CurrentEmblemHealthPolicy RPC2O21OO1O

Preventive Medicine and Screening (Commercial)

Defines how EmblemHealth reimburses preventive medicine (wellness) services, associated screening, counseling, prolonged services, and when Evaluation and Management (E/M) services are payable in commercial lines; applies to providers billing EmblemHealth commercial products.

Policy Summary

PayerEmblemHealth

PolicyPreventive Medicine and Screening (Commercial)

Policy CodePolicy RPC2O21OO1O

Change TypeCoding clarification (material)

Effective DateJan 1, 2022

Next Review DateN/A

Key ActionOnly submit an E/M with modifier 25 when a significant, separately identifiable problem was addressed during the preventive visit; otherwise bill only the preventive medicine code.

SourceLink

POLICY UPDATE CHANGES

Effective 1/1/2024, CPT code 99459 is considered included in payment for the Preventive Medicine Service and illness-related EIM service rendered on the same day and will not be reimbursed separately.

50%E/M payment when modifier 25 applied

100%Preventive medicine reimbursement rate

CPT 99381-99387, 99391-99397Preventive CPT codes referenced

1/1/202499459 clarification effective

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.

Coverage rules for preventive medicine and related services

Coverage criteria for preventive medicine and related services

Covered when ALL of the following rules are met:

Preventive medicine services are comprehensive visits that include age- and gender-appropriate history, examination, counseling, anticipatory guidance, risk-factor reduction interventions, and included screening and counseling procedures (see included items).

When a preventive medicine service and other Evaluation and Management (E/M) services are provided during the same visit by the same provider, only the preventive medicine service will be reimbursed unless the E/M is significant and reported with modifier 25; in that case the preventive medicine service is reimbursed at 100% of the allowable and the E/M is reimbursed at 50%.

Providers should only submit a preventive medicine code and a separate E/M code when a significant abnormality or pre-existing condition is addressed and additional work beyond the preventive service is required; the E/M must have modifier 25 appended to be considered for separate reimbursement.

Screening procedures (including cervical cancer screening; pelvic and breast examinations; prostate screening/digital rectal examination; and obtaining, preparing and conveyance of a Papanicolaou smear) are included in the preventive medicine code and are not separately reimbursed when performed the same day by the same specialty provider or other qualified health care professional reporting the same TIN.

Counseling services, medical nutrition therapy, visual function and visual acuity screening are included in preventive medicine codes and are not separately reimbursed when billed the same day by the same specialty provider or other qualified health care professional reporting the same TIN.

Prolonged service add-on codes are not separately reimbursed with preventive medicine codes; preventive medicine codes are not designated as appropriate primary codes for prolonged service add-ons.

HCPCS 'G' and 'S' codes are usually not reimbursable to commercial lines unless contractually designated and may require resubmission with an applicable CPT code when applicable.

Effective 1/1/2024, CPT 99459 is considered included in payment for the preventive medicine service and the illness-related E/M service rendered on the same day and will not be reimbursed separately.

Referenced procedure codes, E/M payment adjustment, and coding guidance

Referenced HCPCS/G-codesHCPCS

G0402	Annual wellness visit, including a personalized prevention plan of service (PPPS), initial visit
G0463	Facility fee for evaluations and management services for Medicare beneficiaries in a Federally Qualified Health Center (FQHC)
G0245	Telehealth originating site facility fee (Medicare/contract-based) - listed as contract/Medicare only in source
G0270	Medical nutrition therapy; reassessment and subsequent interventions (per session) - contract/Medicare only in source

E/M payment adjustment when billed with preventive service

E/M Payment Adjustment When Billed with Preventive ServiceWhen a preventive medicine service (CPT 99381-99387, 99391-99397 or G0402) and a problem‑oriented E/M service (CPT 99202‑99205, 99211‑99215 or G0463) are provided on the same date by the same provider, the preventive medicine service is reimbursed at 100% of the allowable contracted rate and the E/M service billed with modifier 25 is reimbursed at 50% of the allowable contracted rate. If the E/M visit is minor or modifier 25 is not appended, it will not be separately reimbursed.

Coding Guidance - Additional referenced codesMedical nutrition therapy codes (CPT 97802-97804) may be associated with HCPCS G0270; counseling and prolonged service HCPCS noted in source are contract/Medicare references (e.g., G0245 listed in source). HCPCS 'G' and 'S' codes are usually not reimbursable to commercial lines unless contractually designated and may deny; submit applicable CPT when required.

Billing and modifier usage instructions for providers

Billing Rule

Modifier 25 required for separate E/M reimbursement

When billing a preventive medicine service and an E/M for the same patient, same date of service, and by the same provider, only submit the E/M with modifier 25 when a significant, separately identifiable problem was addressed and additional work beyond the preventive service was required. If modifier 25 is appended and the E/M is reimbursed, the preventive medicine code is reimbursed at 100% of the allowable contracted rate and the E/M is reimbursed at 50% of the allowable (50% reduction applies to the E/M visit).

Only submit both codes when a significant abnormality or pre-existing condition is addressed and additional work is required.
Append modifier 25 to the E/M to indicate a separately identifiable service.
Preventive medicine code reimbursed at 100% of allowable; E/M with modifier 25 reimbursed at 50% of allowable.

Definitions used in this policy

Same Specialty Physician or Other Qualified Health Care Professional

DefinitionPhysicians and/or other qualified health care professionals of the same group and same specialty reporting the same Federal Tax Identification number.

Applies to billingGuidance referencing 'Same Specialty Physician or Other Qualified Health Care Professional' is used to determine when screening, counseling, and other services billed on the same date are considered part of the preventive medicine code and not separately reimbursed.

ContextReimbursement rules (e.g., only the preventive medicine code reimbursed when screening or counseling codes are billed the same day) apply when services are reported by providers meeting this definition.

Preventive Medicine Services

Scope of servicesIncludes annual physical and well-child examinations, usually in the absence of a disease-related diagnosis; preventive visits are comprehensive and reflect age- and gender-appropriate history, exam, and counseling.

Included componentsCounseling, anticipatory guidance, risk factor reduction interventions, screening procedures (e.g., cervical cancer screening, pelvic and breast exams, prostate screening/DRE, and Pap smear collection), medical nutrition therapy, and vision screening are included and not separately reimbursed when performed the same day.

When E/M may be paid separatelyOccasionally an abnormality or pre-existing problem is addressed and significant E/M elements are provided; in that case a problem-oriented E/M may be reimbursed separately only if billed with modifier 25 and by the same provider (see E/M payment adjustment).