CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Preventative Medicine — Billing and Reimbursement Guideline

Guidance on coding, documentation, and reimbursement for preventative (routine) medicine visits submitted to Neighborhood Health Plan of Rhode Island; applies to providers submitting CMS-1500 and UB-92 claims.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPreventative Medicine — Billing and Reimbursement Guideline

Policy CodePolicy N/A

Change TypeFormat change and minor edits (9/1/2013)

Effective DateSep 1, 2010

Next Review DateN/A

Key ActionUse age-based preventative medicine CPT codes and bill only one preventative visit per day; when both preventative and sick visits occur same day, provide clinical notes and supportive diagnosis coding and use modifier 25 or 59 when appropriate.

SourceLink

POLICY UPDATE CHANGES

Format change and minor edits were made on 9/1/2013.

99381-99387, 99391-99397CPT code ranges

onepayable per day

modifiers 25/59separately identifiable service

CMS-1500, UB-92claim forms

Preventative Visit Coverage Criteria

Preventative visit coverage criteria

Covered when ALL of the following billing and documentation criteria are met:

Select CPT preventative code based on patient age on date of service (use 99381-99387 for new patients and 99391-99397 for established patients).

Include a routine/preventative diagnosis code appropriate for the patient’s age on the claim.

Routine infant and childhood visits must include age-appropriate history and examination and, where applicable, assessment of growth, development, motor abilities, coordination, diet, sleep, and exercise habits.

Laboratory, radiology services, and immunizations are not typically included in preventative codes and may be billed separately (itemize on the claim when applicable).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPreventative Medicine — Billing and Reimbursement Guideline

Policy CodePolicy N/A

Change TypeFormat change and minor edits (9/1/2013)

Effective DateSep 1, 2010

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Preventative Medicine Codes and Limits

Preventative medicine CPT codes for new patientsCPTCovered

99381-99387

Preventative medicine codes for new patients (age-based)

Preventative medicine CPT codes for established patientsCPTCovered

99391-99397

Preventative medicine codes for established patients (age-based)

Preventative visits per day — payment limit

Preventative visits payable per dayOnly one preventative visit per day is payable.

Same-day preventative and sick visitsIf a preventative exam and a sick visit are billed on the same day, clinical notes and supportive diagnosis coding are required to justify separate payment.

Modifier use for separate servicesUse modifiers 25 or 59 to indicate a separately identifiable service when applicable.

Billing Rules and Documentation Requirements

Billing Rule

Modifier and Claim Submission Rules

Use modifier 25 or 59 when billing a separately identifiable evaluation and management or procedure in addition to the preventive service to indicate a distinct service. Follow payer-specific claim submission requirements — this guideline applies to both CMS-1500 and UB-92 (UB-04) claim forms. Providers should refer to Neighborhood's provider website for product-line specific provisions.

Use Modifier 25 or 59 to indicate a separately identifiable service
Applicable to CMS-1500 and UB-92/UB-04 claim submissions
Refer to http://www.nhpri.org for product-line specifics

OpenPayer

Preventative Medicine — Billing and Reimbursement Guideline

Preventative Visit Coverage Criteria

Preventative Medicine Codes and Limits

Billing Rules and Documentation Requirements

Definitions