CurrentAnthemPolicy G-05016

Reimbursement Policy Preventive Medicine and Sick Visits on the Same Day

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).

Policy Summary

PayerAnthem

PolicyPreventive Medicine and Sick Visits on the Same Day

Policy CodePolicy G-05016

Change TypeUpdated reimbursement rule

Effective DateAug 1, 202648d

Next Review Date

Key ActionBill modifier 25 with the applicable E/M code for the sick visit and include appropriate diagnosis codes to support reimbursement.

SourceLink

POLICY UPDATE CHANGES

Updated policy to reimburse CPT codes 99214 and 99215 on the same day as preventive medicine at 50% for members aged 22 or over.

50%reimbursement for 99214/99215 (same-day, age 22+)

Modifier 25modifier requirement

NY Medicaidapplicability

FQHCs/RHCsexclusions

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

Policy Summary

PayerAnthem

PolicyPreventive Medicine and Sick Visits on the Same Day

Policy CodePolicy G-05016

Change TypeUpdated reimbursement rule

Effective DateAug 1, 202648d

Next Review Date

Key ActionBill modifier 25 with the applicable E/M code for the sick visit and include appropriate diagnosis codes to support reimbursement.

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.

Allowed Codes and Reimbursement Rates

Allowed same-day sick visit CPT codes (age 22+; reduced payment)CPTCovered

99214	Office or other outpatient visit, established patient, moderate complexity
99215	Office or other outpatient visit, established patient, high complexity

Age threshold for 50% reimbursement — member age applicability

Age thresholdMembers aged 22 or older

Payment impact at/above thresholdSick visit coded as CPT 99214 or 99215 reimbursed at 50% of the fee schedule or contracted/negotiated rate

Applies whenWhen a preventive medicine visit and an allowed sick visit occur the same day and modifier 25 is billed with the E/M code

ExclusionsFQHCs and RHCs reimbursed other than through fee schedules or state encounter rates are not subject to this rule

Billing, Documentation, and Authorization Requirements

Documentation Required

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.

Denial Risk

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

General definitions — standard reimbursement policy definitions

Modifier requirementModifier 25 must be billed with the applicable E/M code for the sick visit; without modifier 25 the sick visit is not eligible for reimbursement.

Diagnosis codingAppropriate diagnosis codes must be billed for each respective visit.

Reimbursement basisReimbursement is based on the fee schedule or contracted/negotiated rate for the preventive medicine and the allowed sick visit.

Excluded facilitiesFQHCs and RHCs reimbursed other than through fee schedules or state encounter rates are not subject to this policy.

PurposeGuidance to assist accurate claims submission and outline basis for reimbursement.