Healthfirst E&M with Preventive Visit Policy Update

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

- For Medicaid Managed Care (MMC), Child Health Plus (CHP), HARP, Essential Plan (EP), Qualified Health Plan (QHP), and Senior Health Partners (SHP): G2211 and G2212 are not separately reimbursable and are bundled into the E&M service.
- G2211 and G2212 are add-on codes and should not be billed with Modifier 25. When billed with an E&M service appended with Modifier 25, the add-on code (G2211/G2212) will be denied.
- Note: For the SHP line of business, CPT codes G2211 and G2212 are not covered benefits.
- For Medicare Advantage, Integrated Benefits Dual (IB-Dual), and CompleteCare (MAP): G2211 and G2212 are payable and may be reimbursed in addition to the E&M service in accordance with the provider's contract with Healthfirst.

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

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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

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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

G0402	Medicare initial preventive physical exam — reimbursed per policy when billed appropriately
G0438	Annual wellness visit (initial) — reimbursed per policy when billed appropriately
G0439	Annual wellness visit (subsequent) — reimbursed per policy when billed appropriately

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

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.

OpenPayer

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

Coverage and Reimbursement Criteria

Relevant CPT / HCPCS and Coding Rules

Claims Submission and Billing Guidance

Definitions and Term Clarifications