CurrentHealthfirstPolicy PO-RE-170v1
Additional Office and Outpatient Services Billed with Evaluation and Management (E&M)
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Defines Healthfirst's reimbursement methodology when preventive medicine and E&M or other qualifying services are billed the same date for the same member by the same provider; applies to multiple lines of business and professional claims submitted on CMS-1500/837P.
Policy Summary
PayerHealthfirst
PolicyAdditional Office and Outpatient Services Billed with Evaluation and Management (E&M)
Policy CodePolicy PO-RE-170v1
Change TypeNo material changes
Effective DateSep 1, 2026
Last ReviewApr 20, 2026
Next Review DateN/A
Key ActionWhen both preventive and E&M services are performed the E&M must be billed on the same claim with Modifier 25 and supported by documentation showing a significant, separately identifiable service.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
50%E&M reduction when billed with preventive
100%Preventive medicine reimbursement when billed appropriately
30+Procedure codes referenced
G2211/G2212E/M add-on codes referenced
25Modifier required on E&M
Coverage and Reimbursement Criteria
Coverage and Reimbursement Criteria
When preventive medicine and an E&M service are reported on the same date of service, reimbursement follows the rules below. Documentation requirements and LOB-specific handling of add-on codes G2211/G2212 are included.
ALL of the following
- Preventive medicine examination codes are reimbursed at 100% of the provider's contracted allowable amount.
Examples: CPT 99381-99397, G0402, G0438, G0439.
- Eligible E&M services billed with Modifier 25 will be considered for reimbursement but are subject to a 50% reduction of the provider's contracted allowable amount to account for overlapping components included in the preventive medicine exam.
This 50% reduction applies regardless of the number or type of additional services billed on the same date of service.
- Documentation must support that the E&M service is significant and separately identifiable from the preventive medicine examination.
- Medical record must clearly distinguish between preventive and problem-oriented services.
- Documentation must support the level of E&M service billed and demonstrate medical necessity for the additional service.
- An E&M service may be denied when documentation does not support a separate and distinct service or duplicates routine preventive components.
- Modifier 25 appended without sufficient justification may result in denial.
Coverage and Reimbursement Criteria
Additional coverage stance and line-of-business (LOB) specific rules for add-on codes G2211/G2212 and disclaimer regarding coverage determinations.
ALL of the following
- The 50% reduction applies only to E&M services and does not apply to services that are separately reimbursable and outside the scope of E&M, including diagnostic tests, laboratory services, immunizations and vaccines, and procedures.
- Reimbursement decisions follow the member's Evidence of Coverage, state and federal requirements or mandates, and the provider's participation agreement. The code listings in this policy are informational and do not guarantee coverage or payment.
- Healthfirst claim edits and coding guidance follow national industry standards (eg, NCCI, NCD/LCD, AMA/CMS CPT/HCPCS/ICD-10 principles) and applicable New York State policies. Failure to follow proper coding, billing, and documentation guidelines may result in denial and/or recoupment of claim payment.
Relevant CPT / HCPCS and Coding Rules
Core Office/Outpatient E&M (Covered)CPTCovered
| 99202 | Office or other outpatient visit for the evaluation and management of a new patient; total time on date of encounter: 15 minutes (when using time) |
| 99203 | Office or other outpatient visit for the evaluation and management of a new patient; total time on date of encounter: 30 minutes (when using time) |
| 99204 | Office or other outpatient visit for the evaluation and management of a new patient; total time on date of encounter: 45 minutes (when using time) |
| 99205 | Office or other outpatient visit for the evaluation and management of a new patient; total time on date of encounter: 60 minutes (when using time) |
| 99211 | Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional |
| 99212 | Office or other outpatient visit for the evaluation and management of an established patient; total time on date of encounter: 10 minutes (when using time) |
| 99213 | Office or other outpatient visit for the evaluation and management of an established patient; total time on date of encounter: 15 minutes (when using time) |
| 99214 | Office or other outpatient visit for the evaluation and management of an established patient; total time on date of encounter: 30 minutes (when using time) |
| 99215 | Office or other outpatient visit for the evaluation and management of an established patient; total time on date of encounter: 40 minutes (when using time) |
Home Visit E&M (Covered)CPTCovered
| 99341 | Home or residence visit for new patient; total time on date of encounter: 15 minutes (when using time) |
| 99342 | Home or residence visit for new patient; total time on date of encounter: 30 minutes (when using time) |
| 99344 | Home or residence visit for new patient; total time on date of encounter: 60 minutes (when using time) |
| 99345 | Home or residence visit for new patient; higher time threshold as applicable |
Nursing Facility E&M (Covered)CPTCovered
| 99304 | Initial nursing facility care, new patient (range included in policy applicable codes) |
| 99305 | Initial nursing facility care |
| 99306 | Initial nursing facility care |
| 99307 | Subsequent nursing facility care; total time on date of encounter: 10 minutes (when using time) |
| 99308 | Subsequent nursing facility care; total time on date of encounter: 20 minutes (when using time) |
| 99309 | Subsequent nursing facility care; total time on date of encounter: 30 minutes (when using time) |
| 99310 | Subsequent nursing facility care; total time on date of encounter: 45 minutes (when using time) |
| 99311 | Subsequent nursing facility care; typically 15 minutes at bedside |
| 99312 | Subsequent nursing facility care; detailed descriptions apply |
| 99313 | Subsequent nursing facility care; typically 35 minutes at bedside |
1–10 of 12
1/2
Preventive Medicine (Covered)CPTCovered
| 99383 | Initial comprehensive preventive medicine evaluation, child age 5-11 |
| 99384 | Initial comprehensive preventive medicine evaluation, adolescent 12-17 |
| 99385 | Initial comprehensive preventive medicine evaluation, adult 18-39 |
| 99386 | Initial comprehensive preventive medicine evaluation, adult 40-64 |
| 99387 | Initial comprehensive preventive medicine evaluation, 65+ |
| 99391 | Periodic comprehensive preventive medicine reevaluation, infant |
| 99392 | Periodic comprehensive preventive medicine reevaluation, early childhood |
| 99393 | Periodic comprehensive preventive medicine reevaluation, late childhood |
| 99394 | Periodic comprehensive preventive medicine reevaluation, adolescent |
| 99395 | Periodic comprehensive preventive medicine reevaluation, adult 18-39 |
1–10 of 15
1/2
E&M Add-On Codes (G-codes)HCPCS
| G2211 | Visit complexity inherent to evaluation and management (add-on). Must be billed with qualifying E&M service (see pairing rules). |
| G2212 | Prolonged office/outpatient E&M beyond maximum time of primary service (add-on). Each additional 15 minutes; must be billed with qualifying E&M service (see pairing rules). |
Additional E/M, Preventive and Related CodesmixedCovered
| 99341-99350 | Home visit series (new/established) — see individual codes for time thresholds |
| 99304-99316 | Nursing facility initial and subsequent care series — see individual codes for time thresholds |
| 99307-99313 | Subsequent nursing facility care series — time thresholds noted per code |
| 99315-99316 | Nursing facility discharge management |
| G2211 | Add-on for visit complexity; must be billed with qualifying E&M code (see pairing). |
| G2212 | Add-on for prolonged services; must be billed with qualifying E&M code (see pairing). |
Preventive / Wellness (Status Notes)CPTCovered
E/M (Status Notes)CPT
| 99202-99205 | New patient office/outpatient E&M codes — covered; note applicable time thresholds for time-based selection |
| 99211-99215 | Established patient office/outpatient E&M codes — covered; note applicable time thresholds for time-based selection |
G2212 Pairing Requirement
G2212 pairing requirementG2212 may only be reported with CPT codes 99205 or 99215.
Time-based Thresholds for Code Selection
Time-based thresholds (examples)99202 = 15 min; 99203 = 30 min; 99204 = 45 min; 99205 = 60 min; 99212 = 10 min; 99213 = 15 min; 99214 = 30 min; 99215 = 40 min; 99307 = 10 min; 99308 = 20 min; 99309 = 30 min; 99310 = 45 min; 99311 = ~15 min; 99313 = ~35 min; 99315 = discharge ≤30 min; 99316 = discharge >30 min
Claims Submission and Billing Guidance
Prior Authorization
Submit professional services on CMS-1500/837P and comply with policy
Submit professional services on CMS-1500 or 837P claims and ensure claims adhere to this policy, the provider contract, and fee schedule. Claims that do not adhere to the policy will be denied or rejected; final reimbursement is determined by member benefits, state/federal mandates, medical necessity, and the provider's contract.
- Submit professional services on CMS-1500 or 837P.
- Ensure claims are coded accurately and comply with this policy and your provider contract/fee schedule.
- Non-adherence may result in claim denial, rejection, or recoupment.
Billing Rule
Follow payer claim edits aligned with CMS/NCCI/NCD/LCD and state coding
Follow Healthfirst claim edits and coding guidance, which align with CMS/NCCI/NCD/LCD standards, state-specific coding and industry-accepted CPT/HCPCS/ICD-10 principles. Failure to follow proper coding, billing, and reimbursement guidelines could result in denial and/or recoupment of claim payment.
- Adhere to national edits (NCCI, NCD/LCD) and appropriate modifier usage.
- Follow New York State–specific coding, billing, and payment policies where applicable.
- Use AMA/CMS CPT, HCPCS, and ICD-10 coding principles to avoid denials.
Definitions and Term Clarifications
Preventive medicine — definition
Preventive medicine definitionPreventive medicine services include routine components such as history, examination, and counseling; separate reimbursement for an E&M service is allowed only when a significant, separately identifiable service is performed and supported by documentation.
Typical componentsRoutine preventive services commonly encompass history, physical examination, and counseling/anticipatory guidance.
Billing interactionWhen preventive medicine and E&M are performed same date for the same member by the same provider, preventive codes are reimbursed per policy and E&M may be reduced unless documentation supports a separately identifiable service.
G2211 / G2212 — code descriptions
G2211 — descriptorG2211 is an add-on code that describes visit complexity related to ongoing or complex patient care and must be billed with a qualifying E&M service.
G2212 — descriptorG2212 is an add-on code that describes prolonged time spent beyond the maximum time of the primary E&M service and must be billed with a qualifying E&M service (paired per policy with 99205 or 99215).
Billing rule for add-on codesG2211 and G2212 are add-on codes and should not be billed as standalone services; modifier and LOB-specific reimbursement rules apply (see LOB guidance).
Definitions (placeholders)
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Policy Summary
PayerHealthfirst
PolicyAdditional Office and Outpatient Services Billed with Evaluation and Management (E&M)
Policy CodePolicy PO-RE-170v1
Change TypeNo material changes
Effective DateSep 1, 2026
Last ReviewApr 20, 2026
Next Review DateN/A
Key ActionWhen both preventive and E&M services are performed the E&M must be billed on the same claim with Modifier 25 and supported by documentation showing a significant, separately identifiable service.
SourceLink
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