Covering the preventive E&M when billed with sick E&M

Effective January 1, 2024, the primary evaluation and management (E&M) code will be reimbursed at 150% of the allowable when billed appropriately with a secondary E&M code. When a member has an appointment for a sick visit, it’s a great opportunity to perform an overdue well-check, which is why Anthem Blue Cross and Blue Shield Medicaid will start reimbursing primary care providers more when both sick and preventive E&M codes and services are billed together.

Kentucky statute 907 KAR 3:005 does not allow MCOs to pay for both services separately.

This enhanced reimbursement applies to the following procedures, places of service, and specialties. Care providers must be in network at the time of service.

Procedures:

• Sick visits: 99201–99205 (new patient), 99211–99215 (established patient)
• Preventive visits: 99381–99386 (new), 99391–99397 (established)

Places of service:

• 11 Office
• 02 Telehealth
• 50 Federally qualified health center (FQHC)
• 71 Public health clinic
• 72 Rural health clinic (RHC)

Specialties/licensures:

• Family medicine
• Pediatrics
• Internal medicine
• General practice
• Obstetrics/gynecology
• Geriatric medicine
• Pediatric internal med spec
• Pediatric infectious diseases
• Pediatric nurse practitioner
• Adolescent medicine
• Certified nurse practitioner
• Physician assistant
• Family practice nurse practitioner

If you have questions about this communication, contact your provider relationship management representative or the Provider Services department at 855-661-2028.

We are committed to finding solutions that help our care provider partners offer quality services to our members.