CurrentAnthemPolicy G-05016

Preventive Medicine and Sick Visits on the Same Day

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Governs Anthem HealthKeepers Medicaid reimbursement when a preventive medicine visit and a sick (E/M) visit occur on the same day for members; specifies billing requirements and payment rates and notes exceptions for FQHCs/RHCs and contractual mandates.

Policy Summary

PayerAnthem

PolicyPreventive Medicine and Sick Visits on the Same Day

Policy CodePolicy G-05016

Change TypeRevised - material change

Effective Date08/01/2026

Last ReviewMar 25, 2026

Next Review DateN/A

Key ActionBill modifier 25 with the sick visit E/M code and include appropriate diagnosis codes; sick visits for members 21+ are reimbursed at 50% when same-day with preventive visits.

SourceLink

POLICY UPDATE CHANGES

Updated policy to reimburse sick visits on the same day as preventive medicine at 50% for members aged 21 or over.

50%Reimbursement rate (same-day sick visit)

Modifier 25Billing requirement

21+Affected age group

ExcludedFQHCs/RHCs

08/01/2026Effective

Same-day Preventive and Sick Visit Coverage

Same-day preventive and sick visit reimbursement criteria

Covered when ALL of the following are met:

Preventive medicine visit is billable per the fee schedule or contracted/negotiated rate

Sick visit billed with the applicable evaluation and management (E/M) code and modifier 25

If modifier 25 is not billed appropriately, the sick visit will not be eligible for reimbursement.

Appropriate diagnosis codes are billed for each respective visit

For members age 21 and older, the sick visit reimbursed at 50% of the fee schedule or contracted/negotiated rate when billed same-day with a preventive medicine visit50% of fee schedule or contracted/negotiated rate

Federally qualified health centers (FQHCs) and rural health centers (RHCs) reimbursed other than through fee schedules or state encounter rates are excluded from this policy

These sites are not subject to this policy when reimbursed other than through their respective fee schedules or state encounter rates.

Services must meet authorization and medical necessity guidelines and comply with applicable provider, state, federal, or CMS contracts or requirements

Failure to follow coding/billing guidelines may result in claim denial, rejection, or recovery of payment.

Coding and Payment Rates

General codingmixed

No codes listed

Payment rate for same-day sick visit (age 21+)

Payment rate for same-day sick visit (members age 21 and older)50% of the fee schedule or contracted/negotiated rate

Preventive visit payment basisFee schedule or contracted/negotiated rate

Condition for reimbursementModifier 25 must be billed with the applicable E/M code for the sick visit

Documentation requirementAppropriate diagnosis codes must be billed for each visit

ExclusionFQHCs and RHCs reimbursed other than through fee schedule or state encounter rates are not subject to this policy

Billing and Authorization Requirements

Billing Rule

Bill modifier 25, use appropriate diagnosis codes, and meet authorization/medical necessity

Bill modifier 25 with the applicable E/M code for the sick visit and bill appropriate diagnosis codes for each visit; if modifier 25 is not billed appropriately, the sick visit will not be eligible for reimbursement. Ensure services meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member’s state of residence.

Use industry-standard CPT, HCPCS, and/or revenue codes and ensure documentation in the medical record or office notes supports billed services.
Failure to follow coding/billing guidelines or current reimbursement policies may result in claim rejection or denial and potential recovery/recoupment of payments.

Policy Definitions

General Reimbursement Policy Definitions

Referenced definitionsGeneral Reimbursement Policy Definitions

ApplicationDefinitions referenced apply to reimbursement rules for same-day preventive and sick visits

Contract precedenceProvider, state, federal, or CMS contracts and requirements may supersede this policy

Authorization/medical necessityServices must meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member's state of residence

Policy Summary

PayerAnthem

PolicyPreventive Medicine and Sick Visits on the Same Day

Policy CodePolicy G-05016

Change TypeRevised - material change

Effective Date08/01/2026

Last ReviewMar 25, 2026

Next Review DateN/A

Key ActionBill modifier 25 with the sick visit E/M code and include appropriate diagnosis codes; sick visits for members 21+ are reimbursed at 50% when same-day with preventive visits.

SourceLink

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