ModifiedHealthy Blue LouisianaPolicy G-05016

Preventive Medicine and Other Visits on the Same Day

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This policy governs reimbursement when preventive medicine services, Medicare Annual Wellness Visits (AWVs), and sick visits are provided on the same day. It applies to providers submitting claims to Healthy Blue Louisiana, subject to applicable provider, state, federal, CMS, and contractual requirements.

Policy Summary

PayerHealthy Blue Louisiana

PolicyPreventive Medicine and Other Visits on the Same Day

Policy CodePolicy G-05016

Change TypeModified

Effective DateApril 1, 2026

Last ReviewJan 14, 2026

Next Review DateN/A

Key ActionBill modifier 25 with the applicable E/M code for an allowed sick visit performed on the same day as preventive medicine or an AWV.

SourceLink

POLICY UPDATE CHANGES

Effective April 1, 2026, same-day sick visits with preventive medicine or AWVs, and same-day preventive medicine visits with AWVs, are reimbursed at 50% of the applicable fee schedule or contracted/negotiated rate when allowed.

The policy title was updated and wellness visits were identified as Medicare Annual Wellness Visits (AWVs) for clarity.

50%Same-day sick visit rate

50%Same-day preventive visit rate

25Required sick visit modifier

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ModifiedHealthy Blue LouisianaPolicy G-05016

Preventive Medicine and Other Visits on the Same Day

Customize your policy alerts

Sign up for healthybluelouisiana Policy G-05016 alerts

Get alerted when Policy G-05016 changes without checking for updates manually.

Monitor payer policy activity

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Policy Summary

PayerHealthy Blue Louisiana

PolicyPreventive Medicine and Other Visits on the Same Day

Policy CodePolicy G-05016

Change TypeModified

Effective DateApril 1, 2026

Last ReviewJan 14, 2026

Next Review DateN/A

Key ActionBill modifier 25 with the applicable E/M code for an allowed sick visit performed on the same day as preventive medicine or an AWV.

SourceLink

POLICY UPDATE CHANGES

The policy title was updated and wellness visits were identified as Medicare Annual Wellness Visits (AWVs) for clarity.

50%Same-day sick visit rate

50%Same-day preventive visit rate

25Required sick visit modifier

Same-Day Reimbursement Conditions

Same-day reimbursement conditions

Reimbursement is allowed when applicable billing and diagnosis requirements are met, subject to provider, state, federal, or CMS contracts and requirements.

ALL applicable conditions

The services are preventive medicine, a Medicare Annual Wellness Visit (AWV), and/or an allowed sick visit performed on the same day.
Federally qualified health centers (FQHCs) and rural health centers (RHCs) reimbursed other than through the health plan fee schedule or state encounter rates are not subject to this policy.
For an allowed sick visit, modifier 25 is billed with the applicable evaluation and management (E/M) code.
If modifier 25 is not billed appropriately, the sick visit is not eligible for reimbursement.
Appropriate diagnosis codes are billed for the respective visits.
ONE applicable same-day service combination
- A sick visit is billed with preventive medicine.
  Reimbursement is based on the fee schedule or contracted/negotiated rate for preventive medicine and 50% of that rate for the allowed sick visit.
- A sick visit is billed with an AWV.
  Reimbursement is based on the fee schedule or contracted/negotiated rate for the AWV and 50% of that rate for the allowed sick visit.
- Preventive medicine is billed with an AWV.
  Reimbursement is based on the fee schedule or contracted/negotiated rate for the AWV and 50% of that rate for the allowed preventive medicine visit.

Billing and Reimbursement Rates

Required modifier for same-day sick visit billingModifierCovered

25	Modifier 25 appended to the applicable E/M code for an allowed sick visit on the same day as preventive medicine or an AWV

Same-day sick visit reimbursement

Reimbursement rate50% of the applicable fee schedule or contracted/negotiated rate

Applies whenAn allowed sick visit is provided on the same day as preventive medicine or a Medicare Annual Wellness Visit (AWV)

Primary servicePreventive medicine or the AWV is reimbursed at the applicable fee schedule or contracted/negotiated rate

Same-day preventive medicine reimbursement

Reimbursement rate50% of the applicable fee schedule or contracted/negotiated rate

Applies whenAn allowed preventive medicine visit is provided on the same day as a Medicare Annual Wellness Visit (AWV)

Provider Billing Requirements

Billing Rule

Append modifier 25 to the sick visit E/M code

Bill modifier 25 with the applicable evaluation and management (E/M) code for an allowed sick visit performed on the same day as preventive medicine or a Medicare Annual Wellness Visit (AWV). If modifier 25 is not billed appropriately, the sick visit will not be eligible for reimbursement.

Documentation Required

Use visit-specific diagnosis coding

Bill appropriate diagnosis codes for each respective visit when preventive medicine, an AWV, and/or a sick visit are performed on the same day.