ModifiedHealthfirstPolicy PO-RE-170v3

Additional Office and Outpatient Services Billed with Evaluation and Management (E&M)

Customize your policy alerts

Sign up for Healthfirst Policy PO-RE-170v3 alerts

Get alerted when Policy PO-RE-170v3 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Governs Healthfirst reimbursement rules for Evaluation and Management (E&M) services, preventive medicine services, add-on complexity codes (e.g., G2211), and other office/outpatient services billed the same date of service for Healthfirst lines of business and participating/non-participating providers submitting CMS-1500/837P claims.

Policy Summary

PayerHealthfirst

PolicyAdditional Office and Outpatient Services Billed with Evaluation and Management (E&M)

Policy CodePolicy PO-RE-170v3

Change TypeScope expansion and LOB reimbursement revisions

Effective DateSep 1, 2026

Last ReviewJul 20, 2026

Next Review Date

Key ActionWhen both a preventive medicine exam and an E&M are performed on the same date, bill both on the same claim and append Modifier 25 to the E&M with documentation supporting a separate, significant service.

SourceLink

POLICY UPDATE CHANGES

Expanded policy scope to include reimbursement guidance for additional office and outpatient services billed with Evaluation and Management (E&M) services and added new chapters for HCPCS G0545, preventive counseling and behavioral counseling services, medical nutrition therapy, prolonged services, screening services, and vision services.

Revised G2211 reimbursement policy for HARP, Essential Plan, and Qualified Health Plan to bundled reimbursement effective November 1, 2026.

Added NYS Medicaid pediatric coverage for HCPCS code G2211 for Medicaid members ages 0-20 with billing requirements including reporting G2211 with a qualifying E&M service, allowance for preventive medicine visit codes, limitation of one unit per patient per week, and eligible POS codes 02, 10, 11, and 22.

Added telehealth billing requirements clarifying G2211 is reimbursable via telehealth when billed in accordance with NYS Medicaid requirements and specifying telehealth modifiers (93 and 95).

Clarified that G2211 is not separately reimbursable for Adult Medicaid members age 21 and older and that claims submitted by in-network providers for adult Medicaid members will be denied.

Added Modifier 25 billing requirements and documentation standards for newly addressed services.

100%preventive exam reimbursement when billed per policy

50%E&M with Modifier 25 paid when supported

multiplelines of business covered

CMS-1500/837Papplies to claim type

0-20NYS Medicaid pediatric G2211 eligible ages

deniedAdult Medicaid G2211 separate reimbursement

Coverage Criteria and Reimbursement Rules

Preventive + E&M coverage criteria

Rules governing payment when preventive medicine examinations are performed with problem-oriented E&M or other services.

Preventive Medicine Examination (CPT 99381-99397, G0402, G0438, G0439) reimbursed at 100% of the provider's contracted allowable when billed in accordance with this policy and supported by appropriate documentation.

When an E&M Office/Outpatient service (CPT 99202-99215) is billed on the same date as a preventive medicine examination with Modifier 25 and documentation supports a separate and significant E&M, the E&M is eligible for reimbursement but payment is reduced to 50% of the provider's contracted allowable amount.

Documentation must support that the E&M service is significant and separately identifiable from the preventive medicine examination, clearly distinguish preventive versus problem-oriented services, support the level of E&M billed, and demonstrate medical necessity for the additional service.

E&M services may be denied when documentation does not support a separate and distinct service, duplicates routine preventive components, or when Modifier 25 is appended without sufficient justification.

The 50% reduction applies only to E&M services and does not apply to services separately reimbursable and outside the scope of E&M (for example diagnostic tests, laboratory services, immunizations/vaccines, and procedures), which are reimbursed separately per usual terms.

Claims remain subject to NCCI edits, CMS coding guidance, LCDs, NCDs, and applicable Healthfirst reimbursement policies.

Example: Reimbursement examples: 99396 paid at 100%; 99214-25 paid at 50%; diagnostic panel (80050) paid at 100% when appropriately billed.

G2211 (pediatric Medicaid) coverage criteria

G2211 reimbursement rules for Medicaid Managed Care (NYS) pediatric members:

G2211 is reimbursable for eligible Healthfirst Medicaid members ages 0–20 years when reported with a qualifying E&M service (NYS Medicaid coverage effective June 1, 2026).

Coverage limited to physicians and nurse practitioners practicing in pediatric primary care and eligible pediatric subspecialties as defined by NYS Medicaid.

G2211 may be billed in conjunction with a qualifying E&M procedure code, including preventive medicine visit codes; it must be billed on the same date as the qualifying E&M service.

Frequency: G2211 may be billed once per week per patient.

Place of service and telehealth: G2211 is payable when reported with POS codes 02, 10, 11, or 22. Telehealth delivery is allowable for POS 02 and 10 when the qualifying E&M is billed with the appropriate telehealth modifier (93, 95, or GT) per NYS Medicaid and Healthfirst billing requirements.

G2211 is not separately reimbursable for Healthfirst Medicaid members age 21 years and older; claims submitted by in‑network providers for adult Medicaid members will be denied.

Modifier and billing note: G2211 must be reported consistent with applicable billing requirements; claims with improper pairing or billing outside NYS Medicaid criteria may be denied.

LOB note: For specified LOB changes, G2211 reimbursement methodology was revised (see revision history) and may be bundled for certain LOBs effective Nov 1, 2026.

G2212 coverage criteria

G2212 coverage and documentation requirements by line of business:

G2212 must be reported only with E&M codes 99205 or 99215; it may not be reported as a standalone service.

Time requirement: G2212 may be reported only when total physician or qualified health care professional time exceeds the maximum time threshold established for the primary E&M service; the medical record must include total time and time exceeding the primary E&M maximum.

LOB payment

For MMC, CHP, HARP, Essential Plan (EP), and QHP: G2212 is not separately reimbursable; reimbursement is inclusive and bundled into the primary E&M service.
For Medicare Advantage, IB‑Dual, and CompleteCare (MAP): G2212 is eligible for separate reimbursement when reported with a qualifying E&M and supported by documentation that meets CMS requirements for prolonged services.
For the SHP line of business: G2212 is not a covered benefit.

Modifier 25 billing requirement: G2212 is an add‑on code and is not separately reimbursable when reported with a primary E&M billed with Modifier 25; claims submitted with G2212 in conjunction with an E&M+25 will be denied.

Documentation: No separate documentation beyond the medical record supporting the primary E&M is required; the record must support medical necessity, total time spent, and the time exceeding the maximum threshold for the primary E&M service.

G0545 coverage criteria

G0545 coverage and documentation requirements by line of business:

G0545 must be reported with a qualifying Evaluation and Management (E&M) service and may not be reported as a standalone service.

LOB payment

For MMC, CHP, HARP, EP, and QHP (effective Nov 1, 2026): G0545 is not separately reimbursable; reimbursement is inclusive and bundled into the E&M service.
For Medicare Advantage, IB‑Dual, and CompleteCare (MAP): G0545 may be separately reimbursed when reported with a qualifying E&M and supported by documentation that meets applicable CMS coding and documentation requirements.
For the SHP line of business: G0545 is not a covered benefit.

Modifier 25 billing requirement: G0545 is an add‑on code and is not separately reimbursable when reported with an E&M service appended with Modifier 25; claims submitted with G0545 in conjunction with an E&M+25 will be denied.

Documentation requirements: The medical record should include medical necessity, clinical circumstances supporting G0545, and documentation demonstrating compliance with applicable CMS coding requirements; providers must maintain documentation sufficient to support billed services and comply with Healthfirst, CMS, state, and federal billing requirements.

Preventive and behavioral counseling coverage

Preventive counseling and behavioral counseling coverage stance:

For MMC, CHP, HARP, EP, and QHP (effective Nov 1, 2026): many listed preventive and behavioral counseling CPT/HCPCS codes (including 0403T, 99401, 99404, 99406, 99407, 99408, 99409, 99411, 99412, G0296, G0396, G0397, G0443, G0445, G0446, G0473, G2011, H0005, S0257, S9470) are considered inclusive to the associated E&M or preventive medicine service and are not separately reimbursable.

For Medicare Advantage, IB‑Dual, and CompleteCare (MAP): coverage and reimbursement for preventive and behavioral counseling services are determined per applicable CMS coverage, coding, billing, and documentation requirements; certain codes (e.g., 99406, 99407, G0396, G0397, G0443, G0445, G0446, G0473, G2011, S9470) may be separately reimbursed when CMS criteria and benefit requirements are met.

Non‑covered under this policy excerpt: H0005 and S0257 are not covered and therefore not reimbursable.

Exception: CPT codes 99401 and 99404 are non‑covered under Original Medicare but will be covered by Healthfirst as supplemental Medicare benefits beginning CY2026 for eligible Medicare members.

Preventive/behavioral counseling coverage rules

Preventive counseling and behavioral counseling services reimbursement rules by LOB:

MMC/CHP/HARP/EP/QHP (effective Nov 1, 2026): specified CPT/HCPCS codes are considered inclusive to the associated E&M or preventive medicine service and are not separately reimbursable; reimbursement is included in the payment for the associated service.

SHP: these preventive and behavioral counseling services are not a covered benefit for Senior Health Partners.

Medicare Advantage/IB‑Dual/CompleteCare/MAP: coverage follows applicable CMS requirements; select codes (99406, 99407, G0396, G0397, G0443, G0445, G0446, G0473, G2011, S9470) may be separately reimbursed when CMS coverage criteria, documentation standards, and benefit requirements are met; CPT codes 99401 and 99404 are covered by Healthfirst as supplemental benefits beginning CY2026 for eligible Medicare members.

HCPCS/CPT codes H0005 and S0257 are not covered under Medicare Advantage lines and are not reimbursable under this policy excerpt.

MNT coverage rules

Medical Nutrition Therapy (MNT) reimbursement rules by LOB:

MMC/CHP/HARP/EP/QHP (effective Nov 1, 2026): CPT/HCPCS codes 97802, 97803, 97804, G0270, G0271, and S9470 are considered inclusive to the associated E&M or preventive medicine service and are not separately reimbursable; separate reimbursement will not be made.

Medicare Advantage/IB‑Dual/CompleteCare/MAP: these MNT codes may be separately reimbursed when CMS coverage criteria, coding requirements, documentation standards, and applicable benefit requirements are met.

Reference: Providers should refer to Policy PO‑RE‑114 for additional information regarding covered MNT services and reimbursement requirements.

Prolonged services coverage rules

Prolonged services reimbursement rules by LOB:

MMC/CHP/HARP/EP/QHP (effective Nov 1, 2026): CPT codes 99415–99418 are considered inclusive to the associated E&M or preventive medicine service and are not separately reimbursable; reimbursement for these services is included in the associated service payment.

Medicare Advantage, IB‑Dual, CompleteCare (MAP), and Senior Health Partners (SHP): CPT codes 99415–99418 are non‑covered services and are not reimbursable under this policy excerpt.

Screening services coverage rules

Screening services reimbursement rules by LOB:

MMC/CHP/HARP/EP/QHP (effective Nov 1, 2026): HCPCS codes G0102 and Q0091 are considered inclusive to the associated E&M or preventive medicine service and are not separately reimbursable; reimbursement is included in the associated service payment.

Medicare Advantage, IB‑Dual, CompleteCare (MAP), and SHP: HCPCS codes G0102 and Q0091 may be separately reimbursed when CMS coverage criteria, coding requirements, documentation standards, and applicable benefit requirements are met.

Vision screening coverage criteria

Coverage and reimbursement vary by line of business and billing context:

ANY of the following

MMC/CHP/HARP/EP/QHP: CPT 99172 and 99173 are inclusive to the associated E&M or preventive medicine service and are not separately reimbursable effective Nov 1, 2026.
SHP: CPT 99172 and 99173 are not a covered benefit for Senior Health Partners.
Medicare Advantage/IB‑Dual/CompleteCare (MAP)/SHP: CPT 99172 and 99173 may be separately reimbursed when CMS coverage criteria, coding requirements, documentation standards, and applicable benefit requirements are met.

Billing context: Vision service codes 99172 and 99173 are not separately reimbursable when reported with an E&M service appended with Modifier 25; they are considered inclusive and not separately reimbursable under this policy.

G2211 and related service coverage criteria

Healthfirst coverage and billing criteria for G2211 and related services (partial — document continues in other parts).

G2211 (Office & Outpatient E&M Visit Complexity add‑on) is covered for NYS Medicaid pediatric members ages 0–20 when reported with a qualifying E&M service; preventive medicine visit codes are allowed; billing is limited to one unit per patient per week; eligible POS codes 02, 10, 11, and 22; telehealth permitted with Modifiers 93 or 95 when billed per NYS Medicaid requirements.

G2211 is not separately reimbursable for Medicaid members age 21 and older; claims submitted by in‑network providers for adult Medicaid members will be denied.

Revision note: G2211 reimbursement methodology was revised for certain lines of business (e.g., bundled reimbursement for HARP, Essential Plan, and QHP effective Nov 1, 2026); see Applicable Codes and revision history for details.

Documentation and modifier requirements: Modifier 25 billing requirements and documentation standards apply to newly addressed services; providers must follow applicable billing and documentation rules when reporting G2211 and related add‑on codes.

Telehealth modifiers: Telehealth billing requirements for G2211 include use of Modifiers 93 and 95 per NYS Medicaid guidance when applicable.

Applicable CPT/HCPCS Codes and Pairing Rules

Key codes and statusCPTCovered

99381-99397	Preventive medicine examination codes
G0402	Preventive medicine examination codes
G0438	Preventive medicine examination codes
G0439	Preventive medicine examination codes
99202-99215	E&M office/outpatient service codes
G2211	Complexity add-on code (must be billed with qualifying E&M)

Add-on HCPCS codes and pairing rulesHCPCS

G2211	Complexity add-on; must be billed with E&M 99202-99205 or 99211-99215; must be billed same date as qualifying E&M; not standalone
G2212	Prolonged service add-on; must be billed with E&M 99205 or 99215; only when total physician/qualified professional time exceeds maximum time threshold for primary E&M; not standalone
G0545	Complexity add-on; must be billed with a qualifying E&M service; may not be reported as a standalone service

Preventive and behavioral counseling codesmixed

0403T	Preventive counseling — considered inclusive to associated E&M or preventive medicine service (not separately reimbursable for MMC/CHP/HARP/EP/QHP effective Nov 1, 2026)
99401	Preventive counseling — listed among codes considered inclusive; non-covered under Original Medicare (Healthfirst covers as supplemental benefit beginning CY2026 for eligible Medicare members)
99404	Preventive counseling — listed among codes considered inclusive; non-covered under Original Medicare (Healthfirst covers as supplemental benefit beginning CY2026 for eligible Medicare members)
99406	Tobacco cessation counseling — may be separately reimbursed for Medicare LOB when CMS criteria met
99407	Tobacco cessation counseling — may be separately reimbursed for Medicare LOB when CMS criteria met
G0396	Smoking cessation counseling — may be separately reimbursed for Medicare LOB when CMS criteria met
G0397	Smoking cessation counseling — may be separately reimbursed for Medicare LOB when CMS criteria met
G0443	Behavioral counseling for obesity — may be separately reimbursed for Medicare LOB when CMS criteria met
G0445	Behavioral counseling to prevent STIs — may be separately reimbursed for Medicare LOB when CMS criteria met
G0446	Behavioral counseling for intensive alcohol misuse — may be separately reimbursed for Medicare LOB when CMS criteria met

1–10 of 20

1/2

preventive/behavioral counselingCPT | HCPCS

0403T, 99401, 99404, 99406, 99407, 99408, 99409, 99411, 99412, G0296, G0396, G0397, G0443, G0445, G0446, G0473, G2011, H0005, S0257, S9470

Preventive counseling and behavioral counseling codes considered inclusive to associated E&M or preventive medicine service for MMC/CHP/HARP/EP/QHP effective Nov 1, 2026; not separately reimbursable unless otherwise specified

Medicare-specific counseling codesCPT | HCPCS

99401	Non-covered under Original Medicare; covered as supplemental benefits by Healthfirst beginning CY2026 for eligible Medicare members
99404	Non-covered under Original Medicare; covered as supplemental benefits by Healthfirst beginning CY2026 for eligible Medicare members
H0005	Not covered under Medicare Advantage lines per this policy excerpt
S0257	Not covered under Medicare Advantage lines per this policy excerpt

medical nutrition therapyCPT | HCPCS

97802	Medical Nutrition Therapy — considered inclusive to associated E&M or preventive medicine service for MMC/CHP/HARP/EP/QHP effective Nov 1, 2026; not separately reimbursable
97803	Medical Nutrition Therapy — considered inclusive to associated E&M or preventive medicine service for MMC/CHP/HARP/EP/QHP effective Nov 1, 2026; not separately reimbursable
97804	Medical Nutrition Therapy — considered inclusive to associated E&M or preventive medicine service for MMC/CHP/HARP/EP/QHP effective Nov 1, 2026; not separately reimbursable
G0270	MNT evaluation and management — considered inclusive to associated E&M or preventive medicine service for MMC/CHP/HARP/EP/QHP effective Nov 1, 2026; not separately reimbursable
G0271	MNT follow-up — considered inclusive to associated E&M or preventive medicine service for MMC/CHP/HARP/EP/QHP effective Nov 1, 2026; not separately reimbursable
S9470	Education and training — may be separately reimbursed for Medicare lines when CMS criteria are met; considered inclusive for MMC/CHP/HARP/EP/QHP

prolonged servicesCPT

99415	Prolonged service — considered inclusive to associated E&M or preventive medicine service for MMC/CHP/HARP/EP/QHP effective Nov 1, 2026; not separately reimbursable
99416	Prolonged service — considered inclusive to associated E&M or preventive medicine service for MMC/CHP/HARP/EP/QHP effective Nov 1, 2026; not separately reimbursable
99417	Prolonged service — considered inclusive to associated E&M or preventive medicine service for MMC/CHP/HARP/EP/QHP effective Nov 1, 2026; not separately reimbursable
99418	Prolonged inpatient/observation E/M service — referenced as prolonged service; may be non-covered for some LOBs per policy excerpt

screening servicesHCPCS

G0102	Prostate cancer screening; considered inclusive to associated E&M or preventive medicine service for MMC/CHP/HARP/EP/QHP effective Nov 1, 2026; may be separately reimbursed for Medicare Advantage/IB-Dual/CompleteCare/SHP when CMS criteria met
Q0091	Screening Papanicolaou smear; obtaining, preparing and conveyance of specimen; considered inclusive to associated E&M or preventive medicine service for MMC/CHP/HARP/EP/QHP effective Nov 1, 2026; may be separately reimbursed for Medicare Advantage/IB-Dual/CompleteCare/SHP when CMS criteria met

Vision screening codesCPTCovered

99172	Visual function screening (automated or semi-automated) — considered inclusive for MMC/CHP/HARP/EP/QHP effective Nov 1, 2026; may be separately reimbursed for Medicare-related LOBs when CMS criteria are met; not covered for SHP
99173	Screening test of visual acuity, quantitative, bilateral — considered inclusive for MMC/CHP/HARP/EP/QHP effective Nov 1, 2026; may be separately reimbursed for Medicare-related LOBs when CMS criteria are met; not covered for SHP

Applicable CPT/HCPCS codes referenced in this sectionmixedCovered

99418	Prolonged inpatient/observation E/M service, each 15 minutes beyond primary service
G0102	Prostate cancer screening; digital rectal examination
Q0091	Screening Papanicolaou smear; obtaining, preparing and conveyance of specimen
99173	Screening test of visual acuity, quantitative, bilateral
G2211	Office/outpatient visit complexity add-on code (visit complexity)

E&M reimbursement reduction when billed with preventive exam

Policy actionWhen a preventive medicine examination (CPT 99381-99397, G0402, G0438, G0439) and a problem‑oriented E&M (CPT 99202-99215) are billed the same date with Modifier 25 and documentation supports a separate service, the E&M is reimbursed at 50% of the provider's contracted allowable.

Preventive exam reimbursementPreventive medicine examination codes reimbursed at 100% of the provider's contracted allowable when billed per policy.

Documentation requirementDocumentation must support that the E&M is significant and separately identifiable from the preventive exam to justify Modifier 25.

Excluded items from 50% reductionDiagnostic tests, laboratory services, immunizations/vaccines, and procedures billed with the preventive visit are not subject to the 50% E&M reduction and are reimbursed separately per usual terms.

Claims editsClaims remain subject to NCCI edits, CMS guidance, LCDs/NCDs, and applicable Healthfirst reimbursement policies.

Time threshold for G2212

Time threshold ruleG2212 may only be reported when total physician or qualified health professional time exceeds the maximum time threshold established for the primary E&M service (applies to E&M codes 99205 or 99215).

Code pairingG2212 must be reported only with E&M codes 99205 or 99215 and is an add‑on, not a standalone code.

Documentation of timeThe medical record must document total time spent by the physician or qualified health professional on the date of service, including time that exceeds the primary E&M maximum threshold.

Modifier 25 guidanceNo separate documentation beyond the E&M record is required; however, the record must support medical necessity and the time elements that justify G2212 reporting.

G2211 units per patient per week (NYS Medicaid pediatric)

Unit limitFor NYS Medicaid pediatric members (ages 0–20), G2211 is limited to one unit per patient per week.

Billing pairingG2211 must be reported with a qualifying E&M service and may be billed with preventive medicine visit codes when applicable.

Eligible POS and telehealthPayable when reported with POS codes 02, 10, 11, and 22; telehealth delivery allowable with required telehealth modifiers (93 or 95) per NYS Medicaid.

Population eligibilityCovered for NYS Medicaid pediatric members ages 0–20; not separately reimbursable for Medicaid members age 21 and older (adult claims denied).

Provider Billing, Documentation, and Compliance Actions

Billing Rule

Bill preventive exam and E&M together; use Modifier 25 and support with documentation

When both a preventive medicine examination and an E&M service are performed on the same date of service, bill both on the same claim and append Modifier 25 to the E&M. Documentation must support that the E&M is significant and separately identifiable from the preventive exam and justify the level of E&M billed and medical necessity for the additional service.

Bill preventive medicine exam and E&M on same claim.
Append Modifier 25 to the E&M service.
Maintain documentation that distinguishes preventive vs problem‑oriented services and supports the E&M level and medical necessity.

Denial Risk

Denial risks when documentation or Modifier 25 justification is insufficient

An E&M service may be denied if the medical record does not support a separate and distinct service, if the E&M duplicates routine preventive components, or if Modifier 25 is appended without sufficient justification.

Denial risk when documentation fails to show a significant, separately identifiable E&M.
Denial risk when E&M duplicates preventive visit components.
Denial risk when Modifier 25 lacks sufficient justification in the record.

Prior Authorization

Only bill add-on codes with qualifying E&M; not as standalone

Add-on codes (e.g., G2211, G2212, G0545) must be reported only with their qualifying E&M codes per the policy pairing rules and may not be billed as standalone services.

G2211 must be reported with E&M 99202–99205 or 99211–99215 and billed same date as the qualifying E&M.
G2212 must be reported with E&M 99205 or 99215 and only when total provider time exceeds the primary E&M maximum threshold.
G0545 must be reported with a qualifying E&M service and not billed standalone.

Documentation Required

Adhere to LOB-specific billing and CMS/NYS Medicaid requirements

Follow line-of-business–specific coding, billing, and documentation requirements: NYS Medicaid pediatric guidance applies to G2211 for ages 0–20; Medicare lines follow CMS coverage and documentation rules and some LOBs do not allow separate reimbursement.

G2211 reimbursable for Medicaid members ages 0–20 per NYS Medicaid; limited provider types and POS/telehealth rules apply.
G2212 and G0545 may be bundled (not separately reimbursable) for MMC/CHP/HARP/EP/QHP; Medicare Advantage/IB‑Dual/CompleteCare may reimburse separately when CMS requirements are met.
Some LOBs (e.g., SHP) list these codes as not covered.

Billing Rule

Comply with applicable coding, billing, and documentation requirements

Providers must report services in compliance with all applicable coding, billing, and documentation requirements referenced by Healthfirst, CMS, and state and federal guidance.

Ensure claims conform to applicable NCCI edits, LCD/NCD, CMS guidance, and Healthfirst policy.
Maintain required documentation to support coding and billing decisions.

Note

Medicare Advantage: confirm CMS criteria before billing select counseling codes separately

Certain preventive/behavioral counseling and related CPT/HCPCS may be separately reimbursed for Medicare Advantage/related lines when CMS coverage criteria, coding, documentation, and benefit requirements are met; confirm CMS criteria before billing separately.

Codes that may be separately reimbursed when CMS criteria met include 99406, 99407, G0396, G0397, G0443, G0445, G0446, G0473, G2011, and S9470.
Follow CMS and Healthfirst documentation and benefit requirement standards for Medicare lines.

Note

MNT codes: Medicare may reimburse separately when CMS criteria met; bundled for many Medicaid/Marketplace LOBs

Medical Nutrition Therapy codes (CPT/HCPCS 97802–97804, G0270, G0271, S9470) may be separately reimbursed for Medicare Advantage/IB‑Dual/CompleteCare when CMS coverage, coding, and documentation requirements are met; otherwise these codes are inclusive for MMC/CHP/HARP/EP/QHP.

For Medicare lines, ensure documentation meets CMS requirements before billing MNT codes separately.
For MMC/CHP/HARP/EP/QHP (effective Nov 1, 2026), these MNT codes are bundled into the associated E&M or preventive service.

Billing Rule

Vision screening (99172/99173) bundled for most LOBs effective Nov 1, 2026; Medicare lines may differ

For MMC, CHP, HARP, EP, and QHP (effective Nov 1, 2026) CPT codes 99172 and 99173 are considered inclusive to the associated E&M or preventive medicine service and are not separately reimbursable; Medicare-related lines may reimburse separately when CMS criteria and benefit requirements are met.

Do not bill CPT 99172/99173 separately for MMC/CHP/HARP/EP/QHP after Nov 1, 2026.
For Medicare Advantage/IB‑Dual/CompleteCare/SHP, verify CMS and benefit requirements before billing separately; SHP does not cover these services.

Billing Rule

Do not bill 99172/99173 separately with an E&M appended with Modifier 25

Vision service codes 99172 and 99173 are not separately reimbursable when reported with an E&M service appended with Modifier 25; these vision services are considered inclusive in that context.

If an E&M is billed with Modifier 25, do not expect separate reimbursement for 99172/99173.
Ensure documentation does not duplicate preventive components when appending Modifier 25.

Documentation Required

Maintain documentation sufficient to support billed services and modifiers

Providers must maintain documentation sufficient to support billed services and comply with all applicable Healthfirst, CMS, state, and federal billing requirements.

Documentation must support that services billed are medically necessary and justify modifiers or add‑on codes.
Retain records that clearly distinguish preventive services from problem‑oriented services.

Billing Rule

Bill G2211 only with qualifying E&M; pediatric NYS Medicaid rules include 1 unit/week and telehealth modifiers

Report HCPCS G2211 only with a qualifying E&M service; preventive medicine visit codes are permitted with G2211 for NYS Medicaid pediatric members, limit one unit per patient per week, and append required telehealth modifiers (93 or 95) for telehealth services.

G2211 must be billed with the qualifying E&M (not standalone).
For NYS Medicaid pediatric members (ages 0–20), G2211 may be billed once per week per patient and is payable with POS 02, 10, 11, or 22.
When delivered via telehealth, append telehealth modifier 93 or 95 to the qualifying E&M as required.

Denial Risk

G2211 is not separately reimbursable for adult Medicaid members (age 21+); claims will be denied

G2211 is not separately reimbursable for Medicaid members age 21 years and older; claims submitted by in‑network providers for adult Medicaid members will be denied.

Do not bill G2211 separately for Medicaid members age 21+; such claims will be denied.
Ensure patient age is validated before submitting claims with G2211.

Billing Rule

Report services in compliance with applicable coding, billing, and documentation requirements

Providers are expected to report services in compliance with applicable coding, billing, and documentation requirements; this is an overarching expectation across the policy.

Follow Healthfirst, CMS, state, and federal billing rules when selecting codes, modifiers, and submitting documentation.
Claims are subject to adjudication per NCCI, LCD/NCD, and Healthfirst policies.

Definitions and Code Descriptions

inv-37: Preventive medicine examination — Preventive medicine services

DefinitionPreventive medicine services include routine components such as history, examination, and counseling.

Payment rulePreventive medicine examination codes (CPT 99381-99397, G0402, G0438, G0439) are reimbursed at 100% of the provider's contracted allowable when billed per policy.

Modifier 25 interactionBecause preventive exams include routine components, separate E&M reimbursement is allowed only when a significant, separately identifiable E&M is performed and supported by documentation.

inv-38: G2211 — G2211 recognizes complexity for longitudinal care; not reportable as standalone and must accompany qualifying office/outpatient E&M.

PurposeG2211 recognizes the complexity associated with establishing and maintaining an ongoing clinician–patient relationship and the additional effort for longitudinal care.

Billing constraintG2211 may not be reported as a standalone service and must be billed with a qualifying office or outpatient E&M service (e.g., 99202–99205 or 99211–99215 per pairing rules).

Clinical basisThe complexity reflected by G2211 is not based on a specific diagnosis or level of medical decision making; it reflects longitudinal care responsibilities.

inv-39: G2211 — G2211: Add-on code recognizing complexity for longitudinal ongoing clinician-patient relationship; not diagnosis- or MDM-based; not stand...

Code purposeG2211 is an add-on code recognizing visit complexity from an ongoing clinician–patient relationship; it captures additional effort for longitudinal care.

Not diagnosis- or MDM-basedG2211 payment reflects complexity unrelated to a specific diagnosis or level of medical decision making.

Billing requirementG2211 may not be billed as a standalone service and must accompany a qualifying office/outpatient E&M service.

inv-40: G2212 — G2212: Add-on code for prolonged physician or qualified professional time beyond maximum of primary E&M; must accompany qualifying E&M.

Code purposeG2212 is an add-on code used to report prolonged physician or qualified health care professional time beyond the maximum time of the primary E&M service.

Pairing requirementG2212 must be billed with a qualifying E&M service and may not be reported as a standalone service (must be paired with 99205 or 99215 per code pairing rules).

Time thresholdMay only be reported when total physician or qualified professional time exceeds the maximum time threshold established for the primary E&M service; the medical record must document total time and the excess time.

inv-41: G0545 — G0545: Add-on code recognizing additional complexity associated with qualifying E&M services; not standalone.

Code purposeG0545 is an add-on code that describes additional complexity associated with qualifying E&M services and recognizes additional resources and clinical effort.

Billing constraintG0545 must be reported in conjunction with an eligible primary E&M service and may not be billed as a standalone service.

DocumentationWhen billed, the record should include medical necessity and clinical circumstances supporting G0545 and compliance with applicable coding and documentation requirements.

inv-42: Prolonged service codes — Prolonged service codes are codes used to report time spent beyond the usual service time associated with a primary Evaluation and Manage...

DefinitionProlonged service codes report time spent beyond the usual service time associated with a primary Evaluation and Management (E&M) service.

Reporting requirementProlonged service codes must be reported in conjunction with an appropriate primary E&M service and may not be billed as standalone services.

PurposeThese codes capture additional physician, qualified healthcare professional, or clinical staff time when requirements of the primary service have been exceeded and coding requirements are met.

inv-43: Medical Nutrition Therapy (MNT) — Medical Nutrition Therapy (MNT) and nutrition counseling services assess, manage, and treat medical conditions through nutritional evalua...

DefinitionMedical Nutrition Therapy (MNT) and nutrition counseling services assess, manage, and treat medical conditions through nutritional evaluation, intervention, education, and counseling.

Service contextMNT may be provided individually or in groups to support treatment and management of chronic diseases and other nutrition-affected conditions.

LOB reimbursement notePer related chapters, certain MNT codes may be considered inclusive to E&M or preventive services for some LOBs; Medicare Advantage lines may reimburse separately when CMS criteria are met.

inv-44: Vision screening services — Vision screening services are preventive services used to assess visual acuity and identify potential vision abnormalities requiring furt...

DefinitionVision screening services are preventive services used to assess visual acuity and identify potential vision abnormalities requiring further evaluation or treatment.

Billing interactionCPT codes 99172 and 99173 may be performed as part of a preventive medicine or E&M service when medically appropriate and documented in the record.

Modifier 25 impactVision screening codes 99172 and 99173 are not separately reimbursable when reported with an E&M service appended with modifier 25 for certain LOBs (considered inclusive).

inv-45: Office & Outpatient Evaluation and Management Visit Complexity Add-on Code — G2211

Code purposeG2211 is described as an office & outpatient E&M visit complexity add-on code that recognizes complexity associated with establishing and maintaining an ongoing clinician–patient relationship.

Billing requirementG2211 may not be reported standalone and must be billed with a qualifying E&M service; NYS Medicaid pediatric guidance and other LOB rules apply.

Effective changesPolicy scope expanded and G2211 guidance was revised to align with NYS Medicaid coverage requirements and updated reimbursement methodologies (see revision history).

Policy Summary

PayerHealthfirst

PolicyAdditional Office and Outpatient Services Billed with Evaluation and Management (E&M)

Policy CodePolicy PO-RE-170v3

Change TypeScope expansion and LOB reimbursement revisions

Effective DateSep 1, 2026

Last ReviewJul 20, 2026

Next Review Date

SourceLink

On This Page

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

Additional Office and Outpatient Services Billed with Evaluation and Management (E&M)

Customize your policy alerts

Sign up for Healthfirst Policy PO-RE-170v3 alerts

Get alerted when Policy PO-RE-170v3 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Coverage Criteria and Reimbursement Rules

Preventive + E&M coverage criteria

Rules governing payment when preventive medicine examinations are performed with problem-oriented E&M or other services.

Claims remain subject to NCCI edits, CMS coding guidance, LCDs, NCDs, and applicable Healthfirst reimbursement policies.

Example: Reimbursement examples: 99396 paid at 100%; 99214-25 paid at 50%; diagnostic panel (80050) paid at 100% when appropriately billed.

G2211 (pediatric Medicaid) coverage criteria

G2211 reimbursement rules for Medicaid Managed Care (NYS) pediatric members:

G2211 is reimbursable for eligible Healthfirst Medicaid members ages 0–20 years when reported with a qualifying E&M service (NYS Medicaid coverage effective June 1, 2026).

Coverage limited to physicians and nurse practitioners practicing in pediatric primary care and eligible pediatric subspecialties as defined by NYS Medicaid.

G2211 may be billed in conjunction with a qualifying E&M procedure code, including preventive medicine visit codes; it must be billed on the same date as the qualifying E&M service.

Frequency: G2211 may be billed once per week per patient.

G2211 is not separately reimbursable for Healthfirst Medicaid members age 21 years and older; claims submitted by in‑network providers for adult Medicaid members will be denied.

Modifier and billing note: G2211 must be reported consistent with applicable billing requirements; claims with improper pairing or billing outside NYS Medicaid criteria may be denied.

LOB note: For specified LOB changes, G2211 reimbursement methodology was revised (see revision history) and may be bundled for certain LOBs effective Nov 1, 2026.

G2212 coverage criteria

G2212 coverage and documentation requirements by line of business:

G2212 must be reported only with E&M codes 99205 or 99215; it may not be reported as a standalone service.

LOB payment

For MMC, CHP, HARP, Essential Plan (EP), and QHP: G2212 is not separately reimbursable; reimbursement is inclusive and bundled into the primary E&M service.
For Medicare Advantage, IB‑Dual, and CompleteCare (MAP): G2212 is eligible for separate reimbursement when reported with a qualifying E&M and supported by documentation that meets CMS requirements for prolonged services.
For the SHP line of business: G2212 is not a covered benefit.

G0545 coverage criteria

G0545 coverage and documentation requirements by line of business:

G0545 must be reported with a qualifying Evaluation and Management (E&M) service and may not be reported as a standalone service.

LOB payment

For MMC, CHP, HARP, EP, and QHP (effective Nov 1, 2026): G0545 is not separately reimbursable; reimbursement is inclusive and bundled into the E&M service.
For Medicare Advantage, IB‑Dual, and CompleteCare (MAP): G0545 may be separately reimbursed when reported with a qualifying E&M and supported by documentation that meets applicable CMS coding and documentation requirements.
For the SHP line of business: G0545 is not a covered benefit.

Preventive and behavioral counseling coverage

Preventive counseling and behavioral counseling coverage stance:

Non‑covered under this policy excerpt: H0005 and S0257 are not covered and therefore not reimbursable.

Exception: CPT codes 99401 and 99404 are non‑covered under Original Medicare but will be covered by Healthfirst as supplemental Medicare benefits beginning CY2026 for eligible Medicare members.

Preventive/behavioral counseling coverage rules

Preventive counseling and behavioral counseling services reimbursement rules by LOB:

SHP: these preventive and behavioral counseling services are not a covered benefit for Senior Health Partners.

HCPCS/CPT codes H0005 and S0257 are not covered under Medicare Advantage lines and are not reimbursable under this policy excerpt.

MNT coverage rules

Medical Nutrition Therapy (MNT) reimbursement rules by LOB:

Reference: Providers should refer to Policy PO‑RE‑114 for additional information regarding covered MNT services and reimbursement requirements.

Prolonged services coverage rules

Prolonged services reimbursement rules by LOB:

Medicare Advantage, IB‑Dual, CompleteCare (MAP), and Senior Health Partners (SHP): CPT codes 99415–99418 are non‑covered services and are not reimbursable under this policy excerpt.

Screening services coverage rules

Screening services reimbursement rules by LOB:

Vision screening coverage criteria

Coverage and reimbursement vary by line of business and billing context:

ANY of the following

MMC/CHP/HARP/EP/QHP: CPT 99172 and 99173 are inclusive to the associated E&M or preventive medicine service and are not separately reimbursable effective Nov 1, 2026.
SHP: CPT 99172 and 99173 are not a covered benefit for Senior Health Partners.
Medicare Advantage/IB‑Dual/CompleteCare (MAP)/SHP: CPT 99172 and 99173 may be separately reimbursed when CMS coverage criteria, coding requirements, documentation standards, and applicable benefit requirements are met.

G2211 and related service coverage criteria

Healthfirst coverage and billing criteria for G2211 and related services (partial — document continues in other parts).

G2211 is not separately reimbursable for Medicaid members age 21 and older; claims submitted by in‑network providers for adult Medicaid members will be denied.

Telehealth modifiers: Telehealth billing requirements for G2211 include use of Modifiers 93 and 95 per NYS Medicaid guidance when applicable.

Applicable CPT/HCPCS Codes and Pairing Rules

Key codes and statusCPTCovered

99381-99397	Preventive medicine examination codes
G0402	Preventive medicine examination codes
G0438	Preventive medicine examination codes
G0439	Preventive medicine examination codes
99202-99215	E&M office/outpatient service codes
G2211	Complexity add-on code (must be billed with qualifying E&M)

Add-on HCPCS codes and pairing rulesHCPCS

G2211	Complexity add-on; must be billed with E&M 99202-99205 or 99211-99215; must be billed same date as qualifying E&M; not standalone
G2212	Prolonged service add-on; must be billed with E&M 99205 or 99215; only when total physician/qualified professional time exceeds maximum time threshold for primary E&M; not standalone
G0545	Complexity add-on; must be billed with a qualifying E&M service; may not be reported as a standalone service

Preventive and behavioral counseling codesmixed

0403T	Preventive counseling — considered inclusive to associated E&M or preventive medicine service (not separately reimbursable for MMC/CHP/HARP/EP/QHP effective Nov 1, 2026)
99401	Preventive counseling — listed among codes considered inclusive; non-covered under Original Medicare (Healthfirst covers as supplemental benefit beginning CY2026 for eligible Medicare members)
99404	Preventive counseling — listed among codes considered inclusive; non-covered under Original Medicare (Healthfirst covers as supplemental benefit beginning CY2026 for eligible Medicare members)
99406	Tobacco cessation counseling — may be separately reimbursed for Medicare LOB when CMS criteria met
99407	Tobacco cessation counseling — may be separately reimbursed for Medicare LOB when CMS criteria met
G0396	Smoking cessation counseling — may be separately reimbursed for Medicare LOB when CMS criteria met
G0397	Smoking cessation counseling — may be separately reimbursed for Medicare LOB when CMS criteria met
G0443	Behavioral counseling for obesity — may be separately reimbursed for Medicare LOB when CMS criteria met
G0445	Behavioral counseling to prevent STIs — may be separately reimbursed for Medicare LOB when CMS criteria met
G0446	Behavioral counseling for intensive alcohol misuse — may be separately reimbursed for Medicare LOB when CMS criteria met

1–10 of 20

1/2

preventive/behavioral counselingCPT | HCPCS

0403T, 99401, 99404, 99406, 99407, 99408, 99409, 99411, 99412, G0296, G0396, G0397, G0443, G0445, G0446, G0473, G2011, H0005, S0257, S9470

Medicare-specific counseling codesCPT | HCPCS

99401	Non-covered under Original Medicare; covered as supplemental benefits by Healthfirst beginning CY2026 for eligible Medicare members
99404	Non-covered under Original Medicare; covered as supplemental benefits by Healthfirst beginning CY2026 for eligible Medicare members
H0005	Not covered under Medicare Advantage lines per this policy excerpt
S0257	Not covered under Medicare Advantage lines per this policy excerpt

medical nutrition therapyCPT | HCPCS

97802	Medical Nutrition Therapy — considered inclusive to associated E&M or preventive medicine service for MMC/CHP/HARP/EP/QHP effective Nov 1, 2026; not separately reimbursable
97803	Medical Nutrition Therapy — considered inclusive to associated E&M or preventive medicine service for MMC/CHP/HARP/EP/QHP effective Nov 1, 2026; not separately reimbursable
97804	Medical Nutrition Therapy — considered inclusive to associated E&M or preventive medicine service for MMC/CHP/HARP/EP/QHP effective Nov 1, 2026; not separately reimbursable
G0270	MNT evaluation and management — considered inclusive to associated E&M or preventive medicine service for MMC/CHP/HARP/EP/QHP effective Nov 1, 2026; not separately reimbursable
G0271	MNT follow-up — considered inclusive to associated E&M or preventive medicine service for MMC/CHP/HARP/EP/QHP effective Nov 1, 2026; not separately reimbursable
S9470	Education and training — may be separately reimbursed for Medicare lines when CMS criteria are met; considered inclusive for MMC/CHP/HARP/EP/QHP

prolonged servicesCPT

99415	Prolonged service — considered inclusive to associated E&M or preventive medicine service for MMC/CHP/HARP/EP/QHP effective Nov 1, 2026; not separately reimbursable
99416	Prolonged service — considered inclusive to associated E&M or preventive medicine service for MMC/CHP/HARP/EP/QHP effective Nov 1, 2026; not separately reimbursable
99417	Prolonged service — considered inclusive to associated E&M or preventive medicine service for MMC/CHP/HARP/EP/QHP effective Nov 1, 2026; not separately reimbursable
99418	Prolonged inpatient/observation E/M service — referenced as prolonged service; may be non-covered for some LOBs per policy excerpt

screening servicesHCPCS

G0102	Prostate cancer screening; considered inclusive to associated E&M or preventive medicine service for MMC/CHP/HARP/EP/QHP effective Nov 1, 2026; may be separately reimbursed for Medicare Advantage/IB-Dual/CompleteCare/SHP when CMS criteria met
Q0091	Screening Papanicolaou smear; obtaining, preparing and conveyance of specimen; considered inclusive to associated E&M or preventive medicine service for MMC/CHP/HARP/EP/QHP effective Nov 1, 2026; may be separately reimbursed for Medicare Advantage/IB-Dual/CompleteCare/SHP when CMS criteria met

Vision screening codesCPTCovered

99172	Visual function screening (automated or semi-automated) — considered inclusive for MMC/CHP/HARP/EP/QHP effective Nov 1, 2026; may be separately reimbursed for Medicare-related LOBs when CMS criteria are met; not covered for SHP
99173	Screening test of visual acuity, quantitative, bilateral — considered inclusive for MMC/CHP/HARP/EP/QHP effective Nov 1, 2026; may be separately reimbursed for Medicare-related LOBs when CMS criteria are met; not covered for SHP

Applicable CPT/HCPCS codes referenced in this sectionmixedCovered

99418	Prolonged inpatient/observation E/M service, each 15 minutes beyond primary service
G0102	Prostate cancer screening; digital rectal examination
Q0091	Screening Papanicolaou smear; obtaining, preparing and conveyance of specimen
99173	Screening test of visual acuity, quantitative, bilateral
G2211	Office/outpatient visit complexity add-on code (visit complexity)

E&M reimbursement reduction when billed with preventive exam

Preventive exam reimbursementPreventive medicine examination codes reimbursed at 100% of the provider's contracted allowable when billed per policy.

Documentation requirementDocumentation must support that the E&M is significant and separately identifiable from the preventive exam to justify Modifier 25.

Claims editsClaims remain subject to NCCI edits, CMS guidance, LCDs/NCDs, and applicable Healthfirst reimbursement policies.

Time threshold for G2212

Code pairingG2212 must be reported only with E&M codes 99205 or 99215 and is an add‑on, not a standalone code.

Modifier 25 guidanceNo separate documentation beyond the E&M record is required; however, the record must support medical necessity and the time elements that justify G2212 reporting.

G2211 units per patient per week (NYS Medicaid pediatric)

Unit limitFor NYS Medicaid pediatric members (ages 0–20), G2211 is limited to one unit per patient per week.

Billing pairingG2211 must be reported with a qualifying E&M service and may be billed with preventive medicine visit codes when applicable.

Eligible POS and telehealthPayable when reported with POS codes 02, 10, 11, and 22; telehealth delivery allowable with required telehealth modifiers (93 or 95) per NYS Medicaid.

Population eligibilityCovered for NYS Medicaid pediatric members ages 0–20; not separately reimbursable for Medicaid members age 21 and older (adult claims denied).

Provider Billing, Documentation, and Compliance Actions

Billing Rule

Bill preventive exam and E&M together; use Modifier 25 and support with documentation

Bill preventive medicine exam and E&M on same claim.
Append Modifier 25 to the E&M service.
Maintain documentation that distinguishes preventive vs problem‑oriented services and supports the E&M level and medical necessity.

Denial Risk

Denial risks when documentation or Modifier 25 justification is insufficient

Denial risk when documentation fails to show a significant, separately identifiable E&M.
Denial risk when E&M duplicates preventive visit components.
Denial risk when Modifier 25 lacks sufficient justification in the record.

Prior Authorization

Only bill add-on codes with qualifying E&M; not as standalone

Add-on codes (e.g., G2211, G2212, G0545) must be reported only with their qualifying E&M codes per the policy pairing rules and may not be billed as standalone services.

G2211 must be reported with E&M 99202–99205 or 99211–99215 and billed same date as the qualifying E&M.
G2212 must be reported with E&M 99205 or 99215 and only when total provider time exceeds the primary E&M maximum threshold.
G0545 must be reported with a qualifying E&M service and not billed standalone.

Documentation Required

Adhere to LOB-specific billing and CMS/NYS Medicaid requirements

G2211 reimbursable for Medicaid members ages 0–20 per NYS Medicaid; limited provider types and POS/telehealth rules apply.
G2212 and G0545 may be bundled (not separately reimbursable) for MMC/CHP/HARP/EP/QHP; Medicare Advantage/IB‑Dual/CompleteCare may reimburse separately when CMS requirements are met.
Some LOBs (e.g., SHP) list these codes as not covered.

Billing Rule

Comply with applicable coding, billing, and documentation requirements

Providers must report services in compliance with all applicable coding, billing, and documentation requirements referenced by Healthfirst, CMS, and state and federal guidance.

Ensure claims conform to applicable NCCI edits, LCD/NCD, CMS guidance, and Healthfirst policy.
Maintain required documentation to support coding and billing decisions.

Note

Medicare Advantage: confirm CMS criteria before billing select counseling codes separately

Codes that may be separately reimbursed when CMS criteria met include 99406, 99407, G0396, G0397, G0443, G0445, G0446, G0473, G2011, and S9470.
Follow CMS and Healthfirst documentation and benefit requirement standards for Medicare lines.

Note

MNT codes: Medicare may reimburse separately when CMS criteria met; bundled for many Medicaid/Marketplace LOBs

For Medicare lines, ensure documentation meets CMS requirements before billing MNT codes separately.
For MMC/CHP/HARP/EP/QHP (effective Nov 1, 2026), these MNT codes are bundled into the associated E&M or preventive service.

Billing Rule

Vision screening (99172/99173) bundled for most LOBs effective Nov 1, 2026; Medicare lines may differ

Do not bill CPT 99172/99173 separately for MMC/CHP/HARP/EP/QHP after Nov 1, 2026.
For Medicare Advantage/IB‑Dual/CompleteCare/SHP, verify CMS and benefit requirements before billing separately; SHP does not cover these services.

Billing Rule

Do not bill 99172/99173 separately with an E&M appended with Modifier 25

Vision service codes 99172 and 99173 are not separately reimbursable when reported with an E&M service appended with Modifier 25; these vision services are considered inclusive in that context.

If an E&M is billed with Modifier 25, do not expect separate reimbursement for 99172/99173.
Ensure documentation does not duplicate preventive components when appending Modifier 25.

Documentation Required

Maintain documentation sufficient to support billed services and modifiers

Providers must maintain documentation sufficient to support billed services and comply with all applicable Healthfirst, CMS, state, and federal billing requirements.

Documentation must support that services billed are medically necessary and justify modifiers or add‑on codes.
Retain records that clearly distinguish preventive services from problem‑oriented services.

Billing Rule

Bill G2211 only with qualifying E&M; pediatric NYS Medicaid rules include 1 unit/week and telehealth modifiers

G2211 must be billed with the qualifying E&M (not standalone).
For NYS Medicaid pediatric members (ages 0–20), G2211 may be billed once per week per patient and is payable with POS 02, 10, 11, or 22.
When delivered via telehealth, append telehealth modifier 93 or 95 to the qualifying E&M as required.

Denial Risk

G2211 is not separately reimbursable for adult Medicaid members (age 21+); claims will be denied

G2211 is not separately reimbursable for Medicaid members age 21 years and older; claims submitted by in‑network providers for adult Medicaid members will be denied.

Do not bill G2211 separately for Medicaid members age 21+; such claims will be denied.
Ensure patient age is validated before submitting claims with G2211.

Billing Rule

Report services in compliance with applicable coding, billing, and documentation requirements

Providers are expected to report services in compliance with applicable coding, billing, and documentation requirements; this is an overarching expectation across the policy.

Follow Healthfirst, CMS, state, and federal billing rules when selecting codes, modifiers, and submitting documentation.
Claims are subject to adjudication per NCCI, LCD/NCD, and Healthfirst policies.