Key ActionWhen billing component services performed the same day as a preventive E/M, append modifier 25 to report separate reimbursement for objective hearing screening, lead testing, vision screening, and developmental assessment.

SourceLink

POLICY UPDATE CHANGES

Updated claim requirement for modifier 25 by adding 'leading test'.

Changed reference from modifier 59 to modifier 25 in prior update; definition remains the same.

Listcomponents bundled into preventive E/M

9separately reimbursable component services listed

Modifier 25same-day separate reimbursement rule

Virginiastate referenced

EPSDT Coverage and Billing Criteria

EPSDT coverage and billing criteria

Covered when ALL of the following are met:

EPSDT coverage stance: The health plan allows reimbursement of EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) Program services unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise; reimbursement is based on the applicable fee schedule or contracted/negotiated rate.

Components included in preventive E/M

Comprehensive health history
Comprehensive unclothed physical examination
Health education

Policy Summary

PayerAnthem

PolicyEPSDT (Early and Periodic Screening, Diagnostic, and Treatment) reimbursement

Policy CodePolicy G-06049

Change TypeRevised modifier 25 claim guidance

Effective DateJul 21, 2025

Next Review Date

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Modifiers, Procedure Coding, and Modifier 25 Guidance

Modifiers and procedure codingmixed

25	Modifier 25 - required for separate reimbursement of objective hearing screening, lead testing, vision screening, and developmental assessment procedures performed using a standardized screening method on the same date of service as a preventive medicine E/M visit.

Modifier 25 usage — Required for separate reimbursement (operational note included)

RequirementModifier 25 is required to report separate reimbursement for objective hearing screening, lead testing, vision screening, and developmental assessment procedures when performed on the same date as a preventive medicine E/M visit.

Applicable servicesObjective hearing screening; lead testing; vision screening; developmental assessment using a standardized screening method.

When to appendAppend Modifier 25 to the procedure code for the component service billed on the same day as a preventive E/M to indicate a significant, separately identifiable E/M service.

Claims elements to includeInclude EPSDT Special Program Indicator, referral indicator codes if applicable, appropriate diagnosis, HCPCS for EPSDT service, E/M code, procedure codes for component services, and applicable modifiers including Modifier 25.

Operational note (policy change)Policy updates include revised claim requirement language clarifying Modifier 25 guidance for same-day 'leading test' scenarios (see policy history/operational notes).

Authorization and Same-day Visit Coordination

Prior Authorization

Authorization, medical necessity, and same‑day visit coordination

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and to the member’s state of residence. When EPSDT services are performed with a sick visit, follow the Preventive Medicine and Sick Visits on the Same Day policy.

Use applicable authorization processes when required by the member’s state or benefit plan.
Ensure documentation supports medical necessity for each procedure and diagnosis billed.
Coordinate billing per the Preventive Medicine and Sick Visits on Same Day policy when EPSDT is provided with a sick visit.

Key Definitions

EPSDT — definition and scope

DefinitionEPSDT (Early and Periodic Screening, Diagnostic, and Treatment) program for Medicaid members, which includes preventive medicine E/M visits and component services.

ScopeCovers preventive screenings, diagnostic evaluations, and treatment services per EPSDT guidelines; reimbursement is allowed unless provider, state, or program rules exclude the service.

Included componentsComprehensive history, unclothed physical exam, health education, nutritional assessment, dental screening, and other EPSDT component services.

Separate reimbursement rulesCertain component services (e.g., developmental screening with a standardized tool, hearing screening, vision screening, immunizations, specified lab tests) may be separately reimbursable when billed appropriately and, when performed same day as preventive E/M, reported with required modifiers per claims requirements.

Claims/Billing guidanceProvider claims should include EPSDT special program indicator, referral indicator codes if applicable, appropriate diagnosis, HCPCS identifying EPSDT service, appropriate E/M code, procedure codes for component services, and applicable modifiers.