Preventive Medicine and Sick Visits on the Same Day
Defines Anthem Wisconsin Medicaid reimbursement rules when a preventive visit and a sick (E/M) visit occur on the same day and who is affected (providers billing under Wisconsin BadgerCare Plus and Medicaid SSI programs).
No material clinical or coverage changes in this revision.
Same-day Preventive and Sick Visit Coverage
Same-day preventive and sick visit coverage criteria
Anthem allows reimbursement for preventive medicine and sick visits on the same day when ALL of the following are met unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise:
All of the following
- 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 be denied.
- Appropriate diagnosis codes must be billed for respective visits
- Reimbursement is based on full fee schedule or contracted/negotiated rate for the preventive medicine visit
- Reimbursement for the allowed sick visit is 50% of the fee schedule or contracted/negotiated rate
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