CurrentBlue Cross Blue Shield - WisconsinPolicy G-05016

Preventive Medicine and Sick Visits on the Same Day

This reimbursement policy governs when Anthem Medicare Advantage (including BCBSWI as listed) will reimburse both a preventive medicine visit and a same-day sick (E/M) visit for members, and specifies billing requirements; it applies to providers submitting claims to the listed Anthem Medicare Advantage plans and states.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin (Anthem Medicare Advantage listed)

PolicyPreventive Medicine and Sick Visits on the Same Day

Policy CodePolicy G-05016

Change TypeReview approved — no material changes

Effective Date05/22/2024

Next Review Date

Key ActionBill Modifier 25 with the applicable E/M code for the same-day sick visit to avoid denial.

SourceLink

POLICY UPDATE CHANGES

Review approved and effective: no changes (05/22/2024).

Updated policy template (05/26/2022).

Removed example from language (07/13/2018).

Initial approval and effective (01/01/2015).

1Modifier 25 required

MultipleApplicable states/markets

ExcludedFQHC/RHC exclusion

YesCMS referenced

Same-day Preventive and Sick Visit Coverage Criteria

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin (Anthem Medicare Advantage listed)

PolicyPreventive Medicine and Sick Visits on the Same Day

Policy CodePolicy G-05016

Change TypeReview approved — no material changes

Effective Date05/22/2024

Next Review Date

Key ActionBill Modifier 25 with the applicable E/M code for the same-day sick visit to avoid denial.

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.

Same-day preventive and sick visit reimbursement criteria

Reimbursement is allowed when ALL of the following conditions are met:

ALL of the following

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.
ALL of the following
- Appropriate diagnosis codes must be billed for the respective preventive medicine and sick (E/M) visits.
ALL of the following
- Federally qualified health centers (FQHCs) and rural health centers (RHCs) reimbursed other than through the Anthem Medicare Advantage fee schedule or state encounter rates are not subject to this policy.
ALL of the following
- Reimbursement is based on the fee schedule or contracted/negotiated rate for the preventive medicine visit and the allowed sick visit.

Required Modifiers and Coding Standards

Required modifier for same-day E/MModifierCovered

Modifier 25

Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service

Coding standards — CPT/HCPCS/revenue codes and compliance

Required coding systemsUse CPT, HCPCS, and/or revenue codes on all claim submissions; codes must be fully supported in the medical record or office notes.

Documentation supportServices billed must be fully supported in the medical record and/or office notes to substantiate the codes submitted.

Consequences for noncomplianceIf coding/billing guidelines or current reimbursement policies are not followed, Anthem Medicare Advantage may recover/recoup payment, reject or deny the claim, or adjust reimbursement.

ApplicabilityPolicies apply to both participating and non‑participating professional providers and facilities unless otherwise noted.

Standards requirementYou are required to use industry standard, compliant codes on all claim submissions.

Billing and Documentation Requirements for Providers

Billing Rule

Bill Modifier 25 with same-day sick E/M

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.

Documentation Required

Submit appropriate diagnoses, authorization, and supporting documentation

Bill appropriate diagnosis codes for each visit and ensure services meet authorization and medical necessity guidelines; use industry-standard CPT, HCPCS, and/or revenue codes fully supported in the medical record. Retain documentation and follow proper billing/submission guidelines because failure to follow may result in recoupment, denial, or adjustment.

Use CPT, HCPCS and/or revenue codes that are fully supported in the medical record and office notes.
Follow authorization and medical necessity requirements applicable to the procedure, diagnosis, and member's state of residence.
Maintain documentation to support billed services and be prepared for review or recoupment.

Plan Sponsor and Issuer Identification

Plan sponsors / issuer identification

Primary plan identificationAnthem Medicare Advantage as referenced throughout this policy (plans administered by Anthem entities).

Anthem Blue Cross and Blue Shield entitiesList includes Anthem Health Plans, Inc.; Rocky Mountain Hospital and Medical Service, Inc.; Anthem Health Plans of New Hampshire, Inc.; Anthem HealthChoice Assurance, Inc.; Anthem HP, LLC; and others as listed by state.

Wisconsin sponsorBlue Cross Blue Shield of Wisconsin (BCBSWI) is listed as the Anthem affiliate for Wisconsin in this policy.

State-specific notesEntity names vary by state (examples provided for CO, CT, GA, IN, KY, MO, NV, NH, NY, OH, VA, WI); refer to policy definitions for exact trade names per state.