Reimbursement Policy Preventive Medicine and Sick Visits on the Same Day
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Governs reimbursement when preventive medicine and an unrelated sick (E/M) visit occur on the same day for Anthem Ohio Medicaid members; applies to providers billing under the plan except where provider, state, federal, or CMS contracts/requirements indicate otherwise.
Updated policy to reimburse sick visits on the same day as preventive medicine at 50%.
Same-day Preventive and Sick Visit Coverage Criteria
Same-day preventive and sick visit reimbursement criteria
Covered when ALL of the following are met:
Coding and Reimbursement Details
| Modifier 25 | 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. |
Provider Billing and Documentation Actions
How to bill same-day preventive and sick visits
Bill the preventive medicine visit at the full fee schedule or contracted/negotiated rate and bill the unrelated sick (E/M) visit on the same day with modifier 25 appended to the applicable E/M code; the allowed sick visit will be reimbursed at 50% of the fee schedule or contracted/negotiated rate when these conditions are met. Ensure appropriate diagnosis codes are billed for each respective visit. FQHCs and RHCs reimbursed outside their health plan fee schedule or state encounter rates are not subject to this policy.
- Modifier 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.
- Appropriate diagnosis codes must be billed for respective visits.
- If coding/billing guidelines or reimbursement policies are not followed, the claim may be rejected, denied, or payment recovered.
Definitions
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