Reimbursement Policy Preventive Medicine and Sick Visits on the Same Day
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Defines Anthem New York Medicaid reimbursement rules when preventive medicine and a sick (E/M) visit are provided on the same day, including modifier, diagnosis, and payment-rate requirements; applies to NY Medicaid providers (excludes FQHCs/RHCs reimbursed outside fee schedules).
Updated policy to reimburse CPT codes 99214 and 99215 on the same day as preventive medicine at 50% for members aged 22 or over.
Same-day Preventive and Sick Visit Coverage
Same-day preventive and sick visit criteria
Conditions under which both preventive medicine and a same-day sick visit may be reimbursed:
ALL of the following
- Modifier 25 must be billed with the applicable evaluation and management (E/M) code for the sick visit; if modifier 25 is not billed appropriately, the sick visit will not be eligible for reimbursement.
- Appropriate diagnosis codes must be billed for each respective visit.
- Reimbursement is based on the fee schedule or contracted/negotiated rate for the preventive medicine visit and the allowed sick visit.
ALL of the following
ALL of the following
- Federally qualified health centers (FQHCs) and rural health centers (RHCs) that are reimbursed other than through their respective health plans' fee schedule or state encounter rates are not subject to this policy.
Allowed Codes and Reimbursement Rates
Billing, Documentation, and Authorization Requirements
Billing and documentation requirements — bill modifier 25 and document E/M
Bill modifier 25 with the applicable E/M code for the sick visit; if modifier 25 is not billed appropriately, the sick visit will not be eligible for reimbursement. Submit appropriate diagnosis codes for each visit and ensure the E/M service is fully supported in the medical record or office notes.
- Modifier 25 must be billed with the applicable E/M code for the allowed sick visit; without modifier 25 the sick visit is ineligible for payment.
- Appropriate diagnosis codes must be billed for respective visits.
- E/M codes and other procedure codes must be supported in the medical record/office notes.
Authorization and claim integrity — meet medical necessity and billing rules
Services must meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member's state of residence; failure to follow coding/billing guidelines or current reimbursement policies may result in claim rejection, denial, recovery/recoupment, or reimbursement adjustment.
- Ensure services meet authorization and medical necessity criteria for the procedure and diagnosis.
- If coding/billing guidelines or reimbursement policies are not followed, the plan may reject/deny the claim, recover/recoup payment, or adjust reimbursement.
General Definitions
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