CurrentBlue Cross Blue Shield - WisconsinPolicy G-05016

Preventive Medicine and Other Visits on the Same Day

This reimbursement policy governs when preventive medicine visits, Medicare Annual Wellness Visits (AWVs), and sick visits performed on the same day are eligible for reimbursement and how they are paid for affected providers under the payer.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyPreventive Medicine and Other Visits on the Same Day

Policy CodePolicy G-05016

Change TypeRevised (payment amounts updated)

Effective Date04/01/2026

Next Review DateN/A

Key ActionWhen billing a same-day sick visit with preventive medicine or AWV, providers must append modifier 25 to the E/M code for the sick visit and bill appropriate diagnosis codes.

SourceLink

POLICY UPDATE CHANGES

Updated policy to reimburse sick visits on the same day as preventive or wellness visits at 50% and reimburse preventive services on the same day as wellness visits at 50% of the applicable fee schedule or contracted/negotiated rate.

Updated policy title from Preventive Medicine and Sick Visits on the Same Day and clarified wellness visits to AWVs.

50%sick visit reimbursement

50%preventive visit reimbursement

01/14/2026last approval

04/01/2026effective

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyPreventive Medicine and Other Visits on the Same Day

Policy CodePolicy G-05016

Change TypeRevised (payment amounts updated)

Effective Date04/01/2026

Next Review DateN/A

Key ActionWhen billing a same-day sick visit with preventive medicine or AWV, providers must append modifier 25 to the E/M code for the sick visit and bill appropriate diagnosis codes.

SourceLink

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Same-day visit reimbursement criteria

Conditions under which same-day visits are reimbursed:

Same-day reimbursement allowed for preventive medicine, Medicare Annual Wellness Visits (AWVs), and/or sick visits 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 not be eligible for reimbursement.
Operational: ensure modifier 25 is appended to the E/M claim line for the sick visit.

Appropriate diagnosis codes must be billed for each respective visit.

ALL of the following

When a sick visit is performed the same day as preventive medicine or an AWV: reimburse the preventive medicine or AWV based on the fee schedule or contracted/negotiated rate.
Reimburse the allowed sick visit at 50% of the fee schedule or contracted/negotiated rate.

ALL of the following

When preventive medicine is performed the same day as an AWV: reimburse the AWV based on the fee schedule or contracted/negotiated rate.
Reimburse the allowed preventive medicine visit at 50% of the fee schedule or contracted/negotiated rate.

Federally qualified health centers (FQHCs) and rural health centers (RHCs) that are reimbursed other than through the health plan fee schedule or state encounter rates are not subject to this policy.

Coding and Reimbursement Details

Required modifierModifierCovered

Modifier 25

Must be billed with the applicable E/M code for allowed same-day sick visit

Reimbursement percentages for same-day services

Reimbursement percentage for secondary same-day serviceAllowed sick visit reimbursed at 50% of the fee schedule or contracted/negotiated rate when performed same day as a preventive medicine visit or Medicare AWV

Preventive medicine when same day as AWVPreventive medicine visit reimbursed at 50% of the fee schedule or contracted/negotiated rate when performed same day as an AWV

Basis for paymentPrimary service (preventive medicine or AWV) reimbursed at full fee schedule or contracted/negotiated rate; secondary same-day service reimbursed at 50%

Effective payment referenceReimbursement percentages apply to fee schedule or contracted/negotiated rates as stated in policy

Billing Requirements and Provider Actions

Billing Rule

Append modifier 25 and bill diagnoses for same-day sick visits

When billing a same-day sick visit performed with a preventive medicine visit or Medicare Annual Wellness Visit (AWV), append modifier 25 to 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.

Append Modifier 25 to the E/M code for the sick visit.
Bill appropriate diagnosis codes for each visit.

Definitions and Special Settings

FQHC / RHC exclusion

FQHC / RHC exclusionFederally qualified health centers (FQHCs) and rural health centers (RHCs) reimbursed other than through the health plan fee schedule or state encounter rates are not subject to this policy

Scope of exclusionApplies when FQHCs/RHCs are reimbursed outside the plan fee schedule or via state encounter rates

ImplicationProviders paid under alternative reimbursement mechanisms (e.g., state encounter rates) should follow those payment terms rather than this policy

Modifier 25 (billing requirement)

Definition of Modifier 25Modifier 25 indicates a significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day as another procedure or service

Billing requirementModifier 25 must be billed with the applicable E/M code for the allowed sick visit; failure to bill Modifier 25 renders the sick visit ineligible for reimbursement

Associated documentationAppropriate diagnosis codes must be billed for respective visits when Modifier 25 is used

OpenPayer

Preventive Medicine and Other Visits on the Same Day

Same-Day Visit Coverage Criteria

Coding and Reimbursement Details

Billing Requirements and Provider Actions

Definitions and Special Settings