CurrentEmpire BluecrossPolicy C-12002

Screening Services with Related Evaluation and Management Services Professional

Defines Anthem/Empire BlueCross reimbursement policy governing when screening services may or may not be separately reimbursed when reported on the same date as preventive medicine, annual GYN exam, or problem-oriented E/M services; applies to professional providers submitting claims for commercial members.

Policy Summary

PayerEmpire Bluecross

PolicyScreening Services with Related Evaluation and Management Services Professional

Policy CodePolicy C-12002

Change TypeAdministrative reviewno material changes (11/17/2023)

Effective DateAug 7, 2020

Next Review Date

Key ActionFollow authorization and medical necessity guidelines and ensure proper coding and documentation to support services billed; failure may result in recoupment, rejection, or denial.

SourceLink

POLICY UPDATE CHANGES

11/17/2023 review approved: no changes.

08/07/2020 review approved and effective: minor administrative changes.

3Related codes not eligible

11/17/2023Last review

08/07/2020Effective

Reimbursement Criteria for Screening Services

Reimbursement criteria for screening services

Policy Summary

PayerEmpire Bluecross

PolicyScreening Services with Related Evaluation and Management Services Professional

Policy CodePolicy C-12002

Change TypeAdministrative reviewno material changes (11/17/2023)

Effective DateAug 7, 2020

Next Review Date

Key ActionFollow authorization and medical necessity guidelines and ensure proper coding and documentation to support services billed; failure may result in recoupment, rejection, or 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.

Screening services reported on the same date of service by the same provider as a preventive medicine service, an annual GYN examination, or a problem-oriented evaluation and management (E/M) service are not eligible for separate reimbursement; the screening should be considered when determining the appropriate E/M level.

Specific codes not separately reimbursable

G0101 — Cervical or vaginal cancer screening; pelvic and clinical breast examination; not eligible for separate reimbursement; modifiers -25 and -59 do not override this position.
G0102 — Prostate cancer screening; digital rectal examination; not eligible for separate reimbursement; modifiers -25 and -59 do not override this position.
Q0091 — Screening Papanicolaou smear; obtaining, preparing, and conveyance of cervical or vaginal; not eligible for separate reimbursement; modifiers -25 and -59 do not override this position.

Annual GYN examinations are considered included in reimbursement for preventive medicine services and are not eligible for separate reimbursement.

Codes and Same-Date Provider Rules

Screening codes not eligible for separate reimbursement with preventive/annual GYN or problem-oriented E/MCPTNot Covered

G0101	Cervical or vaginal cancer screening; pelvic and clinical breast examination
G0102	Prostate cancer screening; digital rectal examination
Q0091	Screening Papanicolaou smear; obtaining; preparing, and conveyance of cervical or vaginal

Same-date same-provider reimbursement rule

RuleScreening services reported on the same date of service by the same provider as a preventive medicine service, an annual GYN examination, or a problem-oriented E/M service are not eligible for separate reimbursement; the screening should be considered when determining the appropriate E/M level.

Annual GYN examsAnnual GYN examinations are considered included in reimbursement for preventive medicine services and are not eligible for separate reimbursement.

Modifier policyModifiers -25 and -59 do not override the non-reimbursement position for screening services reported with the services described above.

Authorization, Billing, and Documentation Requirements

Documentation Required

Authorization, coding, and documentation requirements

Providers must follow authorization and medical necessity guidelines and submit claims using industry-standard CPT/HCPCS/revenue codes that are fully supported in the medical record or office notes. Failure to follow appropriate coding/billing guidelines or current reimbursement policies may result in recoupment, rejection, or denial of claims.

Use compliant CPT, HCPCS, or revenue codes on all claim submissions and ensure services billed are supported in the medical record and/or office notes.
Follow authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member's state of residence.
Noncompliance may lead to recovery/recoupment of payment or claim denial/rejection.

OpenPayer

Screening Services with Related Evaluation and Management Services Professional

Reimbursement Criteria for Screening Services

Codes and Same-Date Provider Rules

Authorization, Billing, and Documentation Requirements

Policy Definitions