CurrentAnthemPolicy G-05016

Reimbursement Policy Preventive Medicine and Other Visits on the Same Day

Defines when and how the health plan reimburses preventive medicine visits, Medicare Annual Wellness Visits (AWVs), and sick/other E/M visits performed on the same calendar day for Anthem members; applies to participating providers unless superseded by provider, state, federal, or CMS contract requirements.

Policy Summary

PayerAnthem

PolicyReimbursement Policy Preventive Medicine and Other Visits on the Same Day

Policy CodePolicy G-05016

Change TypeRevised — material change to reimbursement percentages

Effective DateApr 1, 2026

Next Review Date

Key ActionBill Modifier 25 with the E/M code for the allowed sick visit when performed same day and include appropriate diagnosis codes to ensure eligibility for reimbursement.

SourceLink

POLICY UPDATE CHANGES

Policy updated to reimburse sick visits on the same day as preventive or wellness visits at 50% and reimburse preventive services on the same day as wellness visits at 50% of the applicable fee schedule or contracted/negotiated rate.

Updated policy title from Preventive Medicine and Sick Visits on the Same Day and clarified wellness visits as AWVs.

50%reimbursement rate for allowed same-day sick visit when performed with preventive or AWV

50%reimbursement rate for allowed preventive medicine visit when performed same day as AWV

Modifier 25 requiredmodifier requirement for same-day sick visit reimbursement

AWVwellness visit terminology clarified

Same-day Preventive/AWV and Other Visit Reimbursement Criteria

Same-day preventive/AWV and other visit reimbursement criteria

Reimbursement is allowed under the following conditions unless superseded by provider, state, federal, or CMS contracts and/or requirements:

Modifier 25 must be billed with the applicable evaluation and management (E/M) code for the allowed 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 the respective visits.

Services must meet authorization and medical necessity guidelines and be supported in the medical record; improper coding or noncompliance may result in claim rejection, denial, recovery, or adjustment.

Reimbursement splits

For sick visits on the same day as preventive medicine or AWVs: reimbursement = fee schedule or contracted/negotiated rate for the preventive medicine or AWV + 50% of the fee schedule or contracted/negotiated rate for the allowed sick visit.

Policy Summary

PayerAnthem

PolicyReimbursement Policy Preventive Medicine and Other Visits on the Same Day

Policy CodePolicy G-05016

Change TypeRevised — material change to reimbursement percentages

Effective DateApr 1, 2026

Next Review Date

Key ActionBill Modifier 25 with the E/M code for the allowed sick visit when performed same day and include appropriate diagnosis codes to ensure eligibility for 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.

Coding and Reimbursement Details

General coding guidancemixed

No codes listed

Reimbursement split and modifier requirements — summary

Reimbursement split when sick visit occurs same day as preventive/AWVPayment = full fee schedule or contracted/negotiated rate for the preventive medicine or AWV + 50% of the fee schedule or contracted/negotiated rate for the allowed sick visit.

Reimbursement split when preventive medicine occurs same day as AWVPayment = full fee schedule or contracted/negotiated rate for the AWV + 50% of the fee schedule or contracted/negotiated rate for the allowed preventive medicine visit.

Applicability to FQHCs and RHCsFederally qualified health centers (FQHCs) and rural health centers (RHCs) reimbursed other than through the health plan fee schedule or state encounter rates are not subject to this reimbursement split policy.

Contract and regulatory precedencePolicy applies unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise; contract/regulatory requirements supersede this policy.

Modifier requirement for sick visit reimbursementModifier 25 must be billed with the applicable E/M code for the allowed sick visit; without Modifier 25 the sick visit will not be eligible for reimbursement.

Billing and Claim Submission Requirements

Billing Rule

Modifier 25, diagnosis coding, and claim submission requirements

Bill Modifier 25 with the applicable E/M code for the allowed sick visit when performed the same day as a preventive medicine visit or AWV; if Modifier 25 is not billed appropriately, the sick visit will not be eligible for reimbursement. Ensure appropriate diagnosis codes are billed for each visit and use industry-standard CPT, HCPCS, and/or revenue codes on all claim submissions; services billed must be fully supported in the medical record. Failure to follow appropriate coding/billing guidelines or current reimbursement policies may result in claim rejection or denial, payment recovery/recoupment, or adjustment of reimbursement.

Modifier 25 must be billed with the applicable E/M code for the allowed sick visit; absence of Modifier 25 = no reimbursement for the sick visit. [[cite 2]]
Appropriate diagnosis codes must be billed for respective visits. [[cite 2]]
Use CPT, HCPCS, and/or revenue codes and ensure documentation in the medical record supports billed services. [[cite 9]]
Noncompliance may lead to claim rejection/denial, recovery/recoupment, or adjustment of reimbursement. [[cite 9]]

AWV and Reimbursement Definitions

AWV and related reimbursement definitions

AWV (Annual Wellness Visit)Medicare Annual Wellness Visit (AWV) terminology used in this policy; reimbursement rules for AWVs are specified when AWVs occur on the same day as other visits.

General Reimbursement Policy DefinitionsStandard general reimbursement definitions referenced by the health plan apply to preventive medicine, AWVs, and other visits as noted in this policy.

Appropriate coding and documentationAppropriate diagnosis codes must be billed for respective visits and services must be supported in the medical record to meet reimbursement criteria.

Modifier 25 definition (billing action)Modifier 25 is required to be billed with the applicable E/M code for an allowed sick visit performed the same day as a preventive or AWV visit to qualify for separate reimbursement.