CurrentHighmark Blue Cross Blue Shield WnyPolicy G-05016

Preventive Medicine and Sick Visits on the Same Day

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Governs reimbursement when preventive medicine and sick (E/M) visits occur on the same day for Highmark BCBS WNY members in MMC, HARP, CHPlus, and Essential Plan programs; specifies billing and payment rules and affected member age group.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyPreventive Medicine and Sick Visits on the Same Day

Policy CodePolicy G-05016

Change TypeMaterial reimbursement and billing clarification

Effective Date08/01/2026

Last ReviewMar 25, 2026

Next Review Date

Key ActionBill modifier 25 with the applicable E/M code for the sick visit and document appropriate diagnoses to support both visits.

SourceLink

POLICY UPDATE CHANGES

Updated policy to reimburse CPT codes 99214 and 99215 on the same day as preventive medicine at 50% for members aged 22 or over.

Modifier 25 must be billed with the applicable E/M code for the sick visit to be eligible for reimbursement.

50%99214/99215 same-day rate

G-05016policy id

03/25/2026last approval

08/01/2026effective

Same-day Preventive and Sick Visit Coverage Criteria

Same-day preventive and sick visit criteria

Conditions under which preventive and sick visits on the same day are reimbursed:

Preventive medicine and sick visits are allowed and reimbursable unless provider, state, federal, or CMS contracts/requirements indicate otherwise.

Reimbursement is based on the fee schedule or contracted/negotiated rate for the preventive medicine visit.

Modifier 25 must be billed with the applicable evaluation and management (E/M) code for the allowed sick visit. If modifier 25 is not billed appropriately, the sick visit will not be eligible for reimbursement.

Appropriate diagnosis codes must be billed for each respective visit.

For members age 22 or older, if the allowed sick visit is billed with CPT code 99214 or 99215, payment for that sick visit is 50% of the fee schedule or contracted/negotiated rate; preventive medicine is reimbursed at the full fee schedule or contracted/negotiated rate.

Federally qualified health centers (FQHCs) and rural health centers (RHCs) reimbursed other than through their respective health plans' fee schedule or state encounter rates are not subject to this policy.

Services remain subject to authorization and medical necessity guidelines and standard correct coding; claims may be denied, rejected, or recouped if billing/coding guidelines are not followed.

Codes and Coding Rules for Same-day Visits

High-level E/M codes with reduced same-day reimbursementCPTCovered

99214	Office or other outpatient visit, established patient, high-level E/M
99215	Office or other outpatient visit, established patient, highest-level E/M

Age threshold for reduced reimbursement

Age thresholdMembers age 22 or older

Effect on reimbursementFor members age 22 or older, preventive medicine reimbursed at full fee schedule/contracted rate and allowed sick visit coded as CPT 99214 or 99215 reimbursed at 50% of fee schedule/contracted rate.

Applies to plansMMC, HARP, Child Health Plus (CHPlus), and Essential Plan (EP) members administered by Highmark BCBS, unless contract requirements state otherwise.

ExclusionsFQHCs and RHCs reimbursed other than through their respective health plans' fee schedule or state encounter rates are not subject to this policy.

Billing, Documentation, and Authorization Requirements

Documentation Required

Bill modifier 25; document diagnoses and meet authorization/medical necessity

Bill modifier 25 with the applicable E/M code for the sick visit; if modifier 25 is not billed appropriately the sick visit will not be eligible for reimbursement. Ensure appropriate diagnosis codes are billed for each respective visit and that the medical record/office notes fully support the services billed. Services remain subject to authorization and medical necessity guidelines and may be denied, rejected, or recouped if billing/coding guidelines are not followed.

Modifier 25 must be billed with the applicable evaluation and management (E/M) code for the allowed sick visit; lack of modifier 25 renders the sick visit ineligible for reimbursement. [[citation provided above]]
Appropriate diagnosis codes must be billed for respective visits and documentation must support billed services in the medical record/office notes. [[citation provided above]]
Services must meet authorization and medical necessity guidelines and may be denied, rejected, recovered, or recouped if billing/coding guidelines are not followed. [[citation provided above]]

Definitions and Scope

Same-day preventive and sick visit reimbursement rules

Policy allowanceThe health plan allows reimbursement for preventive medicine and sick visits on the same day unless provider, state, federal, or CMS contracts/requirements indicate otherwise.

Modifier requirementModifier 25 must be billed with the applicable E/M code for the allowed sick visit; if not billed appropriately, the sick visit will not be eligible for reimbursement.

Diagnosis codingAppropriate diagnosis codes must be billed for each respective visit to support reimbursement.

Documentation and authorizationServices remain subject to authorization and medical necessity guidelines and may be denied, rejected, or recouped if billing/coding guidelines are not followed.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyPreventive Medicine and Sick Visits on the Same Day

Policy CodePolicy G-05016

Change TypeMaterial reimbursement and billing clarification

Effective Date08/01/2026

Last ReviewMar 25, 2026

Next Review Date

Key ActionBill modifier 25 with the applicable E/M code for the sick visit and document appropriate diagnoses to support both visits.

SourceLink

On This Page

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Preventive Medicine and Sick Visits on the Same Day

Customize your policy alerts

Sign up for Highmark Blue Cross Blue Shield Wny Policy G-05016 alerts

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

Monitor payer policy activity

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

Same-day Preventive and Sick Visit Coverage Criteria

Same-day preventive and sick visit criteria

Conditions under which preventive and sick visits on the same day are reimbursed:

Preventive medicine and sick visits are allowed and reimbursable unless provider, state, federal, or CMS contracts/requirements indicate otherwise.

Reimbursement is based on the fee schedule or contracted/negotiated rate for the preventive medicine visit.

Appropriate diagnosis codes must be billed for each respective visit.

Services remain subject to authorization and medical necessity guidelines and standard correct coding; claims may be denied, rejected, or recouped if billing/coding guidelines are not followed.

Codes and Coding Rules for Same-day Visits

High-level E/M codes with reduced same-day reimbursementCPTCovered

99214	Office or other outpatient visit, established patient, high-level E/M
99215	Office or other outpatient visit, established patient, highest-level E/M

Age threshold for reduced reimbursement

Age thresholdMembers age 22 or older

Applies to plansMMC, HARP, Child Health Plus (CHPlus), and Essential Plan (EP) members administered by Highmark BCBS, unless contract requirements state otherwise.

ExclusionsFQHCs and RHCs reimbursed other than through their respective health plans' fee schedule or state encounter rates are not subject to this policy.

Billing, Documentation, and Authorization Requirements

Documentation Required

Bill modifier 25; document diagnoses and meet authorization/medical necessity

Modifier 25 must be billed with the applicable evaluation and management (E/M) code for the allowed sick visit; lack of modifier 25 renders the sick visit ineligible for reimbursement. [[citation provided above]]
Appropriate diagnosis codes must be billed for respective visits and documentation must support billed services in the medical record/office notes. [[citation provided above]]
Services must meet authorization and medical necessity guidelines and may be denied, rejected, recovered, or recouped if billing/coding guidelines are not followed. [[citation provided above]]

Definitions and Scope

Same-day preventive and sick visit reimbursement rules

Policy allowanceThe health plan allows reimbursement for preventive medicine and sick visits on the same day unless provider, state, federal, or CMS contracts/requirements indicate otherwise.

Modifier requirementModifier 25 must be billed with the applicable E/M code for the allowed sick visit; if not billed appropriately, the sick visit will not be eligible for reimbursement.

Diagnosis codingAppropriate diagnosis codes must be billed for each respective visit to support reimbursement.

Documentation and authorizationServices remain subject to authorization and medical necessity guidelines and may be denied, rejected, or recouped if billing/coding guidelines are not followed.