CurrentAnthemPolicy C-12002

Preventive Medicine Services with Screening and other Evaluation and Management Services - Professional

Defines Anthem's reimbursement position when preventive medicine (CPT 99381-99397, HCPCS G0402) is billed the same day by the same provider as other E/M, screening, counseling, prolonged services, annual gynecologic exams, or visual screenings; applies to commercial professional claims subject to provider, state, or federal contract exceptions.

Policy Summary

PayerAnthem

PolicyPreventive Medicine Services with Screening and other Evaluation and Management Services - Professional

Policy CodePolicy C-12002

Change TypeTitle and coding updates (non-material)

Effective DateApr 1, 2026

Next Review Date

Key ActionWhen preventive medicine is billed same day by the same provider as other specified services, only the preventive medicine service is reimbursed unless contract requirements override.

SourceLink

POLICY UPDATE CHANGES

Updated title and added specific categories that are not separately reimbursable; updated Related Coding section to include nonreimbursable codes.

CPT 99381-99397, G0402Primary preventive medicine codes referenced

MultipleCategories listed

Modifier 25Modifier override denied

CommercialPayer scope

Policy Summary

PayerAnthem

PolicyPreventive Medicine Services with Screening and other Evaluation and Management Services - Professional

Policy CodePolicy C-12002

Change TypeTitle and coding updates (non-material)

Effective DateApr 1, 2026

Next Review Date

Key ActionWhen preventive medicine is billed same day by the same provider as other specified services, only the preventive medicine service is reimbursed unless contract requirements override.

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.

Coverage Determination

Covered when ALL of the following are met:

ALL of the following

A preventive medicine service (CPT Codes 99381-99387, 99391-99397, or HCPCS Code G0402) is billed on the same day by the same provider as one or more of the services listed below.
Services considered part of the preventive medicine visit (not reimbursed separately)
- Annual gynecological examinations (including S0610, S0612-S0613).
  Not eligible for separate reimbursement; Modifier 25 will not override.
- Counseling services (e.g., 0403T, 99401-99404, 99406-99409, 99411-99412, G0296, G0396-G0397, G0443, G0445-G0447, G0473, H0005, S0257, S0265, S9470, T1006, T1027).
  Not eligible for separate reimbursement; Modifier 25 will not override.
- Medical Nutrition Therapy services (e.g., 97802-97804, G0270-G0271).
  Not eligible for separate reimbursement; Modifier 25 will not override.
- Other E/M services (e.g., 99211, 99242-99245, 99252-99255, 99281-99285, G0246, S0285).
  Not eligible for separate reimbursement; Modifier 25 will not override.
- Prolonged service codes (e.g., 99415-99418, G0316-G0318, G2212).
  Not eligible for separate reimbursement; Modifier 25 will not override.
- Screening services (e.g., G0101, G0102, Q0091, G0442, G0444).
  Not eligible for separate reimbursement; Modifiers 25 and 59 will not override for G0101/G0102/Q0091; Modifier 25 will not override for G0442/G0444.
- Visual function and visual acuity screenings (e.g., 0333T, 99172).
  Not eligible for separate reimbursement; Modifier 25 will not override.
Federal, state, or provider contract requirements may supersede this rule when applicable.
Apply contract- or state-specific provisions as required.

Codes and Modifier Guidance

Non-reimbursable when billed same day as preventive medicinemixedNot Covered

S0610	Annual gynecological examination
S0612	Annual gynecological examination
S0613	Annual gynecological examination
0403T	Counseling service
99401	Counseling service
99402	Counseling service
99403	Counseling service
99404	Counseling service
99406	Counseling service
99407	Counseling service

1–10 of 64

1/7

Modifier override — Modifier 25 (and in some cases 59) will not override to allow separate reimbursement when codes are billed same day by same provider

Policy on modifier overrideModifier 25 (and in some cases modifier 59) will not override to allow separate reimbursement when listed services are billed the same day by the same provider.

Examples of modifiers not overridingChunk 3 notes that Modifiers 25 and 59 will not override for screening services (G0101-G0102, Q0091) and that Modifier 25 will not override for most other listed services.

Applies to listed service categoriesCounseling, Medical Nutrition Therapy, Other E/M, Prolonged services, Screening services, Visual function screening and annual GYN exams are included in the non‑override rule.

Scope of non‑overrideThe non‑override applies when these services are billed the same day by the same provider as a preventive medicine service (CPT 99381-99397 or G0402).

Billing, Authorization, and Documentation Expectations

Documentation Required

Prior authorization and documentation expectations for same‑day preventive medicine services

When a preventive medicine service (CPT 99381-99397 or HCPCS G0402) is billed the same day by the same provider as other specified E/M, counseling, screening, prolonged, nutrition, annual gynecologic, or visual function services, only the preventive medicine service is allowed for reimbursement unless a provider, state, or federal contract requires otherwise. Services billed must meet authorization and medical necessity guidelines and be fully supported in the medical record; failure to follow billing or documentation requirements may result in claim rejection, denial, or recovery of payment.

Services considered part of the preventive medicine visit (annual GYN exams, counseling, medical nutrition therapy, other E/M services, prolonged services, screening services, visual function/acuity screenings) are not reimbursed separately when billed same day by the same provider.
Modifier 25 (and in some cases 59) will not override this policy per related coding guidance; check applicable provider/state/federal contracts for exceptions.

Key Definitions

Preventive medicine service — definition and brief description

DefinitionPreventive medicine involves a history and examination tailored to the member's age and gender; initial and routine preventive medicine examinations include counseling, anticipatory guidance, and interventions to reduce risk factors.

Common CPT/HCPCS codesPrimary preventive medicine codes referenced are CPT 99381-99397 and HCPCS G0402.

Included servicesServices considered part of the preventive medicine visit include annual gynecological examinations, counseling services, medical nutrition therapy, other E/M services, prolonged service consultations, screening services, and visual function/visual acuity screenings.

Reimbursement ruleWhen preventive medicine is billed the same day by the same provider as the listed services, only the preventive medicine service is allowed for reimbursement unless provider, state, or federal contracts require otherwise.

Annual GYN exam — S0610, S0612-S0613 considered part of preventive medicine and not eligible for separate reimbursement