Modifier 25 disclosure, diagnosis position, and payment split

When billing a problem-focused E&M on the same day as a preventive service, apply modifier 25 to the problem-focused E&M and disclose to the member if billing will result in cost-sharing; preventive services must be submitted with a preventive diagnosis in the primary position to avoid cost-sharing. Preventive service reimbursed at 100% and the problem-focused service reimbursed at 50% when modifier 25 is applied (commercial plans); Medicare Advantage members may owe cost-sharing when modifier 25 is used. Regular review of modifier 25 use for coding accuracy will occur.

• Preventive ICD-10 codes must be placed in the primary diagnosis position; if not, cost-sharing may apply.
• Providers must disclose to members when a problem-focused E&M is billed and will result in cost-sharing.
• When modifier 25 is correctly applied, preventive service reimbursed at 100% and problem-focused E&M at 50% of contracted rate for commercial members; Medicare Advantage members may be responsible for copayment/deductible.

Always report preventive diagnosis in primary position

Submit preventive services with preventive diagnosis codes in the primary diagnosis position on the claim; if a non-preventive diagnosis is in the primary position the service may be subject to member cost-sharing.

• Each claim line should indicate the applicable diagnosis; preventive diagnosis must be primary for the service to be considered preventive.
• Failure to use a preventive primary diagnosis may trigger member cost-sharing.

Obtain prior authorization for BRCA testing and high‑tech radiology

Obtain prior authorization where required: BRCA genetic testing and high‑tech radiology (including screening breast MRI) require prior authorization before services are rendered.

• BRCA gene analysis codes (e.g., 81212–81217) are considered preventive only with prior authorization.
• Screening breast MRI and other high‑tech radiology require prior authorization (effective coverage updates noted).

Use modifiers -53 (professional) or -73/-74 (facility) for interrupted colonoscopy

When a covered colonoscopy is attempted but cannot be completed due to extenuating circumstances, submit the professional claim with modifier -53 to indicate the interrupted procedure; facility claims should use modifier -73 or -74 as appropriate.

• Plan will pay for interrupted colonoscopy if coverage conditions are met.
• Professional providers suffix the colonoscopy code with modifier -53; facility claims use -73 or -74 as appropriate.

When and how to bill annual depression screening (G0444)

Bill HCPCS G0444 (annual depression screening, up to 15 minutes) only when staff‑assisted depression care supports are in place and do not report G0444 with IPPE (G0438), initial AWV (G0402) or comprehensive preventive medicine CPTs; G0444 may be billed via telehealth with POS 02 or 10 effective Jan 1, 2025.

• G0444 requires staff-assisted supports (clinical staff to advise and facilitate referrals).
• Do not report G0444 with G0438, G0402 or CPT 99381‑99386/99391‑99396.
• Effective 1/1/2025, G0444 may be provided via telehealth (POS 02 or 10).

Fluoride varnish — exact CPT and ICD-10 pairing by program

For fluoride varnish, bill CPT 99188 with ICD-10 Z00.129 for EPSDT MassHealth well‑child visits on or after Aug 19, 2025; when billed for other visits use CPT 99188 with ICD-10 Z41.8. For Community Care members, bill CPT 99188 with ICD-10 Z29.3; dentists may bill D1206 only for members with preventive dental coverage.

• MassHealth EPSDT well-child visits (effective 8/19/2025): CPT 99188 + ICD-10 Z00.129.
• Other visits: CPT 99188 + ICD-10 Z41.8.
• Community Care: CPT 99188 + ICD-10 Z29.3; D1206 reserved for dentists treating members with dental coverage.

Perform baseline labs and quarterly HIV testing while on PrEP

Before initiating PrEP, obtain baseline testing (HIV, HBV, HCV, pregnancy when applicable, creatinine with eCrCl/eGFR) and STI screening; while on PrEP perform HIV testing every three months and periodic STI screening and counseling as part of monitoring.

• Baseline labs required prior to PrEP initiation: HIV, HBV, HCV, pregnancy test if applicable, renal function (creatinine, eCrCl/eGFR).
• Repeat HIV testing every 3 months while taking PrEP; counseling and STI screening are integral components of PrEP care.
• Use recommended CPT/HCPCS lab and counseling codes per guidance (see PrEP coding lists).

Medicare NCD 210.15 — PrEP covered under Part B with no cost‑sharing

For Medicare members, PrEP drugs and associated clinical and laboratory services are covered under Medicare Part B per NCD 210.15 (effective 9/30/2024) with no deductibles, copayments, or coinsurance for individuals determined by a clinician to be at increased risk of HIV acquisition.

• NCD 210.15 directs Medicare to cover all forms of PrEP (oral and injectable) under Part B with no cost-sharing.
• Determination of 'increased risk' is made by a physician or health care practitioner.
• NCD includes coverage of up to eight counseling visits and up to eight HIV screening tests per 12 months and a single HBV screening with no cost-sharing.

Obtain prior authorization for LDCT (CPT 71271) when applicable

Prior authorization is required for LDCT lung cancer screening (CPT 71271) for commercial and MassHealth ACO members; note prior authorization exceptions for some Medicare plan types per updated guidance.

• CPT 71271 requires prior authorization for commercial and MassHealth ACO plan members.
• Effective 9/1/2021, prior authorization is not required for CPT 71271 for Medicare Advantage, NaviCare and PACE members.

Pharmacists cannot be paid directly under Medicare Part B — use 'incident to' billing when applicable

Pharmacists are not eligible for direct payment under Medicare Part B; pharmacist‑provided PrEP services (counseling, injection, ordering) cannot be paid directly to pharmacists and must be billed 'incident to' a supervising physician/practitioner when all incident‑to conditions and supervision requirements are met.

• Pharmacist services may be provided 'incident to' and billed by the supervising physician/practitioner when regulatory supervision and incident‑to conditions are satisfied.
• Refer to 42 CFR §§ 410.26 and 410.27 for incident‑to regulations and CMS incident‑to guidance.

Offer postpartum depression screening and refer if positive (Community Care)

Offer and perform postpartum depression and major depressive disorder screening for Community Care postnatal individuals within 12 months of birth, adoption/foster custody, or pregnancy loss; if screening is positive, document discussion of treatment options and refer to a mental health clinician. Screening performed as part of a global obstetrical service is considered part of the global package and is not separately reimbursed.

• Postnatal individuals include birth, adoption/foster custody within 12 months, or recent pregnancy loss.
• Providers (PCP, OB/GYN, CNM, licensed midwife, pediatrician) must offer screening and ensure appropriate screening per evidence‑based guidelines.
• If screening positive, discuss treatments and provide referral; screenings in a global obstetrical service are not separately reimbursed.

Report separate E/M with modifier 25 when provided with IPPE/AWV

If a significant, separately identifiable E/M is provided during an IPPE or AWV, report the appropriate E/M CPT code (99202–99215) with modifier 25 to indicate the separate service.

• Report CPT 99202–99215 with modifier 25 when E/M is significant and separately identifiable from IPPE (G0402/G0438) or AWV (G0439).
• Ensure documentation supports the additional E/M and that modifier 25 is applied appropriately.

Bill G0136 with modifier 33 for SDOH assessment when done with AWV

When providing an annual SDOH assessment on the same day as an AWV, provide the assessment on the same day by the same provider and bill HCPCS G0136 with modifier 33 on the same claim as the AWV.

• SDOH assessment must follow standardized evidence‑based practices and be culturally/linguistically appropriate.
• Bill G0136 with modifier 33 on the same claim as the AWV and ensure the same provider furnishes the AWV and the assessment.

Policy applies to services in all settings (place of service)

This policy applies to services rendered in all settings; all preventive coverage, billing and coding rules in this document apply regardless of place of service.

• Place of service applicability: policy covers services in all settings.
• Providers should follow the same billing/coding rules for preventive services in any setting.